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  1. Tracking intraoperative complications. | PSNet

    psnet.ahrq.gov/issue/tracking-intraoperative-complications
    April 30, 2014 - Study Tracking intraoperative complications. Citation Text: Platz J, Hyman N. Tracking intraoperative complications. J Am Coll Surg. 2012;215(4):519-23. doi:10.1016/j.jamcollsurg.2012.06.001. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 …

  2. Missed injuries in trauma patients: a literature review. | PSNet

    psnet.ahrq.gov/issue/missed-injuries-trauma-patients-literature-review
    April 01, 2009 - Review Missed injuries in trauma patients: a literature review. Citation Text: Pfeifer R, Pape H-C. Missed injuries in trauma patients: A literature review. Patient Saf Surg. 2008;2:20. doi:10.1186/1754-9493-2-20. Copy Citation Format: DOI Google Scholar PubMed BibTeX End…

  3. Remembering to learn: the overlooked role of remembrance in safety improvement. | PSNet

    psnet.ahrq.gov/issue/remembering-learn-overlooked-role-remembrance-safety-improvement
    February 28, 2024 - Commentary Remembering to learn: the overlooked role of remembrance in safety improvement. Citation Text: Macrae C. Remembering to learn: the overlooked role of remembrance in safety improvement. BMJ Qual Saf. 2017;26(8):678-682. doi:10.1136/bmjqs-2016-005547. Copy Citation Format:…

  4. Keeping patients safe in healthcare organizations: a structuration theory of safety culture. | PSNet

    psnet.ahrq.gov/issue/keeping-patients-safe-healthcare-organizations-structuration-theory-safety-culture
    September 04, 2010 - Review Keeping patients safe in healthcare organizations: a structuration theory of safety culture. Citation Text: Groves PS, Meisenbach RJ, Scott-Cawiezell J. Keeping patients safe in healthcare organizations: a structuration theory of safety culture. J Adv Nurs. 2011;67(8):1846-55. d…

  5. Advancing Diagnostic Excellence for Older Adults: Proceedings of a Workshop in Brief. | PSNet

    psnet.ahrq.gov/issue/advancing-diagnostic-excellence-older-adults-proceedings-workshop-brief
    April 20, 2022 - Book/Report Advancing Diagnostic Excellence for Older Adults: Proceedings of a Workshop in Brief. Citation Text: Advancing Diagnostic Excellence for Older Adults: Proceedings of a Workshop in Brief.  National Academies of Sciences, Engineering, and Medicine. Washington, DC: The…

  6. Safety strategies in an academic radiation oncology department and recommendations for action. | PSNet

    psnet.ahrq.gov/issue/safety-strategies-academic-radiation-oncology-department-and-recommendations-action
    January 16, 2013 - Commentary Safety strategies in an academic radiation oncology department and recommendations for action. Citation Text: Terezakis SA, Pronovost P, Harris K, et al. Safety strategies in an academic radiation oncology department and recommendations for action. Jt Comm J Qual Patient Saf. …

  7. Dangers and deaths around black pregnancies seen as a ‘completely preventable’ health crisis. | PSNet

    psnet.ahrq.gov/issue/dangers-and-deaths-around-black-pregnancies-seen-completely-preventable-health-crisis
    August 16, 2023 - Newspaper/Magazine Article Dangers and deaths around black pregnancies seen as a ‘completely preventable’ health crisis. Citation Text: Dangers and deaths around black pregnancies seen as a ‘completely preventable’ health crisis. West S. KFF Health News. August 24, 2023. Copy Citatio…

  8. Mistakes, Errors and Failures across Cultures. | PSNet

    psnet.ahrq.gov/issue/mistakes-errors-and-failures-across-cultures-navigating-potentials
    January 20, 2021 - Book/Report Mistakes, Errors and Failures across Cultures. Citation Text: Mistakes, Errors and Failures across Cultures. Vanderheiden E, Mayer C, eds. Springer Nature. Cham, Switzerland: 2020. ISBN 9783030355739 Copy Citation Save Save to your library P…

  9. Recent Evidence That Health IT Improves Patient Safety: Issue Brief. | PSNet

    psnet.ahrq.gov/issue/recent-evidence-health-it-improves-patient-safety-issue-brief
    June 29, 2016 - Book/Report Recent Evidence That Health IT Improves Patient Safety: Issue Brief. Citation Text: Recent Evidence That Health IT Improves Patient Safety: Issue Brief. Banger A, Graber ML. Washington, DC: Office of the National Coordinator for Health Information Technology; February 2015. …

  10. Organizational Learning from Experience in High-Hazard Industries: Problem Investigations as Off-line Reflective Practice. | PSNet

    psnet.ahrq.gov/issue/organizational-learning-experience-high-hazard-industries-problem-investigations-line
    May 24, 2016 - Book/Report Organizational Learning from Experience in High-Hazard Industries: Problem Investigations as Off-line Reflective Practice. Citation Text: Organizational Learning from Experience in High-Hazard Industries: Problem Investigations as Off-line Reflective Practice. Carroll JS, R…

  11. Public reporting of surgical outcomes: surgeons, hospitals, or both? | PSNet

    psnet.ahrq.gov/issue/public-reporting-surgical-outcomes-surgeons-hospitals-or-both
    April 05, 2013 - Commentary Public reporting of surgical outcomes: surgeons, hospitals, or both? Citation Text: Jha AK. Public Reporting of Surgical Outcomes: Surgeons, Hospitals, or Both? JAMA. 2017;318(15):1429-1430. doi:10.1001/jama.2017.13815. Copy Citation Format: DOI Google Scholar Pu…

  12. Improving process while changing practice: FMEA and medication administration. | PSNet

    psnet.ahrq.gov/issue/improving-process-while-changing-practice-fmea-and-medication-administration
    January 18, 2011 - Commentary Improving process while changing practice: FMEA and medication administration. Citation Text: Riehle MA, Bergeron D, Hyrkäs K. Improving process while changing practice. Nurs Manage. 2009;39(2). doi:10.1097/01.numa.0000310533.54708.38. Copy Citation Format: DOI…

  13. Human reliability analysis: a critique and review for managers. | PSNet

    psnet.ahrq.gov/issue/human-reliability-analysis-critique-and-review-managers
    November 21, 2021 - Review Human reliability analysis: a critique and review for managers. Citation Text: French S, Bedford T, Pollard SJT, et al. Human reliability analysis: A critique and review for managers. Saf Sci. 2011;49(6). doi:10.1016/j.ssci.2011.02.008. Copy Citation Format: DOI Go…

  14. Evaluation of the Patient Safety Improvement Corps: Experiences of the First Two Groups of Trainees. | PSNet

    psnet.ahrq.gov/issue/evaluation-patient-safety-improvement-corps-experiences-first-two-groups-trainees
    May 21, 2014 - Book/Report Evaluation of the Patient Safety Improvement Corps: Experiences of the First Two Groups of Trainees. Citation Text: Evaluation of the Patient Safety Improvement Corps: Experiences of the First Two Groups of Trainees. Teleki S, Santa Monica, CA: RAND Corporation; 2006. ISBN: 9…

  15. Getting to the root of medication errors. | PSNet

    psnet.ahrq.gov/issue/getting-root-medication-errors
    March 21, 2009 - Study Getting to the root of medication errors. Citation Text: Cohen H, Shastay AD. Getting to the root of medication errors. Nursing (Brux). 2008;38(12):39-49. doi:10.1097/01.NURSE.0000342031.85246.a1. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML…

  16. Breaking the rules: understanding non-compliance with policies and guidelines. | PSNet

    psnet.ahrq.gov/issue/breaking-rules-understanding-non-compliance-policies-and-guidelines
    September 24, 2018 - Commentary Breaking the rules: understanding non-compliance with policies and guidelines. Citation Text: Carthey J, Walker S, Deelchand V, et al. Breaking the rules: understanding non-compliance with policies and guidelines. BMJ. 2011;343:d5283. doi:10.1136/bmj.d5283. Copy Citation …

  17. Physician perception of hospital safety and barriers to incident reporting. | PSNet

    psnet.ahrq.gov/issue/physician-perception-hospital-safety-and-barriers-incident-reporting
    February 16, 2011 - Study Physician perception of hospital safety and barriers to incident reporting. Citation Text: Schectman JM, Plews-Ogan M. Physician perception of hospital safety and barriers to incident reporting. Jt Comm J Qual Patient Saf. 2006;32(6):337-43. Copy Citation Format: Goog…

  18. Errors and adverse events in otolaryngology. | PSNet

    psnet.ahrq.gov/issue/errors-and-adverse-events-otolaryngology
    October 27, 2010 - Review Errors and adverse events in otolaryngology. Citation Text: Shah RK, Roberson DW, Healy GB. Errors and adverse events in otolaryngology. Curr Opin Otolaryngol Head Neck Surg. 2006;14(3):164-9. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNot…

  19. Measuring safety culture in healthcare: a case for accurate diagnosis. | PSNet

    psnet.ahrq.gov/issue/measuring-safety-culture-healthcare-case-accurate-diagnosis
    May 29, 2014 - Commentary Measuring safety culture in healthcare: a case for accurate diagnosis. Citation Text: Flin R. Measuring safety culture in healthcare: A case for accurate diagnosis. Saf Sci. 2007;45(6). doi:10.1016/j.ssci.2007.04.003. Copy Citation Format: DOI Google Scholar …

  20. Adverse Events in Hospitals: Methods for Identifying Events. | PSNet

    psnet.ahrq.gov/issue/adverse-events-hospitals-methods-identifying-events
    February 18, 2009 - Book/Report Adverse Events in Hospitals: Methods for Identifying Events. Citation Text: Adverse Events in Hospitals: Methods for Identifying Events. Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; March 2010. Report No. OEI-06…
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