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Improved operating room teamwork via SAFETY prep: a rural community hospital's experience. | PSNet

psnet.ahrq.gov/issue/improved-operating-room-teamwork-safety-prep-rural-community-hospitals-experience

September 05, 2009 - Study Improved operating room teamwork via SAFETY prep: a rural community hospital's experience. Citation Text: Paige JT, Aaron DL, Yang T, et al. Improved operating room teamwork via SAFETY prep: a rural community hospital's experience. World J Surg. 2009;33(6):1181-7. doi:10.1007/s00…

A pilot study examining undesirable events among emergency department–boarded patients awaiting inpatient beds. | PSNet

psnet.ahrq.gov/issue/pilot-study-examining-undesirable-events-among-emergency-department-boarded-patients-awaiting

August 04, 2021 - Study A pilot study examining undesirable events among emergency department–boarded patients awaiting inpatient beds. Citation Text: Liu SW, Thomas SH, Gordon JA, et al. A pilot study examining undesirable events among emergency department-boarded patients awaiting inpatient beds. Ann E…

Patterns of errors contributing to trauma mortality: lessons learned from 2,594 deaths. | PSNet

psnet.ahrq.gov/issue/patterns-errors-contributing-trauma-mortality-lessons-learned-2594-deaths

March 24, 2021 - Study Patterns of errors contributing to trauma mortality: lessons learned from 2,594 deaths. Citation Text: Gruen RL, Jurkovich GJ, McIntyre LK, et al. Patterns of Errors Contributing to Trauma Mortality. Transactions of the .. Meeting of the American Surgical Association. 2006;124. d…

Discontinuation of antihyperglycemic therapy after acute myocardial infarction: medical necessity or medical error? | PSNet

psnet.ahrq.gov/issue/discontinuation-antihyperglycemic-therapy-after-acute-myocardial-infarction-medical-necessity

February 28, 2011 - Study Discontinuation of antihyperglycemic therapy after acute myocardial infarction: medical necessity or medical error? Citation Text: Lovig KO, Horwitz LI, Lipska K, et al. Discontinuation of antihyperglycemic therapy after acute myocardial infarction: medical necessity or medical e…

Quality improvement through implementation of discharge order reconciliation. | PSNet

psnet.ahrq.gov/issue/quality-improvement-through-implementation-discharge-order-reconciliation

September 23, 2020 - Commentary Quality improvement through implementation of discharge order reconciliation. Citation Text: Lu Y, Clifford P, Bjorneby A, et al. Quality improvement through implementation of discharge order reconciliation. Am J Health Syst Pharm. 2013;70(9):815-20. doi:10.2146/ajhp120050. …

Shifting and sharing: academic physicians' strategies for navigating underperformance and failure. | PSNet

psnet.ahrq.gov/issue/shifting-and-sharing-academic-physicians-strategies-navigating-underperformance-and-failure

August 21, 2019 - Study Shifting and sharing: academic physicians' strategies for navigating underperformance and failure. Citation Text: LaDonna KA, Ginsburg S, Watling C. Shifting and Sharing: Academic Physicians' Strategies for Navigating Underperformance and Failure. Acad Med. 2018;93(11):1713-1718. d…

Types, prevalence, and potential clinical significance of medication administration errors in assisted living. | PSNet

psnet.ahrq.gov/issue/types-prevalence-and-potential-clinical-significance-medication-administration-errors

October 11, 2023 - Study Types, prevalence, and potential clinical significance of medication administration errors in assisted living. Citation Text: Young HM, Gray SL, McCormick WC, et al. Types, prevalence, and potential clinical significance of medication administration errors in assisted living. J A…

Authentic leadership at the Cleveland Clinic: psychological safety in the midst of crisis. | PSNet

psnet.ahrq.gov/issue/authentic-leadership-cleveland-clinic-psychological-safety-midst-crisis

October 19, 2022 - Study Authentic leadership at the Cleveland Clinic: psychological safety in the midst of crisis. Citation Text: Porter TH, Peck JA, Bolwell B, et al. Authentic leadership at the Cleveland Clinic: psychological safety in the midst of crisis. BMJ Lead. 2023;7(3):196-202. doi:10.1136/leader…

Flawed self-assessment in hand hygiene: a major contributor to infections in clinical practice? | PSNet

psnet.ahrq.gov/issue/flawed-self-assessment-hand-hygiene-major-contributor-infections-clinical-practice

September 02, 2020 - Study Flawed self-assessment in hand hygiene: a major contributor to infections in clinical practice? Citation Text: Kelcikova S, Mazuchova L, Bielena L, et al. Flawed self-assessment in hand hygiene: A major contributor to infections in clinical practice? J Clin Nurs. 2019;28(11-12):226…

Detecting clinical medication errors with AI enabled wearable cameras. | PSNet

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August 03, 2022 - Study Detecting clinical medication errors with AI enabled wearable cameras. Citation Text: Chan J, Nsumba S, Wortsman M, et al. Detecting clinical medication errors with AI enabled wearable cameras. NPJ Dig Med. 2024;7(1):287. doi:10.1038/s41746-024-01295-2. Copy Citation Format: …

Checklists change communication about key elements of patient care. | PSNet

psnet.ahrq.gov/issue/checklists-change-communication-about-key-elements-patient-care

November 16, 2022 - Study Checklists change communication about key elements of patient care. Citation Text: Newkirk M, Pamplin JC, Kuwamoto R, et al. Checklists change communication about key elements of patient care. J Trauma Acute Care Surg. 2012;73(2 Suppl 1):S75-82. doi:10.1097/TA.0b013e3182606239. …

From a blame culture to a just culture in health care. | PSNet

psnet.ahrq.gov/issue/blame-culture-just-culture-health-care

January 23, 2017 - Commentary From a blame culture to a just culture in health care. Citation Text: Khatri N, Brown GD, Hicks LL. From a blame culture to a just culture in health care. Health Care Manag Rev. 2009;34(4):312-322. doi:10.1097/HMR.0b013e3181a3b709. Copy Citation Format: DOI Goog…

Junior doctors and patient safety: evaluating knowledge, attitudes and perception of safety climate. | PSNet

psnet.ahrq.gov/issue/junior-doctors-and-patient-safety-evaluating-knowledge-attitudes-and-perception-safety

February 18, 2019 - Study Junior doctors and patient safety: evaluating knowledge, attitudes and perception of safety climate. Citation Text: Durani P, Dias J, Singh HP, et al. Junior doctors and patient safety: evaluating knowledge, attitudes and perception of safety climate. BMJ Qual Saf. 2013;22(1):65-…

Extraneous tissue a potential source for diagnostic error in surgical pathology. | PSNet

psnet.ahrq.gov/issue/extraneous-tissue-potential-source-diagnostic-error-surgical-pathology

October 27, 2010 - Study Extraneous tissue a potential source for diagnostic error in surgical pathology. Citation Text: Layfield LJ, Witt BL, Metzger KG, et al. Extraneous tissue: a potential source for diagnostic error in surgical pathology. Am J Clin Pathol. 2011;136(5):767-72. doi:10.1309/AJCP4FFSBPHA…

Recognizing and responding to the "toxic" work environment: worker safety, patient safety, and abuse/neglect in nursing homes. | PSNet

psnet.ahrq.gov/issue/recognizing-and-responding-toxic-work-environment-worker-safety-patient-safety-and

July 02, 2019 - Study Recognizing and responding to the "toxic" work environment: worker safety, patient safety, and abuse/neglect in nursing homes. Citation Text: Pickering CEZ, Nurenberg K, Schiamberg L. Recognizing and Responding to the "Toxic" Work Environment: Worker Safety, Patient Safety, and Abu…

Patient risk factors for medical injury: a case–control study. | PSNet

psnet.ahrq.gov/issue/patient-risk-factors-medical-injury-case-control-study

April 12, 2011 - Study Patient risk factors for medical injury: a case–control study. Citation Text: Marbella AM, Laud PW, Brasel KJ, et al. Patient risk factors for medical injury: a case-control study. BMJ Qual Saf. 2011;20(2):187-93. doi:10.1136/bmjqs.2009.032664. Copy Citation Format: …

Systematic review: antimicrobial urinary catheters to prevent catheter-associated urinary tract infection in hospitalized patients. | PSNet

psnet.ahrq.gov/issue/systematic-review-antimicrobial-urinary-catheters-prevent-catheter-associated-urinary-tract

October 19, 2022 - Review Systematic review: antimicrobial urinary catheters to prevent catheter-associated urinary tract infection in hospitalized patients. Citation Text: Johnson JR, Kuskowski MA, Wilt TJ. Systematic review: antimicrobial urinary catheters to prevent catheter-associated urinary tract i…

Reporting and classification of patient safety events in a cardiothoracic intensive care unit and cardiothoracic postoperative care unit. | PSNet

psnet.ahrq.gov/issue/reporting-and-classification-patient-safety-events-cardiothoracic-intensive-care-unit-and

August 02, 2011 - Study Reporting and classification of patient safety events in a cardiothoracic intensive care unit and cardiothoracic postoperative care unit. Citation Text: Nast PA, Avidan M, Harris CB, et al. Reporting and classification of patient safety events in a cardiothoracic intensive care uni…

Structured handover in general surgery: an audit of current practice. | PSNet

psnet.ahrq.gov/issue/structured-handover-general-surgery-audit-current-practice

August 08, 2018 - Study Structured handover in general surgery: an audit of current practice. Citation Text: Jones HG, Watt B, Lewis L, et al. Structured Handover in General Surgery: An Audit of Current Practice. J Patient Saf. 2019;15(1):7-10. doi:10.1097/PTS.0000000000000201. Copy Citation Format:…

Measuring patient safety: the Medicare Patient Safety Monitoring System (past, present, and future). | PSNet

psnet.ahrq.gov/issue/measuring-patient-safety-medicare-patient-safety-monitoring-system-past-present-and-future

December 18, 2014 - Review Measuring patient safety: the Medicare Patient Safety Monitoring System (past, present, and future). Citation Text: Classen D, Munier W, Verzier N, et al. Measuring Patient Safety: The Medicare Patient Safety Monitoring System (Past, Present, and Future). J Patient Saf. 2021;17(3)…

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