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psnet.ahrq.gov/issue/impact-percentage-overlapping-surgery-patient-outcomes-retrospective-cohort-study-87000
February 22, 2019 - Review
Impact of the percentage of overlapping surgery on patient outcomes: a retrospective cohort study of 87,000 surgical cases.
Citation Text:
Pitts CC, Ponce BA, Arguello AM, et al. Impact of the percentage of overlapping surgery on patient outcomes: a retrospective cohort study of 8…
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psnet.ahrq.gov/issue/safe-patient-flow-initiative-collaborative-quality-improvement-journey-yale-new-haven
June 07, 2023 - Study
The Safe Patient Flow Initiative: a collaborative quality improvement journey at Yale-New Haven Hospital.
Citation Text:
Jweinat J, Damore P, Morris V, et al. The safe patient flow initiative: a collaborative quality improvement journey at Yale-New Haven Hospital. Jt Comm J Q…
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psnet.ahrq.gov/issue/parent-engagement-perinatal-mortality-reviews-online-survey-clinicians-six-high-income
April 13, 2022 - Study
Parent engagement in perinatal mortality reviews: an online survey of clinicians from six high-income countries.
Citation Text:
Boyle FM, Horey D, Siassakos D, et al. Parent engagement in perinatal mortality reviews: an online survey of clinicians from six high‐income countries. BJ…
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psnet.ahrq.gov/issue/incidence-and-characteristics-errors-detected-short-team-briefing-pediatric-anesthesia
September 30, 2020 - Study
Incidence and characteristics of errors detected by a short team briefing in pediatric anesthesia.
Citation Text:
Keil O, Brunsmann K, Boethig D, et al. Incidence and characteristics of errors detected by a short team briefing in pediatric anesthesia. Paediatr Anaesth. 2022;32(10):…
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psnet.ahrq.gov/issue/my-five-moments-hand-hygiene-user-centred-design-approach-understand-train-monitor-and-report
September 09, 2020 - Commentary
'My five moments for hand hygiene': a user-centred design approach to understand, train, monitor and report hand hygiene.
Citation Text:
Sax H, Allegranzi B, Uçkay I, et al. 'My five moments for hand hygiene': a user-centred design approach to understand, train, monitor and …
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psnet.ahrq.gov/issue/accuracy-medication-documentation-hospital-discharge-summaries-retrospective-analysis
March 23, 2012 - Study
Accuracy of medication documentation in hospital discharge summaries: a retrospective analysis of medication transcription errors in manual and electronic discharge summaries.
Citation Text:
Callen J, McIntosh J, Li J. Accuracy of medication documentation in hospital discharge su…
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psnet.ahrq.gov/issue/approaches-improving-patient-safety-integrated-care-scoping-review
May 18, 2022 - Review
Approaches to improving patient safety in integrated care: a scoping review.
Citation Text:
Lalani M, Wytrykowski S, Hogan H. Approaches to improving patient safety in integrated care: a scoping review. BMJ Open. 2023;13(4):e067441. doi:10.1136/bmjopen-2022-067441.
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psnet.ahrq.gov/issue/technology-related-safety-event-analysis-community-clinical-informatics-case-study
April 03, 2024 - Commentary
Technology-related safety event analysis in community clinical informatics: a case study.
Citation Text:
Recsky C, Stowe M, Rush KL, et al. Technology-related safety event analysis in community clinical informatics: a case study. Stud Health Technol Inform. 2024;315:452-457. d…
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psnet.ahrq.gov/issue/medicine-self-administration-errors-older-adult-population-systematic-review
August 18, 2021 - Review
Medicine self-administration errors in the older adult population: a systematic review.
Citation Text:
Aldila F, Walpola RL. Medicine self-administration errors in the older adult population: a systematic review. Res Social Adm Pharm. 2021;17(11):1877-1886. doi:10.1016/j.sapharm.2…
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psnet.ahrq.gov/issue/cost-opioid-related-adverse-drug-events
August 30, 2017 - Review
The cost of opioid–related adverse drug events.
Citation Text:
Kane-Gill SL, Rubin EC, Smithburger PL, et al. The cost of opioid-related adverse drug events. J Pain Palliat Care Pharmacother. 2014;28(3):282-93. doi:10.3109/15360288.2014.938889.
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psnet.ahrq.gov/issue/pathology-trainees-rarely-report-safety-incidents-review-13722-safety-reports-and-call-action
September 15, 2021 - Study
Pathology trainees rarely report safety incidents: a review of 13,722 safety reports and a call to action.
Citation Text:
Harris CK, Chen Y, Yarsky B, et al. Pathology trainees rarely report safety incidents: a review of 13,722 safety reports and a call to action. Acad Pathol. 2022…
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psnet.ahrq.gov/issue/how-do-no-harm-empowering-local-leaders-make-care-safer-low-resource-settings
March 03, 2021 - Commentary
How to do no harm: empowering local leaders to make care safer in low-resource settings.
Citation Text:
Vincent CA, Mboga M, Gathara D, et al. How to do no harm: empowering local leaders to make care safer in low-resource settings. Arch Dis Child. 2021;106(4):333-337. doi:10.1…
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psnet.ahrq.gov/issue/standardisation-handoffs-large-academic-paediatric-emergency-department-using-i-pass
October 21, 2020 - Study
The standardisation of handoffs in a large academic paediatric emergency department using I-PASS.
Citation Text:
Chladek MS, Doughty C, Patel B, et al. The Standardisation of handoffs in a large academic paediatric emergency department using I-PASS. BMJ Open Qual. 2021;10(3):e00125…
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psnet.ahrq.gov/issue/evaluation-preoperative-checklist-and-team-briefing-among-surgeons-nurses-and
August 28, 2013 - Study
Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication.
Citation Text:
Lingard LA. Evaluation of a Preoperative Checklist and Team Briefing Among Surgeons, Nurses, and Anesthesiologists to Reduce Fa…
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psnet.ahrq.gov/issue/high-reliability-organisation-principles-implemented-dentistry
April 06, 2022 - Commentary
High-reliability organisation principles implemented in dentistry.
Citation Text:
Minyé HM, Benjamin EM. High-reliability organisation principles implemented in dentistry. Br Dent J. 2022;232(12):879-885. doi:10.1038/s41415-022-4354-z.
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psnet.ahrq.gov/issue/building-patient-trust-hospitals-combination-hospital-related-factors-and-health-care
April 14, 2021 - Study
Building patient trust in hospitals: a combination of hospital-related factors and health care clinician behaviors.
Citation Text:
Greene J, Samuel-Jakubos H. Building patient trust in hospitals: a combination of hospital-related factors and health care clinician behaviors. Jt Comm…
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psnet.ahrq.gov/issue/incident-reporting-systems-what-will-it-take-make-them-less-frustrating-and-achieve-anything
November 03, 2021 - Commentary
Incident reporting systems: what will it take to make them less frustrating and achieve anything useful?
Citation Text:
Shojania KG. Incident reporting systems: what will it take to make them less frustrating and achieve anything useful? Jt Comm J Qual Patient Saf. 2021;47(12)…
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psnet.ahrq.gov/issue/racial-implicit-bias-and-communication-among-physicians-simulated-environment
October 19, 2022 - Study
Racial implicit bias and communication among physicians in a simulated environment.
Citation Text:
Gonzalez CM, Ark TK, Fisher MR, et al. Racial implicit bias and communication among physicians in a simulated environment. JAMA Netw Open. 2024;7(3):e242181. doi:10.1001/jamanetworkop…
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-hit-hie-rev-0724update.pdf
July 01, 2024 - collection of work have achieved their aims with varied outcomes
but have collectively produced:
■ An enhanced … project concluded that
barcode/eMAR technology shows great promise combined with a CPOE system with
enhanced
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www.ahrq.gov/sites/default/files/2024-12/weinger2-report.pdf
January 01, 2024 - theories support the notion that understanding and improving process is critical to
error reduction and enhanced … because most NRE will usually not be associated with any obvious error or
injury, reporting may be enhanced