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psnet.ahrq.gov/issue/transparency-public-reporting-and-culture-change-quality-and-safety-cardiac-surgery
February 17, 2021 - Commentary
Transparency, public reporting, and a culture of change to quality and safety in cardiac surgery.
Citation Text:
Ibrahim M, Szeto WY, Gutsche J, et al. Transparency, public reporting, and a culture of change to quality and safety in cardiac surgery. Ann Thorac Surg. 2022;114(3…
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psnet.ahrq.gov/issue/increasing-trainee-reporting-adverse-events-monthly-trainee-directed-review-adverse-events
July 01, 2017 - Study
Increasing trainee reporting of adverse events with monthly, trainee-directed review of adverse events.
Citation Text:
Smith A, Hatoun J, Moses J. Increasing Trainee Reporting of Adverse Events With Monthly Trainee-Directed Review of Adverse Events. Acad Pediatr. 2017;17(8):902-906…
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psnet.ahrq.gov/issue/changes-adverse-event-rates-hospitals-over-time-longitudinal-retrospective-patient-record
November 03, 2015 - Study
Changes in adverse event rates in hospitals over time: a longitudinal retrospective patient record review study.
Citation Text:
Baines RJ, Langelaan M, de Bruijne M, et al. Changes in adverse event rates in hospitals over time: a longitudinal retrospective patient record review s…
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psnet.ahrq.gov/issue/improving-clinician-well-being-and-patient-safety-through-human-centered-design
April 29, 2018 - Commentary
Improving clinician well-being and patient safety through human-centered design.
Citation Text:
Benishek LE, Kachalia A, Daugherty Biddison L. Improving clinician well-being and patient safety through human-centered design. JAMA. 2023;329(14):1149-1150. doi:10.1001/jama.2023.2…
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psnet.ahrq.gov/issue/long-term-effects-teamwork-training-communication-and-teamwork-climate-ambulatory
May 01, 2019 - Study
Long-term effects of teamwork training on communication and teamwork climate in ambulatory reproductive health care.
Citation Text:
Dodge LE, Nippita S, Hacker MR, et al. Long‐term effects of teamwork training on communication and teamwork climate in ambulatory reproductive health …
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psnet.ahrq.gov/issue/do-written-disclosures-serious-events-increase-risk-malpractice-claims-one-health-care
October 12, 2011 - Study
Do written disclosures of serious events increase risk of malpractice claims? One health care system's experience.
Citation Text:
Painter LM, Kidwell KM, Kidwell RP, et al. Do Written Disclosures of Serious Events Increase Risk of Malpractice Claims? One Health Care System's Experi…
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psnet.ahrq.gov/issue/descriptive-analysis-disproportionate-medication-errors-and-associated-patient
February 14, 2024 - Study
Descriptive analysis on disproportionate medication errors and associated patient characteristics in the Food and Drug Administration's adverse event reporting system.
Citation Text:
Pera V, van Vaerenbergh F, Kors JA, et al. Descriptive analysis on disproportionate medication erro…
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psnet.ahrq.gov/issue/systematic-review-prevalence-medication-errors-resulting-hospitalization-and-death-nursing
July 23, 2008 - Review
Classic
Systematic review of the prevalence of medication errors resulting in hospitalization and death of nursing home residents.
Citation Text:
Ferrah N, Lovell JJ, Ibrahim JE. Systematic Review of the Prevalence of Medication Errors Resulting in Hospit…
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psnet.ahrq.gov/issue/prevalence-second-victim-syndrome-and-emotional-distress-pediatric-intensive-care-providers
April 24, 2018 - Study
The prevalence of second victim syndrome and emotional distress in pediatric intensive care providers.
Citation Text:
Wolf MS, Smith K, Basu M, et al. The prevalence of second victim syndrome and emotional distress in pediatric intensive care providers. J Pediatr Intensive Care. 20…
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psnet.ahrq.gov/issue/fix-and-forget-or-fix-and-report-qualitative-study-tensions-front-line-incident-reporting
May 18, 2016 - Study
Fix and forget or fix and report: a qualitative study of tensions at the front line of incident reporting.
Citation Text:
Hewitt TA, Chreim S. Fix and forget or fix and report: a qualitative study of tensions at the front line of incident reporting. BMJ Qual Saf. 2015;24(5):303-10.…
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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…
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psnet.ahrq.gov/issue/implementation-evaluation-and-recommendations-extension-ahrq-common-formats-capture-patient
June 13, 2018 - Study
Implementation, evaluation, and recommendations for extension of AHRQ Common Formats to capture patient- and carepartner-generated safety data.
Citation Text:
Collins S, Couture B, Dykes PC, et al. Implementation, evaluation, and recommendations for extension of AHRQ Common Formats…
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psnet.ahrq.gov/issue/where-are-my-instruments-hazards-delivery-surgical-instruments
September 25, 2008 - Study
Where are my instruments? Hazards in delivery of surgical instruments.
Citation Text:
Guédon ACP, Wauben LSGL, van der Eijk AC, et al. Where are my instruments? Hazards in delivery of surgical instruments. Surg Endosc. 2016;30(7):2728-35. doi:10.1007/s00464-015-4537-7.
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psnet.ahrq.gov/issue/demonstrating-value-postgraduate-fellowships-physicians-quality-improvement-and-patient
November 04, 2015 - Study
Demonstrating the value of postgraduate fellowships for physicians in quality improvement and patient safety.
Citation Text:
Myers JS, Lane-Fall MB, Perfetti AR, et al. Demonstrating the value of postgraduate fellowships for physicians in quality improvement and patient safety. BMJ…
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psnet.ahrq.gov/issue/rca-recast-root-cause-analysis-simulation-interprofessional-clinical-learning-environment
May 18, 2022 - Study
The RCA ReCAst: a root cause analysis simulation for the interprofessional clinical learning environment.
Citation Text:
Ziemba JB, Berns JS, Huzinec JG, et al. The RCA ReCAst: a root cause analysis simulation for the interprofessional clinical learning environment. Acad Med. 2021;…
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psnet.ahrq.gov/issue/systematic-literature-review-and-narrative-synthesis-risks-medical-discharge-letters-patients
June 26, 2019 - Review
Emerging Classic
A systematic literature review and narrative synthesis on the risks of medical discharge letters for patients' safety.
Citation Text:
Schwarz CM, Hoffmann M, Schwarz P, et al. A systematic literature review and narrative synthesis on the …
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psnet.ahrq.gov/issue/quality-and-patient-safety-metrics-developing-structured-program-improving-patient-care
April 22, 2011 - Study
Quality and patient safety metrics: developing a structured program for improving patient care in the Department of Medicine at The Ottawa Hospital.
Citation Text:
Hasimja-Saraqini D, McNeill K, Kuk H, et al. Quality and patient safety metrics: developing a structured program for i…
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psnet.ahrq.gov/issue/ct-suspected-appendicitis-children-analysis-diagnostic-errors
August 20, 2018 - Study
CT for suspected appendicitis in children: an analysis of diagnostic errors.
Citation Text:
Taylor GA, Callahan MJ, Rodriguez D, et al. CT for suspected appendicitis in children: an analysis of diagnostic errors. Pediatr Radiol. 2006;36(4):331-7.
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psnet.ahrq.gov/issue/improving-employee-voice-about-transgressive-or-disruptive-behavior-case-study
June 16, 2021 - Study
Improving employee voice about transgressive or disruptive behavior: a case study.
Citation Text:
Dixon-Woods M, Campbell A, Martin G, et al. Improving Employee Voice About Transgressive or Disruptive Behavior: A Case Study. Acad Med. 2019;94(4):579-585. doi:10.1097/ACM.00000000000…
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psnet.ahrq.gov/issue/inadequacies-physical-examination-cause-medical-errors-and-adverse-events-collection
June 01, 1989 - Study
Classic
Inadequacies of physical examination as a cause of medical errors and adverse events: a collection of vignettes.
Citation Text:
Verghese A, Charlton B, Kassirer JP, et al. Inadequacies of Physical Examination as a Cause of Medical Errors and Advers…