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psnet.ahrq.gov/issue/dynamic-risk-management-approach-reducing-harm-invasive-bedside-procedures-performed-during
April 13, 2022 - Commentary
A dynamic risk management approach for reducing harm from invasive bedside procedures performed during residency.
Citation Text:
Warm E, Ahmad Y, Kinnear B, et al. A dynamic risk management approach for reducing harm from invasive bedside procedures performed during residency.…
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psnet.ahrq.gov/issue/ask-me-routine-measurement-patient-experience-patient-safety-ambulatory-care-mixed-mode
April 14, 2021 - Study
ASK ME!-Routine measurement of patient experience with patient safety in ambulatory care: a mixed-mode survey
Citation Text:
Stahl K, Groene O. ASK ME!—Routine measurement of patient experience with patient safety in ambulatory care: A mixed-mode survey. PLoS ONE. 2021;16(12):e0259…
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psnet.ahrq.gov/issue/patient-safety-begins-proper-planning-quantitative-method-improve-hospital-design
July 19, 2023 - Study
Patient safety begins with proper planning: a quantitative method to improve hospital design.
Citation Text:
Birnbach DJ, Nevo I, Scheinman SR, et al. Patient safety begins with proper planning: a quantitative method to improve hospital design. Qual Saf Health Care. 2010;19(5):46…
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psnet.ahrq.gov/issue/weekend-and-night-outcomes-statewide-trauma-system
November 16, 2022 - Study
Weekend and night outcomes in a statewide trauma system.
Citation Text:
Carr BG, Reilly PM, Schwab W, et al. Weekend and night outcomes in a statewide trauma system. Arch Surg. 2011;146(7):810-7. doi:10.1001/archsurg.2011.60.
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psnet.ahrq.gov/issue/second-victim-unanticipated-adverse-events
February 12, 2020 - Commentary
The second victim of unanticipated adverse events.
Citation Text:
Chen S, Skidmore S, Ferrigno BN, et al. The second victim of unanticipated adverse events. J Thorac Cardiovasc Surg. 2023;166(3):890-894. doi:10.1016/j.jtcvs.2022.09.010.
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psnet.ahrq.gov/issue/review-healthcare-failure-mode-and-effects-analysis-hfmea-radiotherapy
June 13, 2011 - Review
A review of healthcare failure mode and effects analysis (HFMEA) in radiotherapy.
Citation Text:
Giardina M, Cantone MC, Tomarchio E, et al. A Review of Healthcare Failure Mode and Effects Analysis (HFMEA) in Radiotherapy. Health Phys. 2016;111(4):317-26. doi:10.1097/HP.0000000000…
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psnet.ahrq.gov/issue/who-applies-intervention-influence-cultural-attributes-quality-improvement-collaborative
January 22, 2016 - Study
Who applies an intervention to influence cultural attributes in a quality improvement collaborative?
Citation Text:
Hsu Y-J, Marsteller JA. Who Applies an Intervention to Influence Cultural Attributes in a Quality Improvement Collaborative? J Patient Saf. 2020;16(1):1-6.
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psnet.ahrq.gov/issue/accuracy-send-out-test-ordering-college-american-pathologists-q-probes-study-ordering
November 12, 2008 - Study
Accuracy of send-out test ordering: a College of American Pathologists Q-Probes study of ordering accuracy in 97 clinical laboratories.
Citation Text:
Valenstein PN, Walsh MK, Stankovic AK. Accuracy of send-out test ordering: a College of American Pathologists Q-Probes study of o…
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psnet.ahrq.gov/issue/residents-numeric-inputting-error-computerized-physician-order-entry-prescription
March 24, 2019 - Study
Residents' numeric inputting error in computerized physician order entry prescription.
Citation Text:
Wu X, Wu C, Zhang K, et al. Residents' numeric inputting error in computerized physician order entry prescription. Int J Med Inform. 2016;88:25-33. doi:10.1016/j.ijmedinf.2016.01.0…
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www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/implementation-guides/implementation-guide1/impguide1ref.html
March 01, 2019 - Endnotes
Implementation Guide Number 1
This Implementation Guide includes suggested steps and tips for implementing initiatives for improving child health care quality from the CMS-funded national evaluation of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) Quality Demonstration …
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psnet.ahrq.gov/issue/struggling-invent-high-reliability-organizations-health-care-settings-insights-field
October 02, 2019 - Study
Struggling to invent high-reliability organizations in health care settings: insights from the field.
Citation Text:
Dixon NM, Shofer M. Struggling to invent high-reliability organizations in health care settings: Insights from the field. Health Serv Res. 2006;41(4 Pt 2):1618-32.…
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psnet.ahrq.gov/issue/can-patients-report-patient-safety-incidents-hospital-setting-systematic-review
December 21, 2016 - Review
Can patients report patient safety incidents in a hospital setting? A systematic review.
Citation Text:
Ward JK, Armitage G. Can patients report patient safety incidents in a hospital setting? A systematic review. BMJ Qual Saf. 2012;21(8):685-99. doi:10.1136/bmjqs-2011-000213.
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psnet.ahrq.gov/issue/bone-break-hot-debrief-tool-reduce-second-victim-syndrome-nurses
August 02, 2015 - Study
BONE break: a hot debrief tool to reduce second victim syndrome for nurses.
Citation Text:
Hess A, Flicek T, Watral AT, et al. BONE break: a hot debrief tool to reduce second victim syndrome for nurses. Jt Comm J Qual Patient Saf. 2024;50(9):673-677. doi:10.1016/j.jcjq.2024.05.005.…
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psnet.ahrq.gov/issue/if-no-one-stops-me-ill-make-mistake-again-changing-prescribing-behaviours-through-feedback
July 01, 2017 - Study
'If no-one stops me, I'll make the mistake again': changing prescribing behaviours through feedback; a Perceptual Control Theory perspective.
Citation Text:
Ferguson J, Keyworth C, Tully MP. 'If no-one stops me, I'll make the mistake again': Changing prescribing behaviours through …
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psnet.ahrq.gov/issue/incidence-adverse-events-related-health-care-spain-results-spanish-national-study-adverse
December 01, 2011 - Study
Incidence of adverse events related to health care in Spain: results of the Spanish National Study of Adverse Events.
Citation Text:
Aranaz-Andrés JM, Aibar-Remón C, Vitaller-Murillo J, et al. Incidence of adverse events related to health care in Spain: results of the Spanish Nat…
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psnet.ahrq.gov/issue/day-discharge-does-not-impact-hospital-readmission-after-major-cardiac-surgery
October 16, 2019 - Study
Day of discharge does not impact hospital readmission after major cardiac surgery.
Citation Text:
Sanaiha Y, Ou R, Ramos G, et al. Day of Discharge Does Not Impact Hospital Readmission After Major Cardiac Surgery. Ann Thorac Surg. 2018;106(6):1767-1773. doi:10.1016/j.athoracsur.201…
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psnet.ahrq.gov/issue/empowering-frontline-nurses-structured-intervention-enables-nurses-improve-medication
March 13, 2012 - Study
Empowering frontline nurses: a structured intervention enables nurses to improve medication administration accuracy.
Citation Text:
Kliger J, Blegen MA, Gootee D, et al. Empowering frontline nurses: a structured intervention enables nurses to improve medication administration accur…
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psnet.ahrq.gov/issue/where-errors-occur-preparation-and-administration-intravenous-medicines-systematic-review-and
June 30, 2011 - Review
Where errors occur in the preparation and administration of intravenous medicines: a systematic review and Bayesian analysis.
Citation Text:
McDowell SE, Mt-Isa S, Ashby D, et al. Where errors occur in the preparation and administration of intravenous medicines: a systematic rev…
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psnet.ahrq.gov/issue/national-patient-safety-curriculum-pediatric-emergency-medicine
January 12, 2022 - Study
A national patient safety curriculum in pediatric emergency medicine.
Citation Text:
Stankovic C, Wolff M, Chang TP, et al. A National Patient Safety Curriculum in Pediatric Emergency Medicine. Pediatr Emerg Care. 2019;35(8):519-521. doi:10.1097/PEC.0000000000001533.
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psnet.ahrq.gov/issue/quality-initiative-decrease-pathology-specimen-labeling-errors-using-radiofrequency
August 28, 2017 - Study
A quality initiative to decrease pathology specimen-labeling errors using radiofrequency identification in a high-volume endoscopy center.
Citation Text:
Francis DL, Prabhakar S, Sanderson SO. A quality initiative to decrease pathology specimen-labeling errors using radiofrequenc…