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Implementation of a mock root cause analysis to provide simulated patient safety training. | PSNet

psnet.ahrq.gov/issue/implementation-mock-root-cause-analysis-provide-simulated-patient-safety-training

January 12, 2022 - Commentary Implementation of a mock root cause analysis to provide simulated patient safety training. Citation Text: Murphy M, Duff J, Whitney J, et al. Implementation of a mock root cause analysis to provide simulated patient safety training. BMJ Open Qual. 2017;6(2). doi:10.1136/bmjoq-…

ACGME Summary Report: The Pursuing Excellence Pathway Leaders Patient Safety Collaborative. | PSNet

psnet.ahrq.gov/issue/acgme-summary-report-pursuing-excellence-pathway-leaders-patient-safety-collaborative

October 18, 2017 - Book/Report ACGME Summary Report: The Pursuing Excellence Pathway Leaders Patient Safety Collaborative. Citation Text: ACGME Summary Report: The Pursuing Excellence Pathway Leaders Patient Safety Collaborative. Passiment M, Wagner R, Weiss KB for the Pursuing Excellence in Clinical Learn…

Conversations on diagnostic uncertainty and its management among pediatric acute care physicians. | PSNet

psnet.ahrq.gov/issue/conversations-diagnostic-uncertainty-and-its-management-among-pediatric-acute-care-physicians

March 17, 2021 - Study Conversations on diagnostic uncertainty and its management among pediatric acute care physicians. Citation Text: Patel SJ, Ipsaro A, Brady PW. Conversations on diagnostic uncertainty and its management among pediatric acute care physicians. Hosp Pediatr. 2022;12(3):317-324. doi:10.…

Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010–2011. | PSNet

psnet.ahrq.gov/issue/prevalence-inappropriate-antibiotic-prescriptions-among-us-ambulatory-care-visits-2010-2011

November 12, 2014 - Study Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010–2011. Citation Text: Fleming-Dutra KE, Hersh AL, Shapiro DJ, et al. Prevalence of Inappropriate Antibiotic Prescriptions Among US Ambulatory Care Visits, 2010-2011. JAMA. 2016;315(17):1864-18…

Chemotherapy medication errors in a pediatric cancer treatment center: prospective characterization of error types and frequency and development of a quality improvement initiative to lower the error rate. | PSNet

psnet.ahrq.gov/issue/chemotherapy-medication-errors-pediatric-cancer-treatment-center-prospective-characterization

January 22, 2017 - Study Chemotherapy medication errors in a pediatric cancer treatment center: prospective characterization of error types and frequency and development of a quality improvement initiative to lower the error rate. Citation Text: Watts RG, Parsons K. Chemotherapy medication errors in a pe…

Development of "SWARM" as a model for high reliability, rapid problem solving, and institutional learning. | PSNet

psnet.ahrq.gov/issue/development-swarm-model-high-reliability-rapid-problem-solving-and-institutional-learning

November 16, 2022 - Commentary Development of "SWARM" as a model for high reliability, rapid problem solving, and institutional learning. Citation Text: Williams EA, Nikolai DA, Ladwig L, et al. Development of "SWARM" as a Model for High Reliability, Rapid Problem Solving, and Institutional Learning. Jt Com…

Measuring teamwork in health care settings: a review of survey instruments. | PSNet

psnet.ahrq.gov/issue/measuring-teamwork-health-care-settings-review-survey-instruments

December 14, 2016 - Review Measuring teamwork in health care settings: a review of survey instruments. Citation Text: Valentine MA, Nembhard IM, Edmondson A. Measuring teamwork in health care settings: a review of survey instruments. Med Care. 2015;53(4):e16-e30. doi:10.1097/MLR.0b013e31827feef6. Copy Cit…

Facing ambiguous threats. | PSNet

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December 24, 2008 - Commentary Facing ambiguous threats. Citation Text: Roberto MA, Bohmer RMJ, Edmondson A. Facing ambiguous threats. Harv Bus Rev. 2006;84(11):106-13, 157. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

Impact of pharmacist-provided medication therapy management on healthcare quality and utilization in recently discharged elderly patients. | PSNet

psnet.ahrq.gov/issue/impact-pharmacist-provided-medication-therapy-management-healthcare-quality-and-utilization

November 16, 2022 - Study Impact of pharmacist-provided medication therapy management on healthcare quality and utilization in recently discharged elderly patients. Citation Text: Haag JD, Davis AZ, Hoel RW, et al. Impact of Pharmacist-Provided Medication Therapy Management on Healthcare Quality and Utiliza…

Bad behavior in healthcare: an insidious threat to patients, staff, and organizations. | PSNet

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October 16, 2019 - Commentary Bad behavior in healthcare: an insidious threat to patients, staff, and organizations. Citation Text: Crowe L, Riley CM. Bad behavior in healthcare: an insidious threat to patients, staff, and organizations. Curr Opin Cardiol. 2024;39(4):331-337. doi:10.1097/hco.00000000000011…

Effective followership: a standardized algorithm to resolve clinical conflicts and improve teamwork. | PSNet

psnet.ahrq.gov/issue/effective-followership-standardized-algorithm-resolve-clinical-conflicts-and-improve-teamwork

March 13, 2013 - Commentary Effective followership: a standardized algorithm to resolve clinical conflicts and improve teamwork. Citation Text: Sculli GL, Fore AM, Sine DM, et al. Effective followership: A standardized algorithm to resolve clinical conflicts and improve teamwork. J Healthc Risk Manag. 20…

Factors contributing to preventing operating room "never events": a machine learning analysis. | PSNet

psnet.ahrq.gov/issue/factors-contributing-preventing-operating-room-never-events-machine-learning-analysis

July 26, 2023 - Study Factors contributing to preventing operating room "never events": a machine learning analysis. Citation Text: Arad D, Rosenfeld A, Magnezi R. Factors contributing to preventing operating room “never events”: a machine learning analysis. Patient Saf Surg. 2023;17(1):6. doi:10.1186/s…

Using computerized virtual cases to explore diagnostic error in practicing physicians. | PSNet

psnet.ahrq.gov/issue/using-computerized-virtual-cases-explore-diagnostic-error-practicing-physicians

August 20, 2018 - Study Using computerized virtual cases to explore diagnostic error in practicing physicians. Citation Text: Trowbridge RL, Reilly JB, Clauser JC, et al. Using computerized virtual cases to explore diagnostic error in practicing physicians. Diagnosis (Berl). 2018;5(4):229-233. doi:10.1515…

Misunderstanding of prescription drug warning labels among patients with low literacy. | PSNet

psnet.ahrq.gov/issue/misunderstanding-prescription-drug-warning-labels-among-patients-low-literacy

February 28, 2011 - Study Misunderstanding of prescription drug warning labels among patients with low literacy. Citation Text: Wolf MS, Davis TC, Tilson HH, et al. Misunderstanding of prescription drug warning labels among patients with low literacy. Am J Health Syst Pharm. 2006;63(11):1048-55. Copy Ci…

Resilience and regulation, an odd couple? Consequences of Safety-II on governmental regulation of healthcare quality. | PSNet

psnet.ahrq.gov/issue/resilience-and-regulation-odd-couple-consequences-safety-ii-governmental-regulation

October 06, 2021 - Commentary Resilience and regulation, an odd couple? Consequences of Safety-II on governmental regulation of healthcare quality. Citation Text: Leistikow I, Bal RA. Resilience and regulation, an odd couple? Consequences of Safety-II on governmental regulation of healthcare quality. BMJ Q…

Sharing lessons learned to prevent incorrect surgery. | PSNet

psnet.ahrq.gov/issue/sharing-lessons-learned-prevent-incorrect-surgery

July 16, 2015 - Study Sharing lessons learned to prevent incorrect surgery. Citation Text: Neily J, Mills PD, Paull DE, et al. Sharing lessons learned to prevent incorrect surgery. Am Surg. 2012;78(11):1276-1280. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7…

Root cause analysis of reported patient falls in ORs in the Veterans Health Administration. | PSNet

psnet.ahrq.gov/issue/root-cause-analysis-reported-patient-falls-ors-veterans-health-administration

January 17, 2019 - Commentary Root cause analysis of reported patient falls in ORs in the Veterans Health Administration. Citation Text: Soncrant CM, Warner LJ, Neily J, et al. Root Cause Analysis of Reported Patient Falls in ORs in the Veterans Health Administration. AORN J. 2018;108(4):386-397. doi:10.10…

Systematic review of intraoperative anesthesia handoffs and handoff tools. | PSNet

psnet.ahrq.gov/issue/systematic-review-intraoperative-anesthesia-handoffs-and-handoff-tools

March 10, 2021 - Review Systematic review of intraoperative anesthesia handoffs and handoff tools. Citation Text: Abraham J, Pfeifer E, Doering M, et al. Systematic review of intraoperative anesthesia handoffs and handoff tools. Anesth Analg. 2021;132(6):1563-1575. doi:10.1213/ane.0000000000005367. Cop…

Integrating the intensive care unit safety reporting system with existing incident reporting systems. | PSNet

psnet.ahrq.gov/issue/integrating-intensive-care-unit-safety-reporting-system-existing-incident-reporting-systems

January 12, 2011 - Study Integrating the intensive care unit safety reporting system with existing incident reporting systems. Citation Text: Thompson DA, Lubomski LH, Holzmueller CG, et al. Integrating the intensive care unit safety reporting system with existing incident reporting systems. Jt Comm J Qual…

Negative behaviours in health care: prevalence and strategies. | PSNet

psnet.ahrq.gov/issue/negative-behaviours-health-care-prevalence-and-strategies

May 01, 2024 - Study Negative behaviours in health care: prevalence and strategies. Citation Text: Layne DM, Nemeth LS, Mueller M, et al. Negative behaviours in health care: Prevalence and strategies. J Nurs Manag. 2019;27(1):154-160. doi:10.1111/jonm.12660. Copy Citation Format: DOI Goog…

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