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3101. The second victim: a review. | PSNet
      psnet.ahrq.gov/issue/second-victim-review
      June 26, 2019 - This review discusses second victims in regard to maternity care. … a change of practice in the last 7 years? … February 26, 2014 Evidence-based guidelines for fatigue risk management in emergency … July 16, 2013 Near miss audit in obstetrics. … The reproducibility of assessments by hospital risk management groups.

3102. Voluntarily reported emergency department errors. | PSNet
      psnet.ahrq.gov/issue/voluntarily-reported-emergency-department-errors
      June 20, 2011 - The investigators studied an incentive-based voluntary reporting system in an emergency department and … recovered, mainly by nurses, and that unrecovered errors impacted patients, most often with a delay in … hospital stay. … older patients with severe COVID-19 in intensive care unit. … February 27, 2019 Patient safety in the ED.

3103. Addressing prehospital patient safety using the science of injury prevention and control. | PSNet
      psnet.ahrq.gov/issue/addressing-prehospital-patient-safety-using-science-injury-prevention-and-control
      April 12, 2019 - This commentary discusses patient safety in emergency medical services (EMS) and illustrates how injury … April 22, 2015 Improving timely recognition and treatment of sepsis in the pediatric … Assessment of a wearable fall prevention system at a Veterans Health Administration hospital … May 18, 2022 A culture of safety in EMS systems. … June 9, 2021 Lost in translation?

3104. Unintended doses in radiotherapy—over, under and outside? | PSNet
      psnet.ahrq.gov/issue/unintended-doses-radiotherapy-over-under-and-outside
      August 27, 2009 - Unintended doses in radiotherapy-over, under and outside? … Unintended doses in radiotherapy-over, under and outside? … Hazards in delivery of surgical instruments. … July 10, 2018 Diagnostic error in pediatric cancer. … August 8, 2010 View More See More About The Topic Hospitals Health

3105. The association between culture, climate and quality of care in primary health care teams. | PSNet
      psnet.ahrq.gov/issue/association-between-culture-climate-and-quality-care-primary-health-care-teams
      May 30, 2011 - Commentary The association between culture, climate and quality of care in primary … The association between culture, climate and quality of care in primary health care teams. … : longitudinal patient record review in 21 English general practices. … June 30, 2021 Risk factors for hospital admissions associated with adverse drug events … November 9, 2015 Exploring situational awareness in diagnostic errors in primary care

3106. Operating room fires. | PSNet
      psnet.ahrq.gov/issue/operating-room-fires
      March 14, 2022 - Surgical fires , though uncommon, can result in serious harm. … March 14, 2022 Seroprevalence of SARS-CoV-2 among frontline health care personnel in … a multistate hospital network--13 academic medical centers, April-June 2020. … Clinicians' use of health information exchange technologies for medication reconciliation in … March 8, 2023 Factors causing variation in World Health Organization surgical safety

3107. What went right: lessons for the intensivist from the crew of US Airways Flight 1549. | PSNet
      psnet.ahrq.gov/issue/what-went-right-lessons-intensivist-crew-us-airways-flight-1549
      February 23, 2009 - This commentary highlights how a culture of safety and teamwork can avert failure in health care … Project, and the Office for Human Research Protections: a case for streamlining the approval process in … May 6, 2020 Families as partners in hospital error and adverse event surveillance. … COVID-19 among residents and staff of an independent and assisted living community for older adults in … June 10, 2020 Patient safety in North America: beyond "operate through your initials"

3108. Creating a fair and just culture: one institution's path toward organizational change. | PSNet
      psnet.ahrq.gov/issue/creating-fair-and-just-culture-one-institutions-path-toward-organizational-change
      July 23, 2014 - Dana-Farber Cancer Institute’s (DFCI) efforts at creating a " Just Culture ," which were motivated in … perspective written by two leaders at DFCI also discusses the organizational change that occurred in … March 15, 2023 Medication safety in the ambulatory chemotherapy setting. … May 29, 2014 The meaning of justice in safety incident reporting. … October 1, 2007 View More See More About The Topic Specialty Hospitals

3109. 10 years in, why time out still matters. | PSNet
      psnet.ahrq.gov/issue/10-years-why-time-out-still-matters
      November 08, 2013 - Commentary 10 years in, why time out still matters. … The Universal Protocol has been widely adopted in the decade since its release. … November 8, 2013 Families as partners in hospital error and adverse event surveillance … August 3, 2022 Speaking up to reduce noise in the OR. … February 15, 2012 Communication in the perioperative setting.

3110. Introducing new technology into the operating room: measuring the impact on job performance and satisfaction. | PSNet
      psnet.ahrq.gov/issue/introducing-new-technology-operating-room-measuring-impact-job-performance-and-satisfaction
      May 18, 2022 - October 11, 2023 Auto identification technology and its impact on patient safety in the … getting noticed sooner - SIGNS-for-Kids: developing an illness recognition tool to connect home and hospital … Journal Article Study A novel approach for engagement in … team training in high-technology surgery: the robotic-assisted surgery olympics. … online morbidity, mortality, and near-miss reporting system to identify patterns of adverse events in

3111. How structural racism works - racist policies as a root cause of U.S. racial health inequities. | PSNet
      psnet.ahrq.gov/issue/how-structural-racism-works-racist-policies-root-cause-us-racial-health-inequities
      April 14, 2017 - April 10, 2019 Graded autonomy in medical education—managing things that go bump in the … February 17, 2011 State sepsis mandates—a new era for regulation of hospital quality. … July 29, 2020 Racial bias in pulse oximetry measurement. … December 21, 2022 Bias in mental health diagnosis gets in the way of treatment. … December 22, 2021 Racial disparities in child abuse medicine.

3112. Responsible e-prescribing needs e-discontinuation. | PSNet
      psnet.ahrq.gov/issue/responsible-e-prescribing-needs-e-discontinuation
      July 10, 2017 - November 26, 2014 Effect of restriction of the number of concurrently open records in … July 8, 2020 How often do prescribers include indications in drug orders? … July 10, 2017 Is an indication-based prescribing system in our future? … July 6, 2012 Medication errors in paediatric outpatients. … January 19, 2011 View More See More About The Topic Hospitals Facility

3113. Cascades of care after incidental findings in a US national survey of physicians. | PSNet
      psnet.ahrq.gov/issue/cascades-care-after-incidental-findings-us-national-survey-physicians
      April 24, 2018 - Study Classic Cascades of care after incidental findings in … Cascades of Care After Incidental Findings in a US National Survey of Physicians. … Cascades of Care After Incidental Findings in a US National Survey of Physicians. … Citation Related Resources From the Same Author(s) Families as partners in … hospital error and adverse event surveillance.

3114. Electronic health records and National Patient-Safety Goals. | PSNet
      psnet.ahrq.gov/issue/electronic-health-records-and-national-patient-safety-goals
      December 06, 2023 - 2020 Assessment of health information technology-related outpatient diagnostic delays in … July 1, 2017 Electronic detection of delayed test result follow-up in patients with hypothyroidism … April 24, 2018 Computerized triggers of big data to detect delays in follow-up of chest … December 31, 2014 Enhancing electronic health record usability in pediatric patient care … November 23, 2011 View More See More About The Topic Hospitals Ambulatory

3115. A leadership framework for culture change in health care. | PSNet
      psnet.ahrq.gov/issue/leadership-framework-culture-change-health-care
      January 02, 2017 - Commentary A leadership framework for culture change in health care. … A leadership framework for culture change in health care. … A leadership framework for culture change in health care. … February 10, 2015 Patient safety in surgery. … Quality April 26, 2023 View More See More About The Topic Hospitals

3116. Medical error, incident investigation and the second victim: doing better but feeling worse? | PSNet
      psnet.ahrq.gov/issue/medical-error-incident-investigation-and-second-victim-doing-better-feeling-worse
      July 29, 2020 - This commentary discusses the impact of adverse events on physicians-in-training and provides tactics … 3, 2014 Case studies of patient safety research classics to build research capacity in … August 7, 2019 Decisions and repercussions of second victim experiences for mothers in … September 5, 2018 Do hospitals support second victims? … Collective insights from patient safety leaders in Maryland.

3117. How to discuss errors and adverse events with cancer patients. | PSNet
      psnet.ahrq.gov/issue/how-discuss-errors-and-adverse-events-cancer-patients
      April 01, 2010 - December 29, 2014 Patient safety in palliative care: a mixed-methods study of reports … May 16, 2018 The experiences of risk managers in providing emotional support for health … July 7, 2021 Why do hospital prescribers continue antibiotics when it is safe to stop … September 9, 2011 Confronting medical errors in oncology and disclosing them to cancer … March 4, 2009 Interview In Conversation with…Thomas H.

3118. 'Skating on thin ice?' Consultant surgeon's contemporary experience of adverse surgical events. | PSNet
      psnet.ahrq.gov/issue/skating-thin-ice-consultant-surgeons-contemporary-experience-adverse-surgical-events
      April 17, 2024 - qualitative study used interviews with attending surgeons to identify contributors to adverse events in … Understanding the informal aspects of medication processes to maintain patient safety in … hospitals: a sociotechnical ethnographic study in paediatric units. … July 29, 2020 National trends in patient safety for four common conditions, 2005–2011 … March 21, 2012 Rules and guidelines in clinical practice: a qualitative study in operating

3119. Characteristics of medical liability claims against dermatologists from 1991 through 2015. | PSNet
      psnet.ahrq.gov/issue/characteristics-medical-liability-claims-against-dermatologists-1991-through-2015
      July 29, 2020 - December 11, 2024 Diagnostic errors in primary care pediatrics: Project RedDE. … December 15, 2010 Families as partners in hospital error and adverse event surveillance … February 10, 2012 The electronic medical record in dermatology. … July 14, 2010 Patient safety in dermatology: a review of the literature. … February 17, 2010 Monitoring for medication errors in outpatient settings.

3120. Clinical faculty: taking the lead in teaching quality improvement and patient safety. | PSNet
      psnet.ahrq.gov/issue/clinical-faculty-taking-lead-teaching-quality-improvement-and-patient-safety
      July 01, 2017 - Commentary Clinical faculty: taking the lead in teaching quality improvement and … Clinical faculty: taking the lead in teaching quality improvement and patient safety. … Patient safety has been described as an unmet need in physician training. … Clinical faculty: taking the lead in teaching quality improvement and patient safety. … July 22, 2013 View More See More About The Topic Hospitals Physicians