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psnet.ahrq.gov/issue/confused-and-bewildered-hospital-adverse-event-discovery-pay-performance-and-big-data-tools
September 23, 2020 - Commentary
The confused and bewildered hospital: adverse event discovery, pay-for-performance, and big data tools as halfway technologies.
Citation Text:
Furrow BR. The confused and bewildered hospital: adverse event discovery, pay-for-performance, and big data tools as halfway technolog…
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psnet.ahrq.gov/issue/adverse-events-hospitals-care-study-incidence-among-medicare-beneficiaries-two-selected
January 14, 2009 - Book/Report
Adverse Events in Hospitals: Care Study of Incidence Among Medicare Beneficiaries in Two Selected Counties.
Citation Text:
Adverse Events in Hospitals: Care Study of Incidence Among Medicare Beneficiaries in Two Selected Counties. Levinson DR. Washington, DC: US Departmen…
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psnet.ahrq.gov/issue/role-error-organizing-behaviour
April 21, 2011 - Study
Classic
The role of error in organizing behaviour.
Citation Text:
Rasmussen J. The role of error in organizing behaviour. Qual Saf Health Care. 2003;12(5):377-383. doi:10.1136/qhc.12.5.377.
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psnet.ahrq.gov/issue/nurses-responses-medication-errors-suggestions-development-organizational-strategies-improve
December 16, 2020 - Study
Nurses' responses to medication errors: suggestions for the development of organizational strategies to improve reporting.
Citation Text:
Covell CL, Ritchie JA. Nurses' responses to medication errors: suggestions for the development of organizational strategies to improve reporti…
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psnet.ahrq.gov/issue/whats-past-prologue-organizational-learning-serious-patient-injury
October 26, 2011 - Study
What’s past is prologue: organizational learning from a serious patient injury.
Citation Text:
Tamuz M, Franchois KE, Thomas EJ. What’s past is prologue: Organizational learning from a serious patient injury. Saf Sci. 2010;49(1). doi:10.1016/j.ssci.2010.06.005.
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psnet.ahrq.gov/issue/preventable-anesthesia-mishaps-study-human-factors
June 23, 2015 - Study
Classic
Preventable anesthesia mishaps: a study of human factors.
Citation Text:
Cooper JB, Newbower RS, Long CD, et al. Preventable anesthesia mishaps: a study of human factors. Anesthesiology. 1978;49(6):399-406.
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psnet.ahrq.gov/issue/review-medical-error-taxonomies-human-factors-perspective
July 25, 2012 - Review
A review of medical error taxonomies: a human factors perspective.
Citation Text:
Taib IA, McIntosh AS, Caponecchia C, et al. A review of medical error taxonomies: A human factors perspective. Saf Sci. 2011;49(5):607-615. doi:10.1016/j.ssci.2010.12.014.
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psnet.ahrq.gov/issue/mistreatment-health-care-among-women-appalachia
October 04, 2023 - Study
Mistreatment in health care among women in Appalachia.
Citation Text:
Alspaugh A, Swan LET, Auerbach SL, et al. Mistreatment in health care among women in Appalachia. Cult Health Sex. 2023;25(12):1690-1706. doi:10.1080/13691058.2023.2176547.
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psnet.ahrq.gov/issue/race-differences-malpractice-event-database-large-healthcare-system
December 15, 2021 - Study
Race differences in a malpractice event database in a large healthcare system.
Citation Text:
Thomas AD, Pandit C, Krevat S. Race differences in a malpractice event database in a large healthcare system. J Patient Saf. 2023;19(2):67-70. doi:10.1097/pts.0000000000001090.
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psnet.ahrq.gov/issue/bedside-shift-shift-handoffs-systematic-review-literature
January 23, 2017 - Review
Bedside shift-to-shift handoffs: a systematic review of the literature.
Citation Text:
Mardis T, Mardis M, Davis JJ, et al. Bedside Shift-to-Shift Handoffs: A Systematic Review of the Literature. J Nurs Care Qual. 2016;31(1):54-60. doi:10.1097/NCQ.0000000000000142.
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psnet.ahrq.gov/issue/organizational-perspectives-nurse-executives-15-hospitals-impact-and-effectiveness-rapid
August 03, 2022 - Study
Organizational perspectives of nurse executives in 15 hospitals on the impact and effectiveness of rapid response teams.
Citation Text:
Smith PL, McSweeney J. Organizational Perspectives of Nurse Executives in 15 Hospitals on the Impact and Effectiveness of Rapid Response Teams. Jt…
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psnet.ahrq.gov/issue/positive-deviance-different-approach-achieving-patient-safety
May 15, 2024 - Commentary
Positive deviance: a different approach to achieving patient safety.
Citation Text:
Lawton R, Taylor N, Clay-Williams R, et al. Positive deviance: a different approach to achieving patient safety. BMJ Qual Saf. 2014;23(11):880-3. doi:10.1136/bmjqs-2014-003115.
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psnet.ahrq.gov/issue/educating-medical-trainees-medication-reconciliation-systematic-review
October 16, 2019 - Review
Educating medical trainees on medication reconciliation: a systematic review.
Citation Text:
Ramjaun A, Sudarshan M, Patakfalvi L, et al. Educating medical trainees on medication reconciliation: a systematic review. BMC Med Educ. 2015;15:33. doi:10.1186/s12909-015-0306-5.
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psnet.ahrq.gov/issue/ten-challenges-improving-quality-healthcare-lessons-health-foundations-programme-evaluations
February 19, 2020 - Commentary
Ten challenges in improving quality in healthcare: lessons from the Health Foundation's programme evaluations and relevant literature.
Citation Text:
Dixon-Woods M, McNicol S, Martin G. Ten challenges in improving quality in healthcare: lessons from the Health Foundation's p…
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psnet.ahrq.gov/issue/what-makes-maternity-teams-effective-and-safe-lessons-series-research-teamwork-leadership-and
May 25, 2011 - Commentary
What makes maternity teams effective and safe? Lessons from a series of research on teamwork, leadership and team training.
Citation Text:
Siassakos D, Fox R, Bristowe K, et al. What makes maternity teams effective and safe? Lessons from a series of research on teamwork, lead…
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psnet.ahrq.gov/issue/differentiating-between-detrimental-and-beneficial-interruptions-mixed-methods-study
May 03, 2017 - Study
Differentiating between detrimental and beneficial interruptions: a mixed-methods study.
Citation Text:
Myers RA, McCarthy MC, Whitlatch A, et al. Differentiating between detrimental and beneficial interruptions: a mixed-methods study. BMJ Qual Saf. 2016;25(11):881-888. doi:10.1136…
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psnet.ahrq.gov/issue/effects-educational-patient-safety-campaign-patients-safety-behaviours-and-adverse-events
November 05, 2013 - Study
Effects of an educational patient safety campaign on patients' safety behaviours and adverse events.
Citation Text:
Schwappach DLB, Frank O, Buschmann U, et al. Effects of an educational patient safety campaign on patients' safety behaviours and adverse events. J Eval Clin Pract.…
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psnet.ahrq.gov/issue/ordering-interruptions-tertiary-care-center-prospective-observational-study
July 15, 2020 - Study
Ordering interruptions in a tertiary care center: a prospective observational study.
Citation Text:
Dadlez NM, Azzarone G, Sinnett MJ, et al. Ordering Interruptions in a Tertiary Care Center: A Prospective Observational Study. Hosp Pediatr. 2017;7(3):134-139. doi:10.1542/hpeds.2016…
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psnet.ahrq.gov/issue/progress-interoperability-measuring-us-hospitals-engagement-sharing-patient-data
March 27, 2024 - Study
Progress in interoperability: measuring US hospitals' engagement in sharing patient data.
Citation Text:
Holmgren J, Patel V, Adler-Milstein J. Progress in interoperability: measuring US hospitals' engagement in sharing patient data. Health Aff (Millwood). 2017;36(10):1820-1827. do…
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psnet.ahrq.gov/issue/transferring-responsibility-and-accountability-maternity-care-clinicians-defining-their
August 19, 2009 - Study
Transferring responsibility and accountability in maternity care: clinicians defining their boundaries of practice in relation to clinical handover.
Citation Text:
Chin GSM, Warren N, Kornman L, et al. Transferring responsibility and accountability in maternity care: clinicians d…