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  1. The impact of perioperative catastrophes on anesthesiologists: results of a national survey. | PSNet

    psnet.ahrq.gov/issue/impact-perioperative-catastrophes-anesthesiologists-results-national-survey
    August 27, 2009 - Study The impact of perioperative catastrophes on anesthesiologists: results of a national survey. Citation Text: Gazoni FM, Amato PE, Malik ZM, et al. The impact of perioperative catastrophes on anesthesiologists: results of a national survey. Anesth Analg. 2012;114(3):596-603. doi:10…

  2. Safely practicing in a new environment: a qualitative study to inform physician onboarding practices. | PSNet

    psnet.ahrq.gov/issue/safely-practicing-new-environment-qualitative-study-inform-physician-onboarding-practices
    July 02, 2019 - Study Safely practicing in a new environment: a qualitative study to inform physician onboarding practices. Citation Text: Lagoo J, Berry WR, Henrich N, et al. Safely practicing in a new environment: a qualitative study to inform physician onboarding practices. Jt Comm J Qual Patient Saf…

  3. Non–health care facility medication errors resulting in serious medical outcomes. | PSNet

    psnet.ahrq.gov/issue/non-health-care-facility-medication-errors-resulting-serious-medical-outcomes
    June 14, 2017 - Study Classic Non–health care facility medication errors resulting in serious medical outcomes. Citation Text: Hodges NL, Spiller HA, Casavant MJ, et al. Non-health care facility medication errors resulting in serious medical outcomes. Clin Toxicol (Phila). 2018…

  4. Office surgery incidents: what seven years of Florida data show us. | PSNet

    psnet.ahrq.gov/issue/office-surgery-incidents-what-seven-years-florida-data-show-us
    August 19, 2009 - Study Office surgery incidents: what seven years of Florida data show us. Citation Text: Coldiron BM, Healy C, Bene NI. Office surgery incidents: what seven years of Florida data show us. Dermatol Surg. 2008;34(3):285-91; discussion 291-2. doi:10.1111/j.1524-4725.2007.34060.x. Copy C…

  5. Polypharmacy and potentially inappropriate medication in people with dementia: a nationwide study. | PSNet

    psnet.ahrq.gov/issue/polypharmacy-and-potentially-inappropriate-medication-people-dementia-nationwide-study
    March 06, 2012 - Study Emerging Classic Polypharmacy and potentially inappropriate medication in people with dementia: a nationwide study. Citation Text: Kristensen RU, Nørgaard A, Jensen-Dahm C, et al. Polypharmacy and Potentially Inappropriate Medication in People with Dementi…

  6. Using failure mode and effect analysis to identify potential failures in a psychiatric hospital emergency department. | PSNet

    psnet.ahrq.gov/issue/using-failure-mode-and-effect-analysis-identify-potential-failures-psychiatric-hospital
    June 22, 2017 - Study Using failure mode and effect analysis to identify potential failures in a psychiatric hospital emergency department. Citation Text: Gur-Arieh S, Mendlovic S, Rozenblum R, et al. Using failure mode and effect analysis to identify potential failures in a psychiatric hospital emergen…

  7. Current teaching and evaluation methods in critical care medicine: has the Accreditation Council for Graduate Medical Education affected how we practice and teach in the intensive care unit? | PSNet

    psnet.ahrq.gov/issue/current-teaching-and-evaluation-methods-critical-care-medicine-has-accreditation-council
    February 23, 2022 - Study Current teaching and evaluation methods in critical care medicine: has the Accreditation Council for Graduate Medical Education affected how we practice and teach in the intensive care unit? Citation Text: Chudgar SM, Cox CE, Que LG, et al. Current teaching and evaluation methods…

  8. Development of a multicomponent intervention to decrease racial bias among healthcare staff. | PSNet

    psnet.ahrq.gov/issue/development-multicomponent-intervention-decrease-racial-bias-among-healthcare-staff
    September 23, 2020 - Study Development of a multicomponent intervention to decrease racial bias among healthcare staff. Citation Text: Tajeu GS, Juarez L, Williams JH, et al. Development of a multicomponent intervention to decrease racial bias among healthcare staff. J Gen Intern Med. 2022;37(8):1970-1979. d…

  9. Surgical patient safety outcomes in critical access hospitals: how do they compare? | PSNet

    psnet.ahrq.gov/issue/surgical-patient-safety-outcomes-critical-access-hospitals-how-do-they-compare
    June 05, 2019 - Study Surgical patient safety outcomes in critical access hospitals: how do they compare? Citation Text: Natafgi N, Baloh J, Weigel P, et al. Surgical Patient Safety Outcomes in Critical Access Hospitals: How Do They Compare? J Rural Health. 2016;33(2):117-126. doi:10.1111/jrh.12176. C…

  10. Complication rates of central venous catheters: a systematic review and meta-analysis. | PSNet

    psnet.ahrq.gov/issue/complication-rates-central-venous-catheters-systematic-review-and-meta-analysis
    December 07, 2016 - Review Complication rates of central venous catheters: a systematic review and meta-analysis. Citation Text: Teja B, Bosch NA, Diep C, et al. Complication rates of central venous catheters: a systematic review and meta-analysis. JAMA Intern Med. 2024;184(5):474-482. doi:10.1001/jamainter…

  11. Identifying medication errors in neonatal intensive care units: a two-center study | PSNet

    psnet.ahrq.gov/issue/identifying-medication-errors-neonatal-intensive-care-units-two-center-study
    November 11, 2020 - Study Identifying medication errors in neonatal intensive care units: a two-center study Citation Text: Eslami K, Aletayeb F, Aletayeb SMH, et al. Identifying medication errors in neonatal intensive care units: a two-center study. BMC Pediatr. 2019;19(1):365. doi:10.1186/s12887-019-1748-…

  12. Adapting rapid assessment procedures for implementation research using a team-based approach to analysis: a case example of patient quality and safety interventions in the ICU. | PSNet

    psnet.ahrq.gov/issue/adapting-rapid-assessment-procedures-implementation-research-using-team-based-approach
    November 09, 2022 - Study Adapting rapid assessment procedures for implementation research using a team-based approach to analysis: a case example of patient quality and safety interventions in the ICU. Citation Text: Holdsworth LM, Safaeinili N, Winget M, et al. Adapting rapid assessment procedures for imp…

  13. Standing Order Protocol: Nasal Mupirocin (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/nursing-protocols/standing-order-protocol-mupirocin.docx
    March 01, 2022 - Standing Order Protocol: Nasal Mupirocin Decolonization of Non-ICU Patients With Devices Section 9-3 – Standing Order Protocol: Nasal Mupirocin The following is a standing order protocol for implementing nasal decolonization in adult non-intensive care unit (ICU) patients who are methicillin-resistant Staphylococcus…

  14. Recovery from COVID-19-related disruptions in cancer detection. | PSNet

    psnet.ahrq.gov/issue/recovery-covid-19-related-disruptions-cancer-detection
    November 16, 2022 - Study Recovery from COVID-19-related disruptions in cancer detection. Citation Text: Kim U, Rose J, Carroll BT, et al. Recovery from COVID-19-related disruptions in cancer detection. JAMA Netw Open. 2024;7(10):e2439263. doi:10.1001/jamanetworkopen.2024.39263. Copy Citation Format: …

  15. Understanding and responding when things go wrong: key principles for primary care educators. | PSNet

    psnet.ahrq.gov/issue/understanding-and-responding-when-things-go-wrong-key-principles-primary-care-educators
    January 23, 2017 - Study Understanding and responding when things go wrong: key principles for primary care educators. Citation Text: McNab D, Bowie P, Ross A, et al. Understanding and responding when things go wrong: key principles for primary care educators. Educ Prim Care. 2016;27(4):258-66. doi:10.1080…

  16. Do patient safety events increase readmissions? | PSNet

    psnet.ahrq.gov/issue/do-patient-safety-events-increase-readmissions
    November 04, 2015 - Study Do patient safety events increase readmissions? Citation Text: Friedman B, Encinosa W, Jiang J, et al. Do patient safety events increase readmissions? Med Care. 2009;47(5):583-90. doi:10.1097/MLR.0b013e31819434da. Copy Citation Format: DOI Google Scholar PubMed BibT…

  17. Electronic health record–related safety concerns: a cross-sectional survey. | PSNet

    psnet.ahrq.gov/issue/electronic-health-record-related-safety-concerns-cross-sectional-survey
    August 03, 2016 - Study Electronic health record–related safety concerns: a cross-sectional survey. Citation Text: Menon S, Singh H, Meyer AND, et al. Electronic health record-related safety concerns: a cross-sectional survey. J Healthc Risk Manag. 2014;34(1):14-26. doi:10.1002/jhrm.21146. Copy Citation…

  18. The causes of their death appear (unto our shame perpetual): why root cause analysis is not the best model for error investigation in mental health services. | PSNet

    psnet.ahrq.gov/issue/causes-their-death-appear-unto-our-shame-perpetual-why-root-cause-analysis-not-best-model
    September 27, 2016 - Study The causes of their death appear (unto our shame perpetual): why root cause analysis is not the best model for error investigation in mental health services. Citation Text: Vrklevski LP, McKechnie L, OʼConnor N. The Causes of Their Death Appear (Unto Our Shame Perpetual): Why Root …

  19. Patient safety in palliative care: a mixed-methods study of reports to a national database of serious incidents. | PSNet

    psnet.ahrq.gov/issue/patient-safety-palliative-care-mixed-methods-study-reports-national-database-serious
    May 16, 2018 - Study Emerging Classic Patient safety in palliative care: a mixed-methods study of reports to a national database of serious incidents. Citation Text: Yardley I, Yardley S, Williams H, et al. Patient safety in palliative care: A mixed-methods study of reports to…

  20. Missing clinical and behavioral health data in a large electronic health record (EHR) system. | PSNet

    psnet.ahrq.gov/issue/missing-clinical-and-behavioral-health-data-large-electronic-health-record-ehr-system
    July 19, 2023 - Study Missing clinical and behavioral health data in a large electronic health record (EHR) system. Citation Text: Madden JM, Lakoma MD, Rusinak D, et al. Missing clinical and behavioral health data in a large electronic health record (EHR) system. J Am Med Info Asso. 2016;23(6):1143-114…
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