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  1. Reducing surgical mortality in Scotland by use of the WHO Surgical Safety Checklist. | PSNet

    psnet.ahrq.gov/issue/reducing-surgical-mortality-scotland-use-who-surgical-safety-checklist
    February 09, 2011 - Study Classic Reducing surgical mortality in Scotland by use of the WHO Surgical Safety Checklist. Citation Text: Ramsay G, Haynes AB, Lipsitz SR, et al. Reducing surgical mortality in Scotland by use of the WHO Surgical Safety Checklist. Br J Surg. 2019;106(8):…

  2. Improving patient safety in the ICU by prospective identification of missing safety barriers using the Bow-Tie prospective risk analysis model. | PSNet

    psnet.ahrq.gov/issue/improving-patient-safety-icu-prospective-identification-missing-safety-barriers-using-bow-tie
    February 14, 2024 - Study Improving patient safety in the ICU by prospective identification of missing safety barriers using the Bow-Tie prospective risk analysis model. Citation Text: Kerckhoffs MC, van der Sluijs AF, Binnekade JM, et al. Improving Patient Safety in the ICU by Prospective Identification o…

  3. Intervention of pharmacist included in multidisciplinary team to reduce adverse drug event: a qualitative systematic review. | PSNet

    psnet.ahrq.gov/issue/intervention-pharmacist-included-multidisciplinary-team-reduce-adverse-drug-event-qualitative
    February 12, 2020 - Review Intervention of pharmacist included in multidisciplinary team to reduce adverse drug event: a qualitative systematic review. Citation Text: Zaij S, Pereira Maia K, Leguelinel-Blache G, et al. Intervention of pharmacist included in multidisciplinary team to reduce adverse drug even…

  4. Systematic review: association of shift length, protected sleep time, and night float with patient care, residents' health, and education. | PSNet

    psnet.ahrq.gov/issue/systematic-review-association-shift-length-protected-sleep-time-and-night-float-patient-care
    November 26, 2014 - Review Classic Systematic review: association of shift length, protected sleep time, and night float with patient care, residents' health, and education. Citation Text: Reed DA, Fletcher KE, Arora V. Systematic review: association of shift length, protected sl…

  5. Relationship between patient safety and hospital surgical volume. | PSNet

    psnet.ahrq.gov/issue/relationship-between-patient-safety-and-hospital-surgical-volume
    May 04, 2012 - Study Relationship between patient safety and hospital surgical volume. Citation Text: Hernandez-Boussard T, Downey JR, McDonald KM, et al. Relationship between Patient Safety and Hospital Surgical Volume. Health Serv Res. 2011;47(2). doi:10.1111/j.1475-6773.2011.01310.x. Copy Citati…

  6. Sources of unsafe primary care for older adults: a mixed-methods analysis of patient safety incident reports. | PSNet

    psnet.ahrq.gov/issue/sources-unsafe-primary-care-older-adults-mixed-methods-analysis-patient-safety-incident
    October 12, 2016 - Study Sources of unsafe primary care for older adults: a mixed-methods analysis of patient safety incident reports. Citation Text: Cooper A, Edwards A, Williams H, et al. Sources of unsafe primary care for older adults: a mixed-methods analysis of patient safety incident reports. Age Age…

  7. 1d2 Workflow Assessment Guide (doc file)

    digital.ahrq.gov/sites/default/files/docs/workflowtoolkit/WorkflowInterviewGuide.doc
    December 18, 2021 - 1d2 Workflow Assessment Guide 1d2 Workflow Assessment Guide CFMC Staff Use Only (this box) Individuals interviewed: Workflow Assessors: Workflow Assessment date: Number/type of providers observed: General Information Clinic Name: Total number of exam rooms: Number of patients typica…

  8. Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay: retrospective comparative analysis. | PSNet

    psnet.ahrq.gov/issue/impact-statewide-intensive-care-unit-quality-improvement-initiative-hospital-mortality-and
    October 16, 2012 - Study Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay: retrospective comparative analysis. Citation Text: Lipitz-Snyderman A, Steinwachs D, Needham DM, et al. Impact of a statewide intensive care unit quality improvement…

  9. Association of current opioid use with serious adverse events among older adult survivors of breast cancer. | PSNet

    psnet.ahrq.gov/issue/association-current-opioid-use-serious-adverse-events-among-older-adult-survivors-breast
    February 15, 2023 - Study Association of current opioid use with serious adverse events among older adult survivors of breast cancer. Citation Text: Winn AN, Check DK, Farkas A, et al. Association of current opioid use with serious adverse events among older adult survivors of breast cancer. JAMA Netw Open.…

  10. The missing evidence: a systematic review of patients' experiences of adverse events in health care. | PSNet

    psnet.ahrq.gov/issue/missing-evidence-systematic-review-patients-experiences-adverse-events-health-care
    September 06, 2017 - Review Classic The missing evidence: a systematic review of patients' experiences of adverse events in health care. Citation Text: Harrison R, Walton M, Manias E, et al. The missing evidence: a systematic review of patients' experiences of adverse events in heal…

  11. Misdiagnosis of thoracic aortic emergencies occurs frequently among transfers to aortic referral centers: an analysis of over 3700 patients. | PSNet

    psnet.ahrq.gov/issue/misdiagnosis-thoracic-aortic-emergencies-occurs-frequently-among-transfers-aortic-referral
    October 28, 2020 - Study Misdiagnosis of thoracic aortic emergencies occurs frequently among transfers to aortic referral centers: an analysis of over 3700 patients. Citation Text: Arnaoutakis GJ, Ogami T, Aranda‐Michel E, et al. Misdiagnosis of thoracic aortic emergencies occurs frequently among transfers…

  12. Room of hazards: a comparison of differences in safety hazard recognition among various hospital-based healthcare professionals and trainees in a simulated patient room. | PSNet

    psnet.ahrq.gov/issue/room-hazards-comparison-differences-safety-hazard-recognition-among-various-hospital-based
    April 01, 2020 - Study Room of hazards: a comparison of differences in safety hazard recognition among various hospital-based healthcare professionals and trainees in a simulated patient room. Citation Text: Wang M, Banda B, Rodwin BA, et al. Room of hazards: a comparison of differences in safety hazard …

  13. Patient safety perceptions in pediatric out-of-hospital emergency care: Children's Safety Initiative. | PSNet

    psnet.ahrq.gov/issue/patient-safety-perceptions-pediatric-out-hospital-emergency-care-childrens-safety-initiative
    March 22, 2017 - Study Patient safety perceptions in pediatric out-of-hospital emergency care: Children's Safety Initiative. Citation Text: Guise J-M, Meckler G, O'Brien K, et al. Patient Safety Perceptions in Pediatric Out-of-Hospital Emergency Care: Children's Safety Initiative. J Pediatr. 2015;167(5):…

  14. Adverse medication events related to hospitalization in the United States: a comparison between adults with intellectual and developmental disabilities and those without. | PSNet

    psnet.ahrq.gov/issue/adverse-medication-events-related-hospitalization-united-states-comparison-between-adults
    February 02, 2022 - Study Adverse medication events related to hospitalization in the United States: a comparison between adults with intellectual and developmental disabilities and those without. Citation Text: Erickson SR, Kamdar N, Wu C-H. Adverse Medication Events Related to Hospitalization in the Unite…

  15. Better nurse staffing is associated with survival for Black patients and diminishes racial disparities in survival after in-hospital cardiac arrests. | PSNet

    psnet.ahrq.gov/issue/better-nurse-staffing-associated-survival-black-patients-and-diminishes-racial-disparities
    June 02, 2021 - Study Better nurse staffing is associated with survival for Black patients and diminishes racial disparities in survival after in-hospital cardiac arrests. Citation Text: Brooks Carthon M, Brom H, McHugh MD, et al. Better nurse staffing is associated with survival for black patients and …

  16. Clinician-identified problems and solutions for delayed diagnosis in primary care: a PRIORITIZE study. | PSNet

    psnet.ahrq.gov/issue/clinician-identified-problems-and-solutions-delayed-diagnosis-primary-care-prioritize-study
    December 14, 2016 - Study Clinician-identified problems and solutions for delayed diagnosis in primary care: a PRIORITIZE study. Citation Text: Car LT, Papachristou N, Bull A, et al. Clinician-identified problems and solutions for delayed diagnosis in primary care: a PRIORITIZE study. BMC Fam Pract. 2016;17…

  17. Fall prevention in acute care hospitals: a randomized trial. | PSNet

    psnet.ahrq.gov/issue/fall-prevention-acute-care-hospitals-randomized-trial
    February 01, 2023 - Study Classic Fall prevention in acute care hospitals: a randomized trial. Citation Text: Dykes PC, Carroll DL, Hurley A, et al. Fall prevention in acute care hospitals: a randomized trial. JAMA. 2010;304(17):1912-1918. doi:10.1001/jama.2010.1567. Copy Citat…

  18. Resilience vs. vulnerability: psychological safety and reporting of near misses with varying proximity to harm in radiation oncology. | PSNet

    psnet.ahrq.gov/issue/resilience-vs-vulnerability-psychological-safety-and-reporting-near-misses-varying-proximity
    December 16, 2020 - Study Resilience vs. vulnerability: psychological safety and reporting of near misses with varying proximity to harm in radiation oncology. Citation Text: Jung OS, Kundu P, Edmondson AC, et al. Resilience vs. vulnerability: psychological safety and reporting of near misses with varying p…

  19. Appropriate use of medical interpreters in the breast imaging clinic. | PSNet

    psnet.ahrq.gov/issue/appropriate-use-medical-interpreters-breast-imaging-clinic
    October 16, 2024 - Commentary Appropriate use of medical interpreters in the breast imaging clinic. Citation Text: Feliciano-Rivera YZ, Yepes MM, Sanchez P, et al. Appropriate use of medical interpreters in the breast imaging clinic. J Breast Imaging. 2024;27(3):296-303. doi:10.1093/jbi/wbad109. Copy Cit…

  20. Rates of serious surgical errors in California and plans to prevent recurrence. | PSNet

    psnet.ahrq.gov/issue/rates-serious-surgical-errors-california-and-plans-prevent-recurrence
    March 09, 2022 - Study Rates of serious surgical errors in California and plans to prevent recurrence. Citation Text: Cohen AJ, Lui H, Zheng M, et al. Rates of serious surgical errors in California and plans to prevent recurrence. JAMA Netw Open. 2021;4(5):e217058. doi:10.1001/jamanetworkopen.2021.7058. …
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