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Using root cause analysis to reduce falls with injury in community settings. | PSNet

psnet.ahrq.gov/issue/using-root-cause-analysis-reduce-falls-injury-community-settings

April 25, 2016 - Study Using root cause analysis to reduce falls with injury in community settings. Citation Text: Lee A, Mills PD, Neily J. Using root cause analysis to reduce falls with injury in community settings. Jt Comm J Qual Patient Saf. 2012;38(8):366-374. Copy Citation Format: Goo…

Surgical skill is predicted by the ability to detect errors. | PSNet

psnet.ahrq.gov/issue/surgical-skill-predicted-ability-detect-errors

September 02, 2020 - Study Surgical skill is predicted by the ability to detect errors. Citation Text: Bann S, Khan M, Datta V, et al. Surgical skill is predicted by the ability to detect errors. Am J Surg. 2005;189(4):412-5. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML E…

Using simulation-based training to improve patient safety: what does it take? | PSNet

psnet.ahrq.gov/issue/using-simulation-based-training-improve-patient-safety-what-does-it-take

August 30, 2006 - Commentary Using simulation-based training to improve patient safety: what does it take? Citation Text: Salas E, Wilson K, Burke S, et al. Using simulation-based training to improve patient safety: what does it take? Jt Comm J Qual Patient Saf. 2005;31(7):363-71. Copy Citation Form…

An insurer's care transition program emphasizes medication reconciliation, reduces readmissions and costs. | PSNet

psnet.ahrq.gov/issue/insurers-care-transition-program-emphasizes-medication-reconciliation-reduces-readmissions

November 08, 2017 - Study An insurer's care transition program emphasizes medication reconciliation, reduces readmissions and costs. Citation Text: Polinski JM, Moore JM, Kyrychenko P, et al. An Insurer's Care Transition Program Emphasizes Medication Reconciliation, Reduces Readmissions And Costs. Health Af…

Improving situation awareness to advance patient outcomes: a systematic literature review. | PSNet

psnet.ahrq.gov/issue/improving-situation-awareness-advance-patient-outcomes-systematic-literature-review

January 16, 2010 - Review Improving situation awareness to advance patient outcomes: a systematic literature review. Citation Text: Alqarrain Y, Roudsari A, Courtney KL, et al. Improving situation awareness to advance patient outcomes: a systematic literature review. Comput Inform Nurs. 2024;42(4):277-288.…

Checking it twice: an evaluation of checklists for detecting medication errors at the bedside using a chemotherapy model. | PSNet

psnet.ahrq.gov/issue/checking-it-twice-evaluation-checklists-detecting-medication-errors-bedside-using

September 26, 2016 - Study Checking it twice: an evaluation of checklists for detecting medication errors at the bedside using a chemotherapy model. Citation Text: White RE, Trbovich PL, Easty AC, et al. Checking it twice: an evaluation of checklists for detecting medication errors at the bedside using a c…

Impact of date stamping on patient safety measurement in patients undergoing CABG: experience with the AHRQ Patient Safety Indicators. | PSNet

psnet.ahrq.gov/issue/impact-date-stamping-patient-safety-measurement-patients-undergoing-cabg-experience-ahrq

December 21, 2014 - Study Impact of date stamping on patient safety measurement in patients undergoing CABG: experience with the AHRQ Patient Safety Indicators. Citation Text: Glance LG, Li Y, Osler T, et al. Impact of date stamping on patient safety measurement in patients undergoing CABG: experience wit…

Representative case series from public hospital admissions 1998 II: surgical adverse events. | PSNet

psnet.ahrq.gov/issue/representative-case-series-public-hospital-admissions-1998-ii-surgical-adverse-events

June 07, 2023 - Study Representative case series from public hospital admissions 1998 II: surgical adverse events. Citation Text: Briant R, Morton J, Lay-Yee R, et al. Representative case series from public hospital admissions 1998 II: surgical adverse events. N Z Med J. 2005;118(1219):U1591. Copy C…

When doing wrong feels so right: normalization of deviance. | PSNet

psnet.ahrq.gov/issue/when-doing-wrong-feels-so-right-normalization-deviance

September 03, 2011 - Review When doing wrong feels so right: normalization of deviance. Citation Text: Price MR, Williams TC. When Doing Wrong Feels So Right: Normalization of Deviance. J Patient Saf. 2018;14(1):1-2. doi:10.1097/PTS.0000000000000157. Copy Citation Format: DOI Google Scholar Pub…

In situ simulated cardiac arrest exercises to detect system vulnerabilities. | PSNet

psnet.ahrq.gov/issue/situ-simulated-cardiac-arrest-exercises-detect-system-vulnerabilities

June 27, 2012 - Study In situ simulated cardiac arrest exercises to detect system vulnerabilities. Citation Text: Barbeito A, Bonifacio AS, Holtschneider M, et al. In situ simulated cardiac arrest exercises to detect system vulnerabilities. Simul Healthc. 2015;10(3):154-62. doi:10.1097/SIH.0000000000000…

Adverse effects of computers during bedside rounds in a critical care unit. | PSNet

psnet.ahrq.gov/issue/adverse-effects-computers-during-bedside-rounds-critical-care-unit

August 02, 2015 - Study Adverse effects of computers during bedside rounds in a critical care unit. Citation Text: Dhillon NK, Francis SE, Tatum JM, et al. Adverse Effects of Computers During Bedside Rounds in a Critical Care Unit. JAMA Surg. 2018;153(11):1052-1053. doi:10.1001/jamasurg.2018.1752. Copy …

Measuring communication in the surgical ICU: better communication equals better care. | PSNet

psnet.ahrq.gov/issue/measuring-communication-surgical-icu-better-communication-equals-better-care

April 03, 2005 - Study Measuring communication in the surgical ICU: better communication equals better care. Citation Text: Williams M, Hevelone N, Alban RF, et al. Measuring communication in the surgical ICU: better communication equals better care. J Am Coll Surg. 2010;210(1):17-22. doi:10.1016/j.jamc…

Clinician-directed performance improvement: moving beyond externally mandated metrics. | PSNet

psnet.ahrq.gov/issue/clinician-directed-performance-improvement-moving-beyond-externally-mandated-metrics

July 10, 2008 - Commentary Clinician-directed performance improvement: moving beyond externally mandated metrics. Citation Text: Goitein L. Clinician-directed performance improvement: moving beyond externally mandated metrics. Health Aff (Millwood). 2020;39(2). doi:10.1377/hlthaff.2019.00505. Copy Cit…

The use of a checklist in a pediatric oncology clinic. | PSNet

psnet.ahrq.gov/issue/use-checklist-pediatric-oncology-clinic

April 24, 2019 - Study The use of a checklist in a pediatric oncology clinic. Citation Text: McLean TW, White GM, Bagliani AF, et al. The use of a checklist in a pediatric oncology clinic. Pediatr Blood Cancer. 2013;60(11):1855-9. doi:10.1002/pbc.24657. Copy Citation Format: DOI Google Sch…

"See One, Sim One, Do One"—a national pre-internship boot-camp to ensure a safer "student to doctor" transition. | PSNet

psnet.ahrq.gov/issue/see-one-sim-one-do-one-national-pre-internship-boot-camp-ensure-safer-student-doctor

February 16, 2011 - Study "See One, Sim One, Do One"—a national pre-internship boot-camp to ensure a safer "student to doctor" transition. Citation Text: Minha S'ar, Shefet D, Sagi D, et al. "See One, Sim One, Do One"- A National Pre-Internship Boot-Camp to Ensure a Safer "Student to Doctor" Transition. PLo…

Potentially avoidable hospitalizations among historically marginalized nursing home residents. | PSNet

psnet.ahrq.gov/issue/potentially-avoidable-hospitalizations-among-historically-marginalized-nursing-home-residents

September 09, 2011 - Study Potentially avoidable hospitalizations among historically marginalized nursing home residents. Citation Text: Estrada LV, Barcelona V, Dhingra L, et al. Potentially avoidable hospitalizations among historically marginalized nursing home residents. JAMA Netw Open. 2024;7(5):e249312.…

Do first opinions affect second opinions? | PSNet

psnet.ahrq.gov/issue/do-first-opinions-affect-second-opinions

October 07, 2020 - Study Do first opinions affect second opinions? Citation Text: Vashitz G, Pliskin JS, Parmet Y, et al. Do First Opinions Affect Second Opinions? J Gen Intern Med. 2012;27(10). doi:10.1007/s11606-012-2056-y. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndN…

Increasing patient safety event reporting in 2 intensive care units: A prospective interventional study. | PSNet

psnet.ahrq.gov/issue/increasing-patient-safety-event-reporting-2-intensive-care-units-prospective-interventional

January 11, 2017 - Study Increasing patient safety event reporting in 2 intensive care units: A prospective interventional study. Citation Text: Ilan R, Squires M, Panopoulos C, et al. Increasing patient safety event reporting in 2 intensive care units: a prospective interventional study. J Crit Care. 20…

Toward a new paradigm in hospital-based pediatric education: the development of an onsite simulator program. | PSNet

psnet.ahrq.gov/issue/toward-new-paradigm-hospital-based-pediatric-education-development-onsite-simulator-program

May 18, 2022 - Commentary Toward a new paradigm in hospital-based pediatric education: the development of an onsite simulator program. Citation Text: Weinstock PH, Kappus LJ, Kleinman ME, et al. Toward a new paradigm in hospital-based pediatric education: the development of an onsite simulator progra…

Developing a systematic approach to safer medication use during pregnancy: summary of a Centers for Disease Control and Prevention–convened meeting. | PSNet

psnet.ahrq.gov/issue/developing-systematic-approach-safer-medication-use-during-pregnancy-summary-centers-disease

February 17, 2011 - Commentary Developing a systematic approach to safer medication use during pregnancy: summary of a Centers for Disease Control and Prevention–convened meeting. Citation Text: Broussard CS, Frey MT, Hernandez-Diaz S, et al. Developing a systematic approach to safer medication use during p…

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