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  1. Failure mode and effects analysis to reduce risk of heparin use. | PSNet

    psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-reduce-risk-heparin-use
    July 19, 2023 - Study Failure mode and effects analysis to reduce risk of heparin use. Citation Text: Pino FA, Weidemann DK, Schroeder LL, et al. Failure mode and effects analysis to reduce risk of heparin use. Am J Health Syst Pharm. 2019;76(23):1972-1979. doi:10.1093/ajhp/zxz229. Copy Citation F…

  2. A 60-year-old man with delayed care for a renal mass. | PSNet

    psnet.ahrq.gov/issue/60-year-old-man-delayed-care-renal-mass
    January 31, 2024 - Commentary A 60-year-old man with delayed care for a renal mass. Citation Text: Schiff G. Medical error: a 60-year-old man with delayed care for a renal mass. JAMA. 2011;305(18):1890-8. doi:10.1001/jama.2011.496. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNo…

  3. Assessing and improving safety culture throughout an academic medical centre: a prospective cohort study. | PSNet

    psnet.ahrq.gov/issue/assessing-and-improving-safety-culture-throughout-academic-medical-centre-prospective-cohort
    January 02, 2017 - Study Assessing and improving safety culture throughout an academic medical centre: a prospective cohort study. Citation Text: Paine LA, Rosenstein BJ, Sexton B, et al. Assessing and improving safety culture throughout an academic medical centre: a prospective cohort study. Qual Saf He…

  4. Teaching quality improvement and patient safety to trainees: a systematic review. | PSNet

    psnet.ahrq.gov/issue/teaching-quality-improvement-and-patient-safety-trainees-systematic-review
    June 09, 2015 - Review Classic Teaching quality improvement and patient safety to trainees: a systematic review. Citation Text: Wong BM, Etchells E, Kuper A, et al. Teaching quality improvement and patient safety to trainees: a systematic review. Acad Med. 2010;85(9):1425-39. d…

  5. Using Healthcare Failure Mode and Effect Analysis to reduce medication errors in the process of drug prescription, validation and dispensing in hospitalised patients. | PSNet

    psnet.ahrq.gov/issue/using-healthcare-failure-mode-and-effect-analysis-reduce-medication-errors-process-drug
    August 23, 2017 - Study Using Healthcare Failure Mode and Effect Analysis to reduce medication errors in the process of drug prescription, validation and dispensing in hospitalised patients. Citation Text: Vélez-Díaz-Pallarés M, Delgado-Silveira E, Carretero-Accame ME, et al. Using Healthcare Failure Mo…

  6. Forum: The 100,000 Lives Campaign: a scientific and policy review [with IHI response]. | PSNet

    psnet.ahrq.gov/issue/forum-100000-lives-campaign-scientific-and-policy-review-ihi-response
    March 13, 2013 - Commentary Classic Forum: The 100,000 Lives Campaign: a scientific and policy review [with IHI response]. Citation Text: Wachter R, Pronovost P. The 100,000 Lives Campaign: A scientific and policy review. Jt Comm J Qual Patient Saf. 2006;32(11):621-7. Copy Cit…

  7. Multidisciplinary approaches to reducing error and risk in a patient care setting. | PSNet

    psnet.ahrq.gov/issue/multidisciplinary-approaches-reducing-error-and-risk-patient-care-setting
    January 05, 2017 - Study Classic Multidisciplinary approaches to reducing error and risk in a patient care setting. Citation Text: Connor M, Ponte PR, Conway JB. Multidisciplinary approaches to reducing error and risk in a patient care setting. Crit Care Nurs Clin North Am. 2002…

  8. Adverse events associated with home blood transfusion: a retrospective cohort study. | PSNet

    psnet.ahrq.gov/issue/adverse-events-associated-home-blood-transfusion-retrospective-cohort-study
    October 20, 2021 - Study Adverse events associated with home blood transfusion: a retrospective cohort study. Citation Text: Sharp R, Turner L, Altschwager J, et al. Adverse events associated with home blood transfusion: a retrospective cohort study. J Clin Nurs. 2021;30(11-12):1751-1759. doi:10.1111/jocn.…

  9. Resident participation does not affect surgical outcomes, despite introduction of new techniques. | PSNet

    psnet.ahrq.gov/issue/resident-participation-does-not-affect-surgical-outcomes-despite-introduction-new-techniques
    September 23, 2020 - Study Resident participation does not affect surgical outcomes, despite introduction of new techniques. Citation Text: Patel SP, Gauger PG, Brown DL, et al. Resident participation does not affect surgical outcomes, despite introduction of new techniques. J Am Coll Surg. 2010;211(4):540…

  10. Safety participation at the direct care level: results of a patient questionnaire. | PSNet

    psnet.ahrq.gov/issue/safety-participation-direct-care-level-results-patient-questionnaire
    August 26, 2020 - Study Safety participation at the direct care level: results of a patient questionnaire. Citation Text: Duhn L, Gumapac N, Medves J. Safety participation at the direct care level: results of a patient questionnaire. Patient Exp J. 2021;8(1):59-68. doi:10.35680/2372-0247.1506. Copy Cita…

  11. Error or "act of God"? A study of patients' and operating room team members' perceptions of error definition, reporting, and disclosure. | PSNet

    psnet.ahrq.gov/issue/error-or-act-god-study-patients-and-operating-room-team-members-perceptions-error-definition
    August 10, 2011 - Study Error or "act of God"? A study of patients' and operating room team members' perceptions of error definition, reporting, and disclosure. Citation Text: Espin S, Levinson W, Regehr G, et al. Error or "act of God"? A study of patients' and operating room team members' perceptions o…

  12. Use of paediatric early warning systems in Great Britain: has there been a change of practice in the last 7 years? | PSNet

    psnet.ahrq.gov/issue/use-paediatric-early-warning-systems-great-britain-has-there-been-change-practice-last-7
    September 23, 2020 - Study Use of paediatric early warning systems in Great Britain: has there been a change of practice in the last 7 years? Citation Text: Roland D, Oliver A, Edwards ED, et al. Use of paediatric early warning systems in Great Britain: has there been a change of practice in the last 7 yea…

  13. Exploring relationships between hospital patient safety culture and adverse events. | PSNet

    psnet.ahrq.gov/issue/exploring-relationships-between-hospital-patient-safety-culture-and-adverse-events
    August 27, 2012 - Study Exploring relationships between hospital patient safety culture and adverse events. Citation Text: Mardon RE, Khanna K, Sorra J, et al. Exploring relationships between hospital patient safety culture and adverse events. J Patient Saf. 2010;6(4):226-32. doi:10.1097/PTS.0b013e3181fd1…

  14. An implementation science approach to promote optimal implementation, adoption, use, and spread of continuous clinical monitoring system technology. | PSNet

    psnet.ahrq.gov/issue/implementation-science-approach-promote-optimal-implementation-adoption-use-and-spread
    July 13, 2010 - Study An implementation science approach to promote optimal implementation, adoption, use, and spread of continuous clinical monitoring system technology. Citation Text: Dykes PC, Lowenthal G, Faris A, et al. An Implementation Science Approach to Promote Optimal Implementation, Adoption,…

  15. Sustaining innovations in complex health care environments: a multiple-case study of rapid response teams. | PSNet

    psnet.ahrq.gov/issue/sustaining-innovations-complex-health-care-environments-multiple-case-study-rapid-response
    November 03, 2015 - Study Sustaining innovations in complex health care environments: a multiple-case study of rapid response teams. Citation Text: Stolldorf DP, Havens DS, Jones CB. Sustaining innovations in complex health care environments: a multiple-case study of rapid response teams. J Patient Saf. 202…

  16. Are bad outcomes from questionable clinical decisions preventable medical errors? A case of cascade iatrogenesis. | PSNet

    psnet.ahrq.gov/issue/are-bad-outcomes-questionable-clinical-decisions-preventable-medical-errors-case-cascade
    February 24, 2011 - Study Classic Are bad outcomes from questionable clinical decisions preventable medical errors? A case of cascade iatrogenesis. Citation Text: Hofer TP, Hayward RA. Are bad outcomes from questionable clinical decisions preventable medical errors? A case of cas…

  17. Cognitive engineering to improve patient safety and outcomes in cardiothoracic surgery | PSNet

    psnet.ahrq.gov/issue/cognitive-engineering-improve-patient-safety-and-outcomes-cardiothoracic-surgery
    January 23, 2017 - Commentary Cognitive engineering to improve patient safety and outcomes in cardiothoracic surgery Citation Text: Zenati MA, Kennedy-Metz L, Dias RD. Cognitive Engineering to Improve Patient Safety and Outcomes in Cardiothoracic Surgery. Semin Thorac Cardiovasc Surg. 2019. doi:10.1053/j.s…

  18. Anesthesia Risk Alert program: a proactive safety initiative. | PSNet

    psnet.ahrq.gov/issue/anesthesia-risk-alert-program-proactive-safety-initiative
    September 02, 2015 - Study Anesthesia Risk Alert program: a proactive safety initiative. Citation Text: Lee B, Marhalik-Helms J, Penzi L. Anesthesia Risk Alert program: a proactive safety initiative. Jt Comm J Qual Patient Saf. 2023;49(9):441-449. doi:10.1016/j.jcjq.2023.06.005. Copy Citation Format: …

  19. Navigating a ship with a broken compass: evaluating standard algorithms to measure patient safety. | PSNet

    psnet.ahrq.gov/issue/navigating-ship-broken-compass-evaluating-standard-algorithms-measure-patient-safety
    January 23, 2017 - Study Navigating a ship with a broken compass: evaluating standard algorithms to measure patient safety. Citation Text: Hefner JL, Huerta T, McAlearney AS, et al. Navigating a ship with a broken compass: evaluating standard algorithms to measure patient safety. J Am Med Inform Assoc. 201…

  20. A critical appraisal of AHRQ's "Diagnostic Errors" report. | PSNet

    psnet.ahrq.gov/issue/critical-appraisal-ahrqs-diagnostic-errors-report
    July 13, 2016 - Commentary A critical appraisal of AHRQ's "Diagnostic Errors" report. Citation Text: Carpenter C, Jotte R, Griffey RT, et al. A critical appraisal of AHRQ's "Diagnostic Errors" report. Mo Med. 2023;120(2):114-120. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML E…
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