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psnet.ahrq.gov/issue/using-situ-simulation-improve-hospital-cardiopulmonary-resuscitation
January 02, 2017 - Study
Using in situ simulation to improve in-hospital cardiopulmonary resuscitation.
Citation Text:
Lighthall GK, Poon T, Harrison K. Using in situ simulation to improve in-hospital cardiopulmonary resuscitation. Jt Comm J Qual Patient Saf. 2010;36(5):209-16.
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psnet.ahrq.gov/issue/use-novel-modified-fishbone-diagram-analyze-diagnostic-errors
February 13, 2019 - Commentary
Use of a novel, modified fishbone diagram to analyze diagnostic errors.
Citation Text:
Reilly JB, Myers JS, Salvador D, et al. Use of a novel, modified fishbone diagram to analyze diagnostic errors. Diagnosis (Berl). 2014;1(2):167-171. doi:10.1515/dx-2013-0040.
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psnet.ahrq.gov/issue/randomized-trial-nighttime-physician-staffing-intensive-care-unit
September 23, 2020 - Study
A randomized trial of nighttime physician staffing in an intensive care unit.
Citation Text:
Kerlin MP, Small DS, Cooney E, et al. A randomized trial of nighttime physician staffing in an intensive care unit. N Engl J Med. 2013;368(23):2201-9. doi:10.1056/NEJMoa1302854.
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psnet.ahrq.gov/issue/she-lay-dying-how-i-fought-stop-medical-errors-killing-my-mom
December 19, 2012 - Commentary
As she lay dying: how I fought to stop medical errors from killing my mom.
Citation Text:
Welch JR. As she lay dying: how I fought to stop medical errors from killing my mom. Health Aff (Millwood). 2012;31(12):2817-2820. doi:10.1377/hlthaff.2012.0833.
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psnet.ahrq.gov/issue/revisiting-duty-hour-limits-iom-recommendations-patient-safety-and-resident-education
February 17, 2011 - Commentary
Revisiting duty-hour limits — IOM recommendations for patient safety and resident education.
Citation Text:
Iglehart JK. Revisiting duty-hour limits--IOM recommendations for patient safety and resident education. N Engl J Med. 2008;359(25):2633-5. doi:10.1056/NEJMp0808736.
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psnet.ahrq.gov/issue/journey-no-preventable-risk-baylor-health-care-system-patient-safety-experience
November 23, 2014 - Commentary
Journey to no preventable risk: The Baylor Health Care System patient safety experience.
Citation Text:
Kennerly DA, Richter KM, Good V, et al. Journey to no preventable risk: the Baylor Health Care System patient safety experience. Am J Med Qual. 2011;26(1):43-52. doi:10.11…
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psnet.ahrq.gov/issue/dissemination-lean-methods-improve-pap-testing-quality-and-patient-safety
June 14, 2011 - Study
Dissemination of Lean methods to improve Pap testing quality and patient safety.
Citation Text:
Raab SS, Andrew-JaJa C, Grzybicki DM, et al. Dissemination of Lean methods to improve Pap testing quality and patient safety. J Low Genit Tract Dis. 2009;12(2):103-110. doi:10.1097/lgt.0…
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psnet.ahrq.gov/issue/confused-and-bewildered-hospital-adverse-event-discovery-pay-performance-and-big-data-tools
September 23, 2020 - Commentary
The confused and bewildered hospital: adverse event discovery, pay-for-performance, and big data tools as halfway technologies.
Citation Text:
Furrow BR. The confused and bewildered hospital: adverse event discovery, pay-for-performance, and big data tools as halfway technolog…
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psnet.ahrq.gov/issue/educating-21st-century-health-care-system-interdependent-framework-basic-clinical-and-systems
August 28, 2024 - Commentary
Educating for the 21st-century health care system: an interdependent framework of basic, clinical, and systems sciences.
Citation Text:
Gonzalo JD, Haidet P, Papp KK, et al. Educating for the 21st-Century Health Care System: An Interdependent Framework of Basic, Clinical, and …
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psnet.ahrq.gov/issue/typology-electronic-health-record-workarounds-small-medium-size-primary-care-practices
November 30, 2016 - Study
A typology of electronic health record workarounds in small-to-medium size primary care practices.
Citation Text:
Friedman A, Crosson JC, Howard J, et al. A typology of electronic health record workarounds in small-to-medium size primary care practices. J Am Med Inform Assoc. 2014;…
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psnet.ahrq.gov/issue/barcode-medication-administration-software-technology-use-emergency-department-and-medication
November 04, 2015 - Study
Barcode medication administration software technology use in the emergency department and medication error rates.
Citation Text:
Gauthier-Wetzel HE. Barcode medication administration software technology use in the emergency department and medication error rates. Comput Inform Nurs.…
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psnet.ahrq.gov/issue/seips-101-and-seven-simple-seips-tools
October 03, 2013 - Commentary
SEIPS 101 and seven simple SEIPS tools.
Citation Text:
Holden RJ, Carayon P. SEIPS 101 and seven simple SEIPS tools. BMJ Qual Saf. 2021;30(11):901-910. doi:10.1136/bmjqs-2020-012538.
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psnet.ahrq.gov/issue/teamwork-and-team-performance-multidisciplinary-cancer-teams-development-and-evaluation
August 11, 2010 - Study
Teamwork and team performance in multidisciplinary cancer teams: development and evaluation of an observational assessment tool.
Citation Text:
Lamb BW, Vincent CA, Green JSA, et al. Teamwork and team performance in multidisciplinary cancer teams: development and evaluation of an…
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psnet.ahrq.gov/issue/observational-study-frequency-severity-and-etiology-failures-postoperative-care-after-major
August 11, 2010 - Study
An observational study of the frequency, severity, and etiology of failures in postoperative care after major elective general surgery.
Citation Text:
Symons NRA, Almoudaris AM, Nagpal K, et al. An observational study of the frequency, severity, and etiology of failures in postop…
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psnet.ahrq.gov/issue/toward-theoretical-approach-medical-error-reporting-system-research-and-design
November 30, 2011 - Study
Toward a theoretical approach to medical error reporting system research and design.
Citation Text:
Karsh B-T, Escoto KH, Beasley JW, et al. Toward a theoretical approach to medical error reporting system research and design. Appl Ergon. 2006;37(3):283-95.
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psnet.ahrq.gov/issue/human-factors-and-simulation-emergency-medicine
November 16, 2022 - Commentary
Human factors and simulation in emergency medicine.
Citation Text:
Hayden EM, Wong AH, Ackerman J, et al. Human Factors and Simulation in Emergency Medicine. Acad Emerg Med. 2018;25(2):221-229. doi:10.1111/acem.13315.
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psnet.ahrq.gov/issue/medical-errors-orthopaedics-results-aaos-member-survey
August 04, 2021 - Study
Medical errors in orthopaedics. Results of an AAOS member survey.
Citation Text:
Wong DA, Herndon JH, Canale T, et al. Medical errors in orthopaedics. Results of an AAOS member survey. J Bone Joint Surg Am. 2009;91(3):547-57. doi:10.2106/JBJS.G.01439.
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psnet.ahrq.gov/issue/human-factors-framework-and-study-effect-nursing-workload-patient-safety-and-employee-quality
May 16, 2012 - Study
A human factors framework and study of the effect of nursing workload on patient safety and employee quality of working life.
Citation Text:
Holden RJ, Scanlon MC, Patel NR, et al. A human factors framework and study of the effect of nursing workload on patient safety and employe…
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psnet.ahrq.gov/issue/creating-culture-safety-around-bar-code-medication-administration-evidence-based-evaluation
July 14, 2010 - Commentary
Creating a culture of safety around bar-code medication administration: an evidence-based evaluation framework.
Citation Text:
Kelly K, Harrington L, Matos P, et al. Creating a Culture of Safety Around Bar-Code Medication Administration: An Evidence-Based Evaluation Framework.…
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psnet.ahrq.gov/issue/key-performance-outcomes-patient-safety-curricula-root-cause-analysis-failure-mode-and
July 23, 2010 - Commentary
Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects analysis, and structured communications skills.
Citation Text:
Fassett WE. Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects …