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Leadership and the high reliability transformation: a qualitative study at Truman VA medical center. | PSNet

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May 31, 2023 - Study Leadership and the high reliability transformation: a qualitative study at Truman VA medical center. Citation Text: Leonard C, Gilmartin HM, Starr LM, et al. Leadership and the high reliability transformation: a qualitative study at Truman VA medical center. J Healthc Risk Manag. 2…

Educator toolkits on second victim syndrome, mindfulness and meditation, and positive psychology: the 2017 Resident Wellness Consensus Summit. | PSNet

psnet.ahrq.gov/issue/educator-toolkits-second-victim-syndrome-mindfulness-and-meditation-and-positive-psychology

June 28, 2023 - Commentary Educator toolkits on second victim syndrome, mindfulness and meditation, and positive psychology: the 2017 Resident Wellness Consensus Summit. Citation Text: Chung AS, Smart J, Zdradzinski M, et al. Educator Toolkits on Second Victim Syndrome, Mindfulness and Meditation, and P…

Impact of the World Health Organization's Surgical Safety Checklist on safety culture in the operating theatre: a controlled intervention study. | PSNet

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November 03, 2015 - Study Impact of the World Health Organization's Surgical Safety Checklist on safety culture in the operating theatre: a controlled intervention study. Citation Text: Haugen AS, Søfteland E, Eide GE, et al. Impact of the World Health Organization's Surgical Safety Checklist on safety cu…

Transparency when things go wrong: physician attitudes about reporting medical errors to patients, peers, and institutions. | PSNet

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April 13, 2011 - Study Transparency when things go wrong: physician attitudes about reporting medical errors to patients, peers, and institutions. Citation Text: Bell SK, White AA, Yi JC, et al. Transparency When Things Go Wrong. J Patient Saf. 2015;13(4):243-248. doi:10.1097/pts.0000000000000153. Copy…

Application of failure mode effect analysis to improve the care of septic patients admitted through the emergency department. | PSNet

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February 01, 2013 - Study Application of failure mode effect analysis to improve the care of septic patients admitted through the emergency department. Citation Text: Alamry A, Owais SMA, Marini AM, et al. Application of Failure Mode Effect Analysis to Improve the Care of Septic Patients Admitted Through th…

A dynamic risk management approach for reducing harm from invasive bedside procedures performed during residency. | PSNet

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April 13, 2022 - Commentary A dynamic risk management approach for reducing harm from invasive bedside procedures performed during residency. Citation Text: Warm E, Ahmad Y, Kinnear B, et al. A dynamic risk management approach for reducing harm from invasive bedside procedures performed during residency.…

A comprehensive program to reduce rates of hospital-acquired pressure ulcers in a system of community hospitals. | PSNet

psnet.ahrq.gov/issue/comprehensive-program-reduce-rates-hospital-acquired-pressure-ulcers-system-community

May 12, 2021 - Study A comprehensive program to reduce rates of hospital-acquired pressure ulcers in a system of community hospitals. Citation Text: Englebright J, Westcott R, McManus K, et al. A Comprehensive Program to Reduce Rates of Hospital-Acquired Pressure Ulcers in a System of Community Hospita…

A target to achieve zero preventable trauma deaths through quality improvement. | PSNet

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March 03, 2011 - Study A target to achieve zero preventable trauma deaths through quality improvement. Citation Text: Hashmi ZG, Haut ER, Efron DT, et al. A Target to Achieve Zero Preventable Trauma Deaths Through Quality Improvement. JAMA Surg. 2018;153(7):686-689. doi:10.1001/jamasurg.2018.0159. Copy…

Implementing delivery room checklists and communication standards in a multi-neonatal ICU quality improvement collaborative. | PSNet

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November 20, 2019 - Study Implementing delivery room checklists and communication standards in a multi-neonatal ICU quality improvement collaborative. Citation Text: Bennett SC, Finer N, Halamek LP, et al. Implementing Delivery Room Checklists and Communication Standards in a Multi-Neonatal ICU Quality Impr…

Who applies an intervention to influence cultural attributes in a quality improvement collaborative? | PSNet

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January 22, 2016 - Study Who applies an intervention to influence cultural attributes in a quality improvement collaborative? Citation Text: Hsu Y-J, Marsteller JA. Who Applies an Intervention to Influence Cultural Attributes in a Quality Improvement Collaborative? J Patient Saf. 2020;16(1):1-6. Copy Cit…

Active surveillance of vaccine safety: a system to detect early signs of adverse events. | PSNet

psnet.ahrq.gov/issue/active-surveillance-vaccine-safety-system-detect-early-signs-adverse-events

March 29, 2010 - Study Active surveillance of vaccine safety: a system to detect early signs of adverse events. Citation Text: Davis RL, Kolczak M, Lewis E, et al. Active surveillance of vaccine safety: a system to detect early signs of adverse events. Epidemiology. 2005;16(3):336-41. Copy Citation …

Retained guidewires in the Veterans Health Administration: getting to the root of the problem. | PSNet

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March 13, 2013 - Study Retained guidewires in the Veterans Health Administration: getting to the root of the problem. Citation Text: Cherara L, Sculli GL, Paull DE, et al. Retained Guidewires in the Veterans Health Administration: Getting to the Root of the Problem. J Patient Saf. 2021;17(8):e991-e928. d…

Difficult diagnosis in the ICU: making the right call but beware uncertainty and bias. | PSNet

psnet.ahrq.gov/issue/difficult-diagnosis-icu-making-right-call-beware-uncertainty-and-bias

May 19, 2021 - Review Difficult diagnosis in the ICU: making the right call but beware uncertainty and bias. Citation Text: Pisciotta W, Arina P, Hofmaenner D, et al. Difficult diagnosis in the ICU: making the right call but beware uncertainty and bias. Anaesthesia. 2023;78(4):501-509. doi:10.1111/anae…

Blood bank specimen mislabeling: a College of American Pathologists Q-Probes study of 41,333 blood bank specimens in 30 institutions. | PSNet

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November 16, 2022 - Study Blood bank specimen mislabeling: a College of American Pathologists Q-Probes study of 41,333 blood bank specimens in 30 institutions. Citation Text: Novis DA, Lindholm PF, Ramsey G, et al. Blood Bank Specimen Mislabeling: A College of American Pathologists Q-Probes Study of 41 333 …

Crew resource management in the intensive care unit: a prospective 3-year cohort study. | PSNet

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August 10, 2022 - Study Crew resource management in the intensive care unit: a prospective 3-year cohort study. Citation Text: Haerkens MHTM, Kox M, Lemson J, et al. Crew Resource Management in the Intensive Care Unit: a prospective 3-year cohort study. Acta Anaesthesiol Scand. 2015;59(10):1319-29. doi:10…

The impact of rapid response team on outcome of patients transferred from the ward to the ICU: a single-center study. | PSNet

psnet.ahrq.gov/issue/impact-rapid-response-team-outcome-patients-transferred-ward-icu-single-center-study

May 27, 2011 - Study The impact of rapid response team on outcome of patients transferred from the ward to the ICU: a single-center study. Citation Text: Karpman C, Keegan MT, Jensen J, et al. The impact of rapid response team on outcome of patients transferred from the ward to the ICU: a single-cent…

Prevalence of triggers and patient harm identified by Global Trigger Tool in specialized palliative care. | PSNet

psnet.ahrq.gov/issue/prevalence-triggers-and-patient-harm-identified-global-trigger-tool-specialized-palliative

June 14, 2023 - Study Prevalence of triggers and patient harm identified by Global Trigger Tool in specialized palliative care. Citation Text: Fredheim OMS, Klingenberg E, Lindahl AK. Prevalence of triggers and patient harm identified by Global Trigger Tool in specialized palliative care. J Palliat Med.…

Incidence of adverse events in an integrated US healthcare system: a retrospective observational study of 82,784 surgical hospitalizations. | PSNet

psnet.ahrq.gov/issue/incidence-adverse-events-integrated-us-healthcare-system-retrospective-observational-study

April 08, 2011 - Study Incidence of adverse events in an integrated US healthcare system: a retrospective observational study of 82,784 surgical hospitalizations. Citation Text: Zeeshan MF, Dembe AE, Seiber EE, et al. Incidence of adverse events in an integrated US healthcare system: a retrospective obse…

Parental preferences for error disclosure, reporting, and legal action after medical error in the care of their children. | PSNet

psnet.ahrq.gov/issue/parental-preferences-error-disclosure-reporting-and-legal-action-after-medical-error-care

May 24, 2010 - Study Parental preferences for error disclosure, reporting, and legal action after medical error in the care of their children. Citation Text: Hobgood C, Tamayo-Sarver JH, Elms A, et al. Parental preferences for error disclosure, reporting, and legal action after medical error in the c…

Preventable anesthesia-related adverse events at a large tertiary care center: a nine-year retrospective analysis. | PSNet

psnet.ahrq.gov/issue/preventable-anesthesia-related-adverse-events-large-tertiary-care-center-nine-year

November 12, 2014 - Study Preventable anesthesia-related adverse events at a large tertiary care center: a nine-year retrospective analysis. Citation Text: Curatolo CJ, McCormick PJ, Hyman JB, et al. Preventable Anesthesia-Related Adverse Events at a Large Tertiary Care Center: A Nine-Year Retrospective Ana…

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