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American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update. | PSNet

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October 23, 2018 - Review American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update. Citation Text: Ban KA, Minei JP, Laronga C, et al. American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update. J Am Coll …

Standardized orders for titrating vasopressors: do efforts to improve safety slow delivery of care? | PSNet

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March 20, 2019 - Commentary Standardized orders for titrating vasopressors: do efforts to improve safety slow delivery of care? Citation Text: Baker DW, Campbell R. Standardized Orders for Titrating Vasopressors: Do Efforts to Improve Safety Slow Delivery of Care? Jt Comm J Qual Patient Saf. 2019;45(9):5…

Learning from preventable deaths: exploring case record reviewers' narratives using change analysis. | PSNet

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June 17, 2014 - Study Learning from preventable deaths: exploring case record reviewers' narratives using change analysis. Citation Text: Hogan H, Healey F, Neale G, et al. Learning from preventable deaths: exploring case record reviewers' narratives using change analysis. J R Soc Med. 2014;107(9):365-7…

Adopting high reliability organization principles to lead a large scale clinical transformation. | PSNet

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November 21, 2021 - Commentary Adopting high reliability organization principles to lead a large scale clinical transformation. Citation Text: Pozzobon LD, Lam J, Chimonides E, et al. Adopting high reliability organization principles to lead a large scale clinical transformation. Healthc Manage Forum. 2023;…

Information transfer in multidisciplinary operating room teams: a simulation-based observational study. | PSNet

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November 17, 2014 - Study Information transfer in multidisciplinary operating room teams: a simulation-based observational study. Citation Text: Cumin D, Skilton C, Weller J. Information transfer in multidisciplinary operating room teams: a simulation-based observational study. BMJ Qual Saf. 2017;26(3):209-…

Emergency departments are higher-risk locations for wrong blood in tube errors. | PSNet

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November 17, 2021 - Study Emergency departments are higher-risk locations for wrong blood in tube errors. Citation Text: Dunbar NM, Delaney M, Murphy MF, et al. Emergency departments are higher‐risk locations for wrong blood in tube errors. Transfusion (Paris). 2021;61(9):2601-2610. doi:10.1111/trf.16588. …

Putting the "action" in RCA(2): an analysis of intervention strength after adverse events. | PSNet

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April 17, 2024 - Study Putting the "action" in RCA(2): an analysis of intervention strength after adverse events. Citation Text: Zerillo JA, Tardiff SA, Flood D, et al. Putting the "action" in RCA(2): an analysis of intervention strength after adverse events. Jt Comm J Qual Patient Saf. 2024;50(7):492-49…

Effect of noise on auditory processing in the operating room. | PSNet

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November 16, 2022 - Study Effect of noise on auditory processing in the operating room. Citation Text: Way J, Long A, Weihing J, et al. Effect of noise on auditory processing in the operating room. J Am Coll Surg. 2013;216(5):933-8. doi:10.1016/j.jamcollsurg.2012.12.048. Copy Citation Format: …

Does lean management improve patient safety culture? An extensive evaluation of safety culture in a radiotherapy institute. | PSNet

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December 05, 2018 - Study Does lean management improve patient safety culture? An extensive evaluation of safety culture in a radiotherapy institute. Citation Text: Simons P, Houben R, Vlayen A, et al. Does lean management improve patient safety culture? An extensive evaluation of safety culture in a radiot…

Clinical communities at Johns Hopkins Medicine: an emerging approach to quality improvement. | PSNet

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November 16, 2022 - Commentary Clinical communities at Johns Hopkins Medicine: an emerging approach to quality improvement. Citation Text: Gould LJ, Wachter PA, Aboumatar HJ, et al. Clinical Communities at Johns Hopkins Medicine: An Emerging Approach to Quality Improvement. Jt Comm J Qual Patient Saf. 2015;…

Serious hazards of transfusion: evaluating the dangers of a wrong patient autologous salvaged blood in cardiac surgery. | PSNet

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May 11, 2022 - Commentary Serious hazards of transfusion: evaluating the dangers of a wrong patient autologous salvaged blood in cardiac surgery. Citation Text: Uramatsu M, Maeda H, Mishima S, et al. Serious hazards of transfusion: evaluating the dangers of a wrong patient autologous salvaged blood in …

What we can do about maternal mortality—and how to do it quickly. | PSNet

psnet.ahrq.gov/issue/what-we-can-do-about-maternal-mortality-and-how-do-it-quickly

September 01, 2016 - Commentary Emerging Classic What we can do about maternal mortality—and how to do it quickly. Citation Text: Mann S, Hollier LM, McKay K, et al. What We Can Do about Maternal Mortality - And How to Do It Quickly. New Engl J Med. 2018;379(18):1689-1691. doi:10.10…

Randomized trial to improve prescribing safety in ambulatory elderly patients. | PSNet

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March 10, 2011 - Study Randomized trial to improve prescribing safety in ambulatory elderly patients. Citation Text: Raebel MA, Charles J, Dugan J, et al. Randomized trial to improve prescribing safety in ambulatory elderly patients. J Am Geriatr Soc. 2007;55(7):977-85. Copy Citation Format: …

Using potentially preventable severe maternal morbidity to monitor hospital performance. | PSNet

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February 02, 2022 - Study Using potentially preventable severe maternal morbidity to monitor hospital performance. Citation Text: Fridman M, Korst LM, Reynen DJ, et al. Using potentially preventable severe maternal morbidity to monitor hospital performance. Jt Comm J Qual Patient Saf. 2023;49(3):129-137. do…

Improving safety by evaluating the impact of the supply chain and drug shortages on health-systems. | PSNet

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November 04, 2020 - Commentary Improving safety by evaluating the impact of the supply chain and drug shortages on health-systems. Citation Text: Patel V, Cieslak K, Hertig JB. Improving safety by evaluating the impact of the supply chain and drug shortages on health-systems. Hosp Pharm. 2023;58(2):120-124.…

Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication station. | PSNet

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July 27, 2018 - Study Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication station. Citation Text: Colligan L, Guerlain S, Steck SE, et al. Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication…

Adverse events present on arrival to the emergency department: the ED as a dual safety net. | PSNet

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September 30, 2020 - Study Adverse events present on arrival to the emergency department: the ED as a dual safety net. Citation Text: Griffey RT, Schneider RM, Todorov AA. Adverse Events Present on Arrival to the Emergency Department: The ED as a Dual Safety Net. Jt Comm J Qual Patient Saf. 2020;46(4):192-19…

Unsafe by design: infusion task reallocation and safety perceptions in U.S. hospitals. | PSNet

psnet.ahrq.gov/issue/unsafe-design-infusion-task-reallocation-and-safety-perceptions-us-hospitals

December 21, 2017 - Study Unsafe by design: infusion task reallocation and safety perceptions in U.S. hospitals. Citation Text: Pratt BR, Dunford BB, Vogus TJ, et al. Unsafe by design: infusion task reallocation and safety perceptions in U.S. hospitals. Health Care Manage Rev. 2022;48(1):14-22. doi:10.1097/…

Teaching medical error disclosure to physicians-in-training: a scoping review. | PSNet

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June 09, 2015 - Review Teaching medical error disclosure to physicians-in-training: a scoping review. Citation Text: Stroud L, Wong BM, Hollenberg E, et al. Teaching medical error disclosure to physicians-in-training: a scoping review. Acad Med. 2013;88(6):884-92. doi:10.1097/ACM.0b013e31828f898f. Cop…

Reducing the rate of catheter-associated bloodstream infections in a surgical intensive care unit using the Institute for Healthcare Improvement Central Line Bundle. | PSNet

psnet.ahrq.gov/issue/reducing-rate-catheter-associated-bloodstream-infections-surgical-intensive-care-unit-using

November 16, 2022 - Study Reducing the rate of catheter-associated bloodstream infections in a surgical intensive care unit using the Institute for Healthcare Improvement Central Line Bundle. Citation Text: Sacks GD, Diggs BS, Hadjizacharia P, et al. Reducing the rate of catheter-associated bloodstream infe…

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