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psnet.ahrq.gov/node/43596/psn-pdf
December 19, 2014 - The role of the anesthesiologist in perioperative patient
safety.
December 19, 2014
Wacker J, Staender S. The role of the anesthesiologist in perioperative patient safety. Curr Opin
Anaesthesiol. 2014;27(6):649-656. doi:10.1097/ACO.0000000000000124.
https://psnet.ahrq.gov/issue/role-anesthesiologist-perioperative-…
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psnet.ahrq.gov/node/38663/psn-pdf
May 27, 2009 - Prevention of retained surgical sponges: a decision-
analytic model predicting relative cost-effectiveness.
May 27, 2009
Regenbogen SE, Greenberg CC, Resch SC, et al. Prevention of retained surgical sponges: a decision-
analytic model predicting relative cost-effectiveness. Surgery. 2009;145(5):527-35.
doi:10.1016…
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psnet.ahrq.gov/node/34674/psn-pdf
December 23, 2008 - Incidence and preventability of adverse drug events in
hospitalized patients.
December 23, 2008
Bates DW, Leape L, Petrycki S. Incidence and preventability of adverse drug events in hospitalized adults.
J Gen Intern Med. 1993;8(6):289-294.
https://psnet.ahrq.gov/issue/incidence-and-preventability-adverse-drug-even…
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psnet.ahrq.gov/node/73332/psn-pdf
May 26, 2021 - An evolving hospital quality star rating system from CMS:
aligning the stars.
May 26, 2021
Bilimoria KY, Barnard C. An evolving hospital quality star rating system from CMS: aligning the stars.
JAMA. 2021;325(21):2151-2152. doi:10.1001/jama.2021.6946.
https://psnet.ahrq.gov/issue/evolving-hospital-quality-star-rat…
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psnet.ahrq.gov/issue/characteristics-and-predictors-missed-opportunities-lung-cancer-diagnosis-electronic-health
January 19, 2012 - October 31, 2014
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/diagnostic-errors-musculoskeletal-oncology-and-possible-mitigation-strategies
May 01, 2013 - December 27, 2014
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/big-dog-effect-variability-assessing-causes-error-diagnoses-patients-lung-cancer
March 28, 2012 - April 9, 2013
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/patient-safety-leadership-academy-university-pennsylvania-first-cohorts-learning-experience
October 04, 2011 - June 18, 2013
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/missed-lesions-abdominal-oncologic-ct-lessons-learned-quality-assurance
April 21, 2011 - October 4, 2011
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/delayed-or-missed-diagnosis-cervical-spine-injuries
May 05, 2010 - October 31, 2014
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/evaluation-12-strategies-obtaining-second-opinions-improve-interpretation-breast
November 03, 2015 - April 9, 2013
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/computer-alert-system-prevent-injury-adverse-drug-events-development-and-evaluation-community
November 01, 2016 - Study
Classic
A computer alert system to prevent injury from adverse drug events: development and evaluation in a community teaching hospital.
Citation Text:
Raschke RA, Gollihare B, Wunderlich TA, et al. A Computer Alert System to Prevent Injury From Adverse …
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psnet.ahrq.gov/issue/hospital-board-and-management-practices-are-strongly-related-hospital-performance-clinical
October 27, 2021 - Study
Classic
Hospital board and management practices are strongly related to hospital performance on clinical quality metrics.
Citation Text:
Tsai TC, Jha AK, Gawande AA, et al. Hospital board and management practices are strongly related to hospital performanc…
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psnet.ahrq.gov/innovation/esimpler-dynamic-electronic-health-record-integrated-checklist-clinical-decision-support
June 16, 2021 - EMERGING INNOVATIONS
eSIMPLER: a dynamic, electronic health record-integrated checklist for clinical decision support during PICU daily rounds.
Citation Text:
Geva A, Albert BD, Hamilton S, et al. eSIMPLER: a dynamic, electronic health record-integrated checklist for clinical decision support duri…
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psnet.ahrq.gov/innovation/pharmacist-led-mobile-health-intervention-and-transplant-medication-safety-randomized
April 07, 2021 - EMERGING INNOVATIONS
Pharmacist-led mobile health intervention and transplant medication safety: a randomized controlled clinical trial.
Citation Text:
Gonzales HM, Fleming JN, Gebregziabher M, et al. Pharmacist-led mobile health intervention and transplant medication safety: a randomized controll…
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psnet.ahrq.gov/node/46952/psn-pdf
January 01, 2019 - Perspectives on patient and family engagement with
reduction in harm: the forgotten voice.
December 21, 2018
Schenk EC, Bryant RA, Van Son CR, et al. Perspectives on Patient and Family Engagement With
Reduction in Harm: The Forgotten Voice. J Nurs Care Qual. 2019;34(1):73-79.
doi:10.1097/NCQ.0000000000000333.
htt…
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psnet.ahrq.gov/node/74704/psn-pdf
January 26, 2022 - Improving self-reported empathy and communication
skills through harm in healthcare response training.
January 26, 2022
Samuels A, Broome ME, McDonald TB, et al. Improving self-reported empathy and communication skills
through harm in healthcare response training. J Patient Saf Risk Manage. 2021;26(6):251-260.
doi…
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psnet.ahrq.gov/node/854383/psn-pdf
January 01, 2024 - What can safety cases offer for patient safety? A multisite
case study.
October 11, 2023
Liberati EG, Martin GP, Lamé G, et al. What can Safety Cases offer for patient safety? A multisite case
study. BMJ Qual Saf. 2024;33(3):156-165. doi:10.1136/bmjqs-2023-016042.
https://psnet.ahrq.gov/issue/what-can-safety-cases…
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psnet.ahrq.gov/node/38027/psn-pdf
October 15, 2008 - Assessing the Evidence Base for Context-Sensitive
Effectiveness and Safety of Patient Safety Practices:
Developing Criteria.
October 15, 2008
US Department of Health and Human Services; HHS; Agency for Healthcare Research and Quality; AHRQ.
https://psnet.ahrq.gov/issue/assessing-evidence-base-context-sensitive-eff…
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psnet.ahrq.gov/node/36888/psn-pdf
November 30, 2016 - Hospital Survey on Patient Safety Culture: 2007
Comparative Database Report.
November 30, 2016
Sorra J, Nieva V, Famolaro T, et al. Rockville, MD: Agency for Healthcare; 2007. AHRQ publication, no. 07-
0025.
https://psnet.ahrq.gov/issue/hospital-survey-patient-safety-culture-2007-comparative-database-report
A key…