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psnet.ahrq.gov/issue/prescription-errors-and-outcomes-related-inconsistent-information-transmitted-through
April 04, 2011 - Study
Prescription errors and outcomes related to inconsistent information transmitted through computerized order entry: a prospective study.
Citation Text:
Singh H, Mani S, Espadas D, et al. Prescription errors and outcomes related to inconsistent information transmitted through compu…
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psnet.ahrq.gov/issue/systematic-root-cause-analysis-adverse-drug-events-tertiary-referral-hospital
November 16, 2022 - Study
Classic
Systematic root cause analysis of adverse drug events in a tertiary referral hospital.
Citation Text:
Rex JH, Turnbull JE, Allen SJ, et al. Systematic Root Cause Analysis of Adverse Drug Events in a Tertiary Referral Hospital. Jt Comm J Qual Improv…
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psnet.ahrq.gov/issue/changes-safety-attitude-and-relationship-decreased-postoperative-morbidity-and-mortality
May 27, 2010 - Study
Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention.
Citation Text:
Haynes AB, Weiser TG, Berry WR, et al. Changes in safety attitude and relationship to decrease…
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psnet.ahrq.gov/issue/analysis-readmissions-mobile-integrated-health-transitional-care-program-using-root-cause
June 08, 2022 - Study
Analysis of readmissions in a mobile integrated health transitional care program using root cause analysis and common cause analysis.
Citation Text:
Buitrago I, Seidl KL, Gingold DB, et al. Analysis of readmissions in a mobile integrated health transitional care program using root …
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psnet.ahrq.gov/issue/comprehensive-overview-medical-error-hospitals-using-incident-reporting-systems-patient
October 16, 2013 - Study
A comprehensive overview of medical error in hospitals using incident-reporting systems, patient complaints and chart review of inpatient deaths.
Citation Text:
de Feijter JM, de Grave WS, Muijtjens AM, et al. A comprehensive overview of medical error in hospitals using incident-r…
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psnet.ahrq.gov/issue/policy-based-intervention-reduction-communication-breakdowns-inpatient-surgical-care-results
January 04, 2010 - Study
A policy-based intervention for the reduction of communication breakdowns in inpatient surgical care: results from a Harvard surgical safety collaborative.
Citation Text:
Arriaga AF, Elbardissi AW, Regenbogen SE, et al. A policy-based intervention for the reduction of communication…
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psnet.ahrq.gov/issue/exploring-changes-patient-safety-incidents-during-covid-19-pandemic-canadian-regional
March 18, 2020 - Study
Exploring changes in patient safety incidents during the COVID-19 pandemic in a Canadian regional hospital system: a retrospective time series analysis.
Citation Text:
Lombardi J, Strobel S, Pullar V, et al. Exploring changes in patient safety incidents during the COVID-19 pandemic…
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psnet.ahrq.gov/issue/surgical-case-listing-accuracy-failure-analysis-high-volume-academic-medical-center
September 25, 2011 - Study
Surgical case listing accuracy: failure analysis at a high-volume academic medical center.
Citation Text:
Cima RR, Hale C, Kollengode A, et al. Surgical case listing accuracy: failure analysis at a high-volume academic medical center. Arch Surg. 2010;145(7):641-6. doi:10.1001/archs…
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psnet.ahrq.gov/issue/complications-associated-anesthesia-transport-pediatric-patients-analysis-wake-safe-database
February 12, 2020 - Study
Complications associated with the anesthesia transport of pediatric patients: an analysis of the Wake Up Safe database.
Citation Text:
Haydar B, Baetzel A, Stewart M, et al. Complications associated with the anesthesia transport of pediatric patients: an analysis of the Wake Up Saf…
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psnet.ahrq.gov/issue/comprehensive-healthcare-inspection-summary-report-evaluation-mental-health-veterans-health
July 13, 2022 - Book/Report
Comprehensive Healthcare Inspection Summary Report: Evaluation of Mental Health in Veterans Health Administration Facilities, Fiscal Year 2020.
Citation Text:
Comprehensive Healthcare Inspection Summary Report: Evaluation of Mental Health in Veterans Health Administration Fac…
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psnet.ahrq.gov/issue/chief-resident-indirect-supervision-training-safety-study-chief-resident-general-surgery
December 16, 2011 - Study
Chief resident indirect supervision in training safety study: is a chief resident general surgery service safe for patients?
Citation Text:
Speaks L, Helmer SD, Quinn KR, et al. Chief resident indirect supervision in training safety study: is a chief resident general surgery servic…
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psnet.ahrq.gov/issue/differences-between-managers-and-safety-professionals-perceptions-upwards-influence-attempts
December 08, 2021 - Study
Differences between managers’ and safety professionals’ perceptions of upwards influence attempts within safety practice.
Citation Text:
Madigan C, Way KA, Johnstone K, et al. Differences between managers’ and safety professionals’ perceptions of upwards influence attempts within s…
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psnet.ahrq.gov/issue/proactive-risk-avoidance-system-using-failure-mode-and-effects-analysis-same-name-physician
February 23, 2022 - Commentary
A proactive risk avoidance system using failure mode and effects analysis for "same-name" physician orders.
Citation Text:
Tarpey K, Schaaf E, Lakhani U, et al. A proactive risk avoidance system using failure mode and effects analysis for "same-name" physician orders. Jt Comm …
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psnet.ahrq.gov/issue/implicit-bias-and-caring-diverse-populations-pediatric-trainee-attitudes-and-gaps-training
April 22, 2020 - Study
Implicit bias and caring for diverse populations: pediatric trainee attitudes and gaps in training.
Citation Text:
Barber Doucet H, Ward VL, Johnson TJ, et al. Implicit bias and caring for diverse populations: pediatric trainee attitudes and gaps in training. Clin Pediatr (Phila). …
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psnet.ahrq.gov/issue/repeat-prescribing-medications-system-centred-risk-management-model-primary-care
January 20, 2016 - Study
Repeat prescribing of medications: a system-centred risk management model for primary care organisations.
Citation Text:
Price J, Man SL, Bartlett S, et al. Repeat prescribing of medications: A system-centred risk management model for primary care organisations. J Eval Clin Pract. …
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psnet.ahrq.gov/issue/application-aviation-black-box-principle-pediatric-cardiac-surgery-tracking-all-failures
October 07, 2013 - Study
Application of the aviation black box principle in pediatric cardiac surgery: tracking all failures in the pediatric cardiac operating room.
Citation Text:
Bowermaster R, Miller M, Ashcraft T, et al. Application of the aviation black box principle in pediatric cardiac surgery: trac…
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psnet.ahrq.gov/issue/interventions-employed-improve-intrahospital-handover-systematic-review
January 20, 2015 - Review
Interventions employed to improve intrahospital handover: a systematic review.
Citation Text:
Robertson ER, Morgan L, Bird S, et al. Interventions employed to improve intrahospital handover: a systematic review. BMJ Qual Saf. 2014;23(7):600-7. doi:10.1136/bmjqs-2013-002309.
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psnet.ahrq.gov/issue/computerized-prescribing-alerts-and-group-academic-detailing-reduce-use-potentially
July 10, 2008 - Study
Computerized prescribing alerts and group academic detailing to reduce the use of potentially inappropriate medications in older people.
Citation Text:
Simon SR, Smith DH, Feldstein AC, et al. Computerized prescribing alerts and group academic detailing to reduce the use of poten…
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psnet.ahrq.gov/issue/role-informal-dimensions-safety-high-volume-organisational-routines-ethnographic-study-test
August 01, 2018 - Study
The role of informal dimensions of safety in high-volume organisational routines: an ethnographic study of test results handling in UK general practice.
Citation Text:
Grant S, Checkland K, Bowie P, et al. The role of informal dimensions of safety in high-volume organisational rout…
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psnet.ahrq.gov/issue/safety-competency-exploring-impact-environmental-and-personal-factors-nurses-ability-deliver
September 14, 2022 - Study
Safety competency: exploring the impact of environmental and personal factors on the nurse's ability to deliver safe care.
Citation Text:
Dillon-Bleich K, Dolansky MA, Burant CJ, et al. Safety competency: exploring the impact of environmental and personal factors on the nurse's abi…