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Looking back on the history of patient safety: an opportunity to reflect and ponder future challenges. | PSNet

psnet.ahrq.gov/issue/looking-back-history-patient-safety-opportunity-reflect-and-ponder-future-challenges

July 10, 2019 - Commentary Looking back on the history of patient safety: an opportunity to reflect and ponder future challenges. Citation Text: Schiff G, Shojania KG. Looking back on the history of patient safety: an opportunity to reflect and ponder future challenges. BMJ Qual Saf. 2022;31(2):148-152.…

World Health Organization-World Federation of Societies of Anaesthesiologists (WHO-WFSA) International Standards for a Safe Practice of Anesthesia. | PSNet

psnet.ahrq.gov/issue/world-health-organization-world-federation-societies-anaesthesiologists-who-wfsa

November 16, 2015 - Commentary World Health Organization-World Federation of Societies of Anaesthesiologists (WHO-WFSA) International Standards for a Safe Practice of Anesthesia. Citation Text: Gelb AW, Morriss WW, Johnson W, et al. World Health Organization-World Federation of Societies of Anaesthesiologis…

A prospective study of paediatric cardiac surgical microsystems: assessing the relationships between non-routine events, teamwork and patient outcomes. | PSNet

psnet.ahrq.gov/issue/prospective-study-paediatric-cardiac-surgical-microsystems-assessing-relationships-between

February 14, 2024 - Study A prospective study of paediatric cardiac surgical microsystems: assessing the relationships between non-routine events, teamwork and patient outcomes. Citation Text: Schraagen JM, Schouten T, Smit M, et al. A prospective study of paediatric cardiac surgical microsystems: assessi…

Collaboration with regulators to support quality and accountability following medical errors: the communication and resolution program certification pilot. | PSNet

psnet.ahrq.gov/issue/collaboration-regulators-support-quality-and-accountability-following-medical-errors

September 29, 2017 - Study Collaboration with regulators to support quality and accountability following medical errors: the communication and resolution program certification pilot. Citation Text: Gallagher TH, Farrell ML, Karson H, et al. Collaboration with Regulators to Support Quality and Accountability …

Animated stories of medical error as a means of teaching undergraduates patient safety: an evaluation study. | PSNet

psnet.ahrq.gov/issue/animated-stories-medical-error-means-teaching-undergraduates-patient-safety-evaluation-study

June 10, 2020 - Study Animated stories of medical error as a means of teaching undergraduates patient safety: an evaluation study. Citation Text: Cooper K, Hatfield E, Yeomans J. Animated stories of medical error as a means of teaching undergraduates patient safety: an evaluation study. Perspect Med Edu…

Communication and collaboration: it's about the pharmacists, as well as the physicians and nurses. | PSNet

psnet.ahrq.gov/issue/communication-and-collaboration-its-about-pharmacists-well-physicians-and-nurses

November 25, 2009 - Study Communication and collaboration: it's about the pharmacists, as well as the physicians and nurses. Citation Text: Holden LM, Watts DD, Walker PH. Communication and collaboration: it's about the pharmacists, as well as the physicians and nurses. Qual Saf Health Care. 2010;19(3):16…

I-PSI: short- and long-term efficacy of a comprehensive initiative to promote patient safety event reporting by trainees. | PSNet

psnet.ahrq.gov/issue/i-psi-short-and-long-term-efficacy-comprehensive-initiative-promote-patient-safety-event

November 18, 2020 - Study I-PSI: short- and long-term efficacy of a comprehensive initiative to promote patient safety event reporting by trainees. Citation Text: Prabhu V, Mikhly M, Chung R, et al. I-PSI: short- and long-term efficacy of a comprehensive initiative to promote patient safety event reporting …

Racial, ethnic, and socioeconomic disparities in patient safety events for hospitalized children. | PSNet

psnet.ahrq.gov/issue/racial-ethnic-and-socioeconomic-disparities-patient-safety-events-hospitalized-children

August 14, 2018 - Study Racial, ethnic, and socioeconomic disparities in patient safety events for hospitalized children. Citation Text: Stockwell DC, Landrigan CP, Toomey SL, et al. Racial, Ethnic, and Socioeconomic Disparities in Patient Safety Events for Hospitalized Children. Hosp Pediatr. 2019;9(1):1…

Patient falls in the operating room setting: an analysis of reported safety events. | PSNet

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November 17, 2021 - Study Patient falls in the operating room setting: an analysis of reported safety events. Citation Text: Tan J, Krishnan S, Vacanti JC, et al. Patient falls in the operating room setting: an analysis of reported safety events. J Healthc Risk Manag. 2022;42(1):9-14. doi:10.1002/jhrm.21503…

Changes in efficiency and safety culture after integration of an I-PASS-supported handoff process. | PSNet

psnet.ahrq.gov/issue/changes-efficiency-and-safety-culture-after-integration-i-pass-supported-handoff-process

June 25, 2018 - Study Changes in efficiency and safety culture after integration of an I-PASS-supported handoff process. Citation Text: Sheth S, McCarthy E, Kipps AK, et al. Changes in Efficiency and Safety Culture After Integration of an I-PASS-Supported Handoff Process. PEDIATRICS. 2016;137(2). doi:10…

The morbidity and mortality conference: opportunities for enhancing patient safety. | PSNet

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March 17, 2021 - Commentary The morbidity and mortality conference: opportunities for enhancing patient safety. Citation Text: Lazzara EH, Salisbury M, Hughes AM, et al. The morbidity and mortality conference: opportunities for enhancing patient safety. J Patient Saf. 2022;18(1):e275-e281. doi:10.1097/pt…

Chemotherapy errors: a call for a standardized approach to measurement and reporting. | PSNet

psnet.ahrq.gov/issue/chemotherapy-errors-call-standardized-approach-measurement-and-reporting

October 28, 2020 - Commentary Chemotherapy errors: a call for a standardized approach to measurement and reporting. Citation Text: Lennes IT, Bohlen N, Park ER, et al. Chemotherapy Errors: A Call for a Standardized Approach to Measurement and Reporting. J Oncol Pract. 2016;12(4):e495-501. doi:10.1200/JOP.2…

Effects of individual nurse and hospital characteristics on patient adverse events and quality of care: a multilevel analysis. | PSNet

psnet.ahrq.gov/issue/effects-individual-nurse-and-hospital-characteristics-patient-adverse-events-and-quality-care

February 08, 2019 - Study Effects of individual nurse and hospital characteristics on patient adverse events and quality of care: a multilevel analysis. Citation Text: Lee SE, Vincent C, Dahinten S, et al. Effects of Individual Nurse and Hospital Characteristics on Patient Adverse Events and Quality of Care…

Patterns of communication breakdowns resulting in injury to surgical patients. | PSNet

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March 03, 2011 - Study Classic Patterns of communication breakdowns resulting in injury to surgical patients. Citation Text: Greenberg CC, Regenbogen SE, Studdert DM, et al. Patterns of communication breakdowns resulting in injury to surgical patients. J Am Coll Surg. 2007;204…

Putting the "action" in RCA(2): an analysis of intervention strength after adverse events. | PSNet

psnet.ahrq.gov/issue/putting-action-rca2-analysis-intervention-strength-after-adverse-events

April 17, 2024 - Study Putting the "action" in RCA(2): an analysis of intervention strength after adverse events. Citation Text: Zerillo JA, Tardiff SA, Flood D, et al. Putting the "action" in RCA(2): an analysis of intervention strength after adverse events. Jt Comm J Qual Patient Saf. 2024;50(7):492-49…

Talking with patients about other clinicians' errors. | PSNet

psnet.ahrq.gov/issue/talking-patients-about-other-clinicians-errors

October 27, 2021 - Study Classic Talking with patients about other clinicians' errors. Citation Text: Gallagher TH, Mello MM, Levinson W, et al. Talking with patients about other clinicians' errors. N Engl J Med. 2013;369(18):1752-7. doi:10.1056/NEJMsb1303119. Copy Citation …

Speaking up about patient safety concerns: the influence of safety management approaches and climate on nurses' willingness to speak up. | PSNet

psnet.ahrq.gov/issue/speaking-about-patient-safety-concerns-influence-safety-management-approaches-and-climate

August 12, 2020 - Study Classic Speaking up about patient safety concerns: the influence of safety management approaches and climate on nurses' willingness to speak up. Citation Text: Alingh CW, van Wijngaarden JDH, van de Voorde K, et al. Speaking up about patient safety concern…

Prevalence and characteristics of diagnostic error in pediatric critical care: a multicenter study. | PSNet

psnet.ahrq.gov/issue/prevalence-and-characteristics-diagnostic-error-pediatric-critical-care-multicenter-study

December 11, 2024 - Study Prevalence and characteristics of diagnostic error in pediatric critical care: a multicenter study. Citation Text: Cifra CL, Custer JW, Smith CM, et al. Prevalence and characteristics of diagnostic error in pediatric critical care: a multicenter study. Crit Care Med. 2023;51(11):14…

Minor flow disruptions, traffic-related factors and their effect on major flow disruptions in the operating room. | PSNet

psnet.ahrq.gov/issue/minor-flow-disruptions-traffic-related-factors-and-their-effect-major-flow-disruptions

August 19, 2020 - Study Minor flow disruptions, traffic-related factors and their effect on major flow disruptions in the operating room. Citation Text: Joseph A, Khoshkenar A, Taaffe KM, et al. Minor flow disruptions, traffic-related factors and their effect on major flow disruptions in the operating roo…

Using potentially preventable severe maternal morbidity to monitor hospital performance. | PSNet

psnet.ahrq.gov/issue/using-potentially-preventable-severe-maternal-morbidity-monitor-hospital-performance

February 02, 2022 - Study Using potentially preventable severe maternal morbidity to monitor hospital performance. Citation Text: Fridman M, Korst LM, Reynen DJ, et al. Using potentially preventable severe maternal morbidity to monitor hospital performance. Jt Comm J Qual Patient Saf. 2023;49(3):129-137. do…

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