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  1. Is there a benefit to multidisciplinary rounds in an open trauma intensive care unit regarding ventilator-associated pneumonia? | PSNet

    psnet.ahrq.gov/issue/there-benefit-multidisciplinary-rounds-open-trauma-intensive-care-unit-regarding-ventilator
    January 06, 2010 - Study Is there a benefit to multidisciplinary rounds in an open trauma intensive care unit regarding ventilator-associated pneumonia? Citation Text: Johnson V, Mangram A, Mitchell C, et al. Is there a benefit to multidisciplinary rounds in an open trauma intensive care unit regarding v…

  2. Failure to report poor care as a breach of moral and professional expectation. | PSNet

    psnet.ahrq.gov/issue/failure-report-poor-care-breach-moral-and-professional-expectation
    March 05, 2025 - Commentary Failure to report poor care as a breach of moral and professional expectation. Citation Text: Ion R, Olivier S, Darbyshire P. Failure to report poor care as a breach of moral and professional expectation. Nurs Inq. 2019;26(3):e12299. doi:10.1111/nin.12299. Copy Citation …

  3. Speaking up and sharing information improves trainee neonatal resuscitations. | PSNet

    psnet.ahrq.gov/issue/speaking-and-sharing-information-improves-trainee-neonatal-resuscitations
    April 08, 2011 - Study Speaking up and sharing information improves trainee neonatal resuscitations. Citation Text: Katakam LI, Trickey AW, Thomas EJ. Speaking up and sharing information improves trainee neonatal resuscitations. J Patient Saf. 2012;8(4):202-9. doi:10.1097/PTS.0b013e3182699b4f. Copy C…

  4. With Safety in Mind: Mental Health Services and Patient Safety. | PSNet

    psnet.ahrq.gov/issue/safety-mind-mental-health-services-and-patient-safety
    August 07, 2018 - Book/Report With Safety in Mind: Mental Health Services and Patient Safety. Citation Text: With Safety in Mind: Mental Health Services and Patient Safety. Scobie S, Minghella E, Dale C, et al. London, UK: National Patient Safety Agency; 2006. Copy Citation Save …

  5. ReCASTing the RCA: an improved model for performing root cause analyses. | PSNet

    psnet.ahrq.gov/issue/recasting-rca-improved-model-performing-root-cause-analyses
    November 10, 2010 - Commentary ReCASTing the RCA: an improved model for performing root cause analyses. Citation Text: Pham JC, Kim GR, Natterman JP, et al. ReCASTing the RCA: An Improved Model for Performing Root Cause Analyses. American Journal of Medical Quality. 2010;25(3). doi:10.1177/1062860609359533…

  6. Content analysis of team communication in an obstetric emergency scenario. | PSNet

    psnet.ahrq.gov/issue/content-analysis-team-communication-obstetric-emergency-scenario
    July 13, 2009 - Study Content analysis of team communication in an obstetric emergency scenario. Citation Text: Siassakos D, Draycott TJ, Montague I, et al. Content analysis of team communication in an obstetric emergency scenario. J Obstet Gynaecol. 2009;29(6):499-503. doi:10.1080/01443610903039153. …

  7. Patient safety initiatives in obstetrics: a rapid review. | PSNet

    psnet.ahrq.gov/issue/patient-safety-initiatives-obstetrics-rapid-review
    September 23, 2020 - Review Patient safety initiatives in obstetrics: a rapid review. Citation Text: Antony J, Zarin W, Pham B', et al. Patient safety initiatives in obstetrics: a rapid review. BMJ Open. 2018;8(7):e020170. doi:10.1136/bmjopen-2017-020170. Copy Citation Format: DOI Google Schola…

  8. Errors associated with oxytocin use: a multi-organization analysis by ISMP and ISMP Canada. | PSNet

    psnet.ahrq.gov/issue/errors-associated-oxytocin-use-multi-organization-analysis-ismp-and-ismp-canada
    February 23, 2022 - Newspaper/Magazine Article Errors associated with oxytocin use: a multi-organization analysis by ISMP and ISMP Canada. Citation Text: Errors associated with oxytocin use: a multi-organization analysis by ISMP and ISMP Canada. ISMP Medication Safety Alert! Acute care edition. Februar…

  9. Imitating incidents: how simulation can improve safety investigation and learning from adverse events. | PSNet

    psnet.ahrq.gov/issue/imitating-incidents-how-simulation-can-improve-safety-investigation-and-learning-adverse
    February 28, 2024 - Commentary Imitating incidents: how simulation can improve safety investigation and learning from adverse events. Citation Text: Macrae C. Imitating Incidents: How Simulation Can Improve Safety Investigation and Learning From Adverse Events. Simul Healthc. 2018;13(4):227-232. doi:10.1097…

  10. "Canary measures" among the AHRQ Patient Safety Indicators. | PSNet

    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. Copy Citation Format: DOI G…

  11. Reevaluation of diagnosis in adults with physician-diagnosed asthma. | PSNet

    psnet.ahrq.gov/issue/reevaluation-diagnosis-adults-physician-diagnosed-asthma
    March 15, 2017 - Study Reevaluation of diagnosis in adults with physician-diagnosed asthma. Citation Text: Aaron SD, Vandemheen KL, FitzGerald M, et al. Reevaluation of Diagnosis in Adults With Physician-Diagnosed Asthma. JAMA. 2017;317(3):269-279. doi:10.1001/jama.2016.19627. Copy Citation Format:…

  12. Health care provider use of private sector internal error-reporting systems. | PSNet

    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. Copy Citation Format: Google S…

  13. Barriers and facilitators to communicating nursing errors in long-term care settings. | PSNet

    psnet.ahrq.gov/issue/barriers-and-facilitators-communicating-nursing-errors-long-term-care-settings
    March 27, 2018 - Study Barriers and facilitators to communicating nursing errors in long-term care settings. Citation Text: Wagner LM, Damianakis T, Pho L, et al. Barriers and facilitators to communicating nursing errors in long-term care settings. J Patient Saf. 2013;9(1):1-7. doi:10.1097/PTS.0b013e31…

  14. Interdisciplinary team training: five lessons learned. | PSNet

    psnet.ahrq.gov/issue/interdisciplinary-team-training-five-lessons-learned
    August 21, 2013 - Commentary Interdisciplinary team training: five lessons learned. Citation Text: Contratti F, Ng G, Deeb J. Interdisciplinary team training: five lessons learned. Am J Nurs. 2012;112(6):47-52. doi:10.1097/01.NAJ.0000415127.84605.1f. Copy Citation Format: DOI Google Schol…

  15. The path to diagnostic excellence includes feedback to calibrate how clinicians think. | PSNet

    psnet.ahrq.gov/issue/path-diagnostic-excellence-includes-feedback-calibrate-how-clinicians-think
    May 04, 2022 - Commentary Emerging Classic The path to diagnostic excellence includes feedback to calibrate how clinicians think. Citation Text: Meyer AND, Singh H. The Path to Diagnostic Excellence Includes Feedback to Calibrate How Clinicians Think. JAMA. 2019;321(8):737-738…

  16. How doctors think: common diagnostic errors in clinical judgment--lessons from an undiagnosed and rare disease program. | PSNet

    psnet.ahrq.gov/issue/how-doctors-think-common-diagnostic-errors-clinical-judgment-lessons-undiagnosed-and-rare
    September 14, 2022 - Review How doctors think: common diagnostic errors in clinical judgment--lessons from an undiagnosed and rare disease program. Citation Text: Kliegman RM, Bordini BJ, Basel D, et al. How Doctors Think: Common Diagnostic Errors in Clinical Judgment-Lessons from an Undiagnosed and Rare Dis…

  17. Wake Up Safe and root cause analysis: quality improvement in pediatric anesthesia. | PSNet

    psnet.ahrq.gov/issue/wake-safe-and-root-cause-analysis-quality-improvement-pediatric-anesthesia
    February 03, 2021 - Commentary Wake Up Safe and root cause analysis: quality improvement in pediatric anesthesia. Citation Text: Tjia I, Rampersad S, Varughese AM, et al. Wake Up Safe and root cause analysis: quality improvement in pediatric anesthesia. Anesth Analg. 2014;119(1):122-136. doi:10.1213/ANE.000…

  18. Variation in surgical time-out and site marking within pediatric otolaryngology. | PSNet

    psnet.ahrq.gov/issue/variation-surgical-time-out-and-site-marking-within-pediatric-otolaryngology
    October 27, 2010 - Study Variation in surgical time-out and site marking within pediatric otolaryngology. Citation Text: Shah RK, Arjmand E, Roberson DW, et al. Variation in surgical time-out and site marking within pediatric otolaryngology. Arch Otolaryngol Head Neck Surg. 2011;137(1):69-73. doi:10.1001/a…

  19. A piece of my mind. Despite my best intentions. | PSNet

    psnet.ahrq.gov/issue/piece-my-mind-despite-my-best-intentions
    September 13, 2016 - Commentary A piece of my mind. Despite my best intentions. Citation Text: Kahn JS. Despite My Best Intentions. JAMA. 2017;318(17). doi:10.1001/jama.2017.6123. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  20. Avoiding iatrogenic harm to patient and family while discussing goals of care near the end of life. | PSNet

    psnet.ahrq.gov/issue/avoiding-iatrogenic-harm-patient-and-family-while-discussing-goals-care-near-end-life
    September 09, 2010 - Review Avoiding iatrogenic harm to patient and family while discussing goals of care near the end of life. Citation Text: Weiner JS, Roth J. Avoiding iatrogenic harm to patient and family while discussing goals of care near the end of life. J Palliat Med. 2006;9(2):451-63. Copy Citat…
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