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psnet.ahrq.gov/issue/introductions-during-time-outs-do-surgical-team-members-know-one-anothers-names
November 09, 2015 - Study
Introductions during time-outs: do surgical team members know one another's names?
Citation Text:
Birnbach DJ, Rosen LF, Fitzpatrick M, et al. Introductions during time-outs: do surgical team members know one another's names? Jt Comm J Qual Patient Saf. 2017;43(6):284-288. doi:10.1…
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psnet.ahrq.gov/issue/association-health-literacy-postoperative-outcomes-patients-undergoing-major-abdominal
May 08, 2017 - Study
Association of health literacy with postoperative outcomes in patients undergoing major abdominal surgery.
Citation Text:
Wright JP, Edwards GC, Goggins K, et al. Association of Health Literacy With Postoperative Outcomes in Patients Undergoing Major Abdominal Surgery. JAMA Surg. 2…
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psnet.ahrq.gov/issue/medication-errors-antituberculosis-therapy-inpatient-academic-setting-forgotten-not-gone
April 27, 2016 - Study
Medication errors with antituberculosis therapy in an inpatient, academic setting: forgotten but not gone.
Citation Text:
Jen SP, Zucker J, Buczynski P, et al. Medication errors with antituberculosis therapy in an inpatient, academic setting: forgotten but not gone. J Clin Pharm Th…
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psnet.ahrq.gov/issue/combined-sna-and-lda-methods-understand-adverse-medical-events
November 15, 2023 - Journal Article
Combined SNA and LDA methods to understand adverse medical events
Citation Text:
Zhu L, Reychav I, McHaney R, et al. Combined SNA and LDA methods to understand adverse medical events. Int J Risk Saf Med. 2019;30(3):129-153. doi:10.3233/JRS-180052.
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Form…
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psnet.ahrq.gov/issue/diagnostic-discordance-uncertainty-and-treatment-ambiguity-community-acquired-pneumonia
June 07, 2023 - Study
Diagnostic discordance, uncertainty, and treatment ambiguity in community-acquired pneumonia: a national cohort study of 115 U.S. Veterans Affairs hospitals.
Citation Text:
Jones BE, Chapman AB, Ying J, et al. Diagnostic discordance, uncertainty, and treatment ambiguity in communit…
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psnet.ahrq.gov/issue/assessment-fidelity-interventions-improve-hand-hygiene-healthcare-workers-systematic-review
June 02, 2019 - Review
Assessment of fidelity in interventions to improve hand hygiene of healthcare workers: a systematic review.
Citation Text:
Musuuza JS, Barker A, Ngam C, et al. Assessment of Fidelity in Interventions to Improve Hand Hygiene of Healthcare Workers: A Systematic Review. Infect Contro…
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psnet.ahrq.gov/issue/performance-variability-perioperative-sentinel-events-report-nationwide-data-set
November 04, 2020 - Study
Performance variability in perioperative sentinel events: report on a nationwide data set.
Citation Text:
Reijmerink IM, Bos K, Leistikow IP, et al. Performance variability in perioperative sentinel events: report on a nationwide data set. Br J Surg. 2022;109(7):573-575. doi:10.109…
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psnet.ahrq.gov/issue/effect-facility-complexity-perceptions-safety-climate-operating-room-size-matters
December 21, 2014 - Study
The effect of facility complexity on perceptions of safety climate in the operating room: size matters.
Citation Text:
Carney BT, West P, Neily J, et al. The effect of facility complexity on perceptions of safety climate in the operating room: size matters. Am J Med Qual. 2010;25…
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psnet.ahrq.gov/node/33731/psn-pdf
June 01, 2012 - came largely from the National Health Service (NHS), which owns
the hospitals and employs all the doctors
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psnet.ahrq.gov/web-mm/its-all-syringe
February 01, 2013 - number of prescriptions are written electronically, although the precise number is not known.( 3 ) While doctors
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psnet.ahrq.gov/perspective/conversation-john-d-birkmeyer-md
January 31, 2024 - JB : Medical students basically get to be the types of doctors they want to be, primarily as a function … individual hospital's credentialing process and from the boards that assessing the quality of individual doctors
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psnet.ahrq.gov/sites/default/files/2023-09/a_missed_bowel_perforation_-_the_importance_of_diagnostic_reasoning.pdf
January 01, 2023 - examination when it was warranted.
14
Diagnostic Failure: The Missing Bedside Examination (1)
• When doctors … Incomplete medical records
– Cultural and language barriers with patients
– Communication barriers between doctors
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psnet.ahrq.gov/node/33748/psn-pdf
April 01, 2013 - That said,
other countries have limited senior doctors' shift duration. … would be that in the States things are
more likely to go that way than mandated work hours for senior doctors
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psnet.ahrq.gov/node/33776/psn-pdf
January 01, 2015 - 04/my-skepticism-about-gms-speak-up-for-safety-program/
I cringe when organizations complain that doctors … Instead of blaming the
doctors, we have a systemic issue where the technology either wasn't selected
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psnet.ahrq.gov/web-mm/urine-tough-position
January 01, 2009 - Urine a Tough Position
Citation Text:
Gandhi TK. Urine a Tough Position. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMe…
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psnet.ahrq.gov/node/49556/psn-pdf
March 01, 2008 - Hold That Order
March 1, 2008
Grissinger M. Hold That Order. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/hold-order
The Case
A 25-year-old woman with a history of a pituitary tumor was admitted with hypernatremia. Because of her
previous pituitary resection and radiation, the patient had a long history …
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psnet.ahrq.gov/web-mm/fatal-error-neonate-does-just-culture-provide-answer
June 24, 2020 - SPOTLIGHT CASE
Fatal Error in Neonate: Does "Just Culture" Provide an Answer?
Citation Text:
Dekker SWA. Fatal Error in Neonate: Does "Just Culture" Provide an Answer?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. …
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psnet.ahrq.gov/node/49872/psn-pdf
August 08, 2019 - Why patients visit their doctors: assessing the most prevalent
conditions in a defined American population
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psnet.ahrq.gov/node/33617/psn-pdf
August 01, 2005 - RW: Could you comment on how nurses and doctors are being trained to improve safety?
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psnet.ahrq.gov/node/33593/psn-pdf
June 15, 2024 - fraction
of adverse events (in hospitals, most
reports are submitted by nurses;
relatively few by doctors