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psnet.ahrq.gov/issue/how-develop-second-victim-support-program-toolkit-health-care-organizations
April 03, 2019 - Commentary
How to develop a second victim support program: a toolkit for health care organizations.
Citation Text:
Pratt SD, Kenney L, Scott SD, et al. How to develop a second victim support program: a toolkit for health care organizations. Jt Comm J Qual Patient Saf. 2012;38(5):235-40, …
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psnet.ahrq.gov/issue/learning-incidents-health-care-critique-safety-ii-perspective
August 19, 2020 - Commentary
Learning from incidents in health care: critique from a Safety-II perspective.
Citation Text:
Learning from incidents in health care: critique from a Safety-II perspective. Sujan MA, Huang H, Braithwaite J. Safety Sci. 2017;99:115-121.
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psnet.ahrq.gov/issue/activating-knowledge-patient-safety-practices-canadian-academic-policy-partnership
January 08, 2015 - Commentary
Activating knowledge for patient safety practices: a Canadian academic-policy partnership.
Citation Text:
Harrison MB, Nicklin W, Owen M, et al. Activating knowledge for patient safety practices: a Canadian academic-policy partnership. Worldviews Evid Based Nurs. 2012;9(1):4…
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psnet.ahrq.gov/issue/pediatric-rapid-response-teams-academic-medical-center
November 21, 2016 - Study
Pediatric rapid response teams in the academic medical center.
Citation Text:
Mistry KP, Turi J, Hueckel RM, et al. Pediatric Rapid Response Teams in the Academic Medical Center. Clin Pediatr Emerg Med. 2006;7(4). doi:10.1016/j.cpem.2006.08.010.
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psnet.ahrq.gov/issue/swapping-horses-midstream-factors-related-physicians-changing-their-minds-about-diagnosis
January 29, 2020 - Study
Swapping horses midstream: factors related to physicians' changing their minds about a diagnosis.
Citation Text:
Eva KW, Link CL, Lutfey KE, et al. Swapping horses midstream: factors related to physicians' changing their minds about a diagnosis. Acad Med. 2010;85(7):1112-7. doi:10.…
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psnet.ahrq.gov/issue/system-approach-prevent-common-bile-duct-injury-and-enhance-performance-laparoscopic
March 09, 2009 - Commentary
System approach to prevent common bile duct injury and enhance performance of laparoscopic cholecystectomy.
Citation Text:
Lien H-H, Huang C-C, Liu J-S, et al. System approach to prevent common bile duct injury and enhance performance of laparoscopic cholecystectomy. Surg La…
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psnet.ahrq.gov/issue/eliminating-preventable-death-ascension-health
June 03, 2020 - Commentary
Eliminating preventable death at Ascension Health.
Citation Text:
Tolchin S, Brush R, Lange P, et al. Eliminating preventable death at Ascension Health. Jt Comm J Qual Patient Saf. 2007;33(3):145-54.
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psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-act-2005-0
December 21, 2011 - Commentary
Patient Safety and Quality Improvement Act of 2005.
Citation Text:
Fassett WE. Patient Safety and Quality Improvement Act of 2005. Ann Pharmacother. 2006;40(5):917-24.
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psnet.ahrq.gov/issue/patient-safety-and-adverse-events
July 20, 2022 - Special or Theme Issue
Patient Safety and Adverse Events.
Citation Text:
Patient Safety and Adverse Events. Adlassnig KP, Blobel B, Mantas J, Masic I, eds. Stud Health Technol Inform. 2009;150:497-566. In: Medical Informatics in a United and Healthy Europe. Washington, DC: IOS Press. ISB…
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psnet.ahrq.gov/issue/diagnostic-errors-pediatric-radiology
November 16, 2022 - Study
Diagnostic errors in pediatric radiology.
Citation Text:
Taylor GA, Voss SD, Melvin PR, et al. Diagnostic errors in pediatric radiology. Pediatr Radiol. 2011;41(3):327-34. doi:10.1007/s00247-010-1812-6.
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psnet.ahrq.gov/issue/concept-error-and-malpractice-radiology
January 24, 2018 - Commentary
The concept of error and malpractice in radiology.
Citation Text:
Pinto A, Brunese L, Pinto F, et al. The concept of error and malpractice in radiology. Semin Ultrasound CT MR. 2012;33(4):275-9. doi:10.1053/j.sult.2012.01.009.
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psnet.ahrq.gov/issue/national-reporting-and-learning-system-research-and-development
April 06, 2016 - Book/Report
National Reporting and Learning System Research and Development.
Citation Text:
National Reporting and Learning System Research and Development. Mayer E, Flott K, Callahan R, Darzi A. London, UK: NIHR Imperial Patient Safety Translational Research Centre; 2016.
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psnet.ahrq.gov/issue/accident-prevention-day-day-clinical-radiation-therapy-practice
February 07, 2018 - Commentary
Accident prevention in day-to-day clinical radiation therapy practice.
Citation Text:
Baeza M. Accident prevention in day-to-day clinical radiation therapy practice. Ann ICRP. 2012;41(3-4):179-87. doi:10.1016/j.icrp.2012.06.001.
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psnet.ahrq.gov/issue/health-care-provider-use-private-sector-internal-error-reporting-systems
May 29, 2019 - Study
Health care provider use of private sector internal error-reporting systems.
Citation Text:
Roumm AR, Sciamanna CN, Nash DB. Health care provider use of private sector internal error-reporting systems. Am J Med Qual. 2005;20(6):304-12.
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psnet.ahrq.gov/issue/what-do-healthcare-incident-reporting-systems
November 12, 2014 - Review
What to do with healthcare incident reporting systems.
Citation Text:
Pham JC, Girard T, Pronovost PJ. What to do with healthcare Incident Reporting Systems. J Public Health Res. 2013;2(3). doi:10.4081/jphr.2013.e27.
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psnet.ahrq.gov/issue/canary-measures-among-ahrq-patient-safety-indicators
November 27, 2012 - Study
"Canary measures" among the AHRQ Patient Safety Indicators.
Citation Text:
Yu H, Greenberg MD, Haviland AM, et al. "Canary measures" among the AHRQ patient safety indicators. Am J Med Qual. 2009;24(6):465-73. doi:10.1177/1062860609341585.
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psnet.ahrq.gov/issue/nurse-reports-adverse-events-during-sedation-procedures-pediatric-hospital
November 02, 2016 - Study
Nurse reports of adverse events during sedation procedures at a pediatric hospital.
Citation Text:
Lightdale JR, Mahoney LB, Fredette ME, et al. Nurse reports of adverse events during sedation procedures at a pediatric hospital. J Perianesth Nurs. 2009;24(5):300-6. doi:10.1016/j.j…
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psnet.ahrq.gov/issue/noise-operating-room-what-do-we-know-review-literature
August 13, 2014 - Review
Noise in the operating room—what do we know? A review of the literature.
Citation Text:
Hasfeldt D, Laerkner E, Birkelund R. Noise in the operating room--what do we know? A review of the literature. J Perianesth Nurs. 2010;25(6):380-6. doi:10.1016/j.jopan.2010.10.001.
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psnet.ahrq.gov/issue/patient-safety-north-america-beyond-operate-through-your-initials-and-sign-your-site
March 18, 2009 - Meeting/Conference Proceedings
Patient safety in North America: beyond "operate through your initials" and "sign your site."
Citation Text:
Wong DA, Lewis B, Herndon JH, et al. Patient Safety in North America: Beyond “Operate Through Your Initials” and “Sign Your Site”*. doi:10.2106/jb…
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psnet.ahrq.gov/issue/operating-room-fires
March 14, 2022 - Review
Emerging Classic
Operating room fires.
Citation Text:
Jones TS, Black IH, Robinson TN, et al. Operating Room Fires. Anesthesiology. 2019;130(3):492-501. doi:10.1097/ALN.0000000000002598.
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