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Two decades since To Err Is Human: an assessment of progress and emerging priorities in patient safety. | PSNet

psnet.ahrq.gov/issue/two-decades-err-human-assessment-progress-and-emerging-priorities-patient-safety

January 16, 2019 - Commentary Classic Two decades since To Err Is Human: an assessment of progress and emerging priorities in patient safety. Citation Text: Bates DW, Singh H. Two Decades Since To Err Is Human: An Assessment Of Progress And Emerging Priorities In Patient Safety. H…

Exposure to incivility hinders clinical performance in a simulated operative crisis. | PSNet

psnet.ahrq.gov/issue/exposure-incivility-hinders-clinical-performance-simulated-operative-crisis

June 14, 2019 - Study Emerging Classic Exposure to incivility hinders clinical performance in a simulated operative crisis. Citation Text: Katz D, Blasius K, Isaak R, et al. Exposure to incivility hinders clinical performance in a simulated operative crisis. BMJ Qual Saf. 2019;…

Appropriate use of medical interpreters in the breast imaging clinic. | PSNet

psnet.ahrq.gov/issue/appropriate-use-medical-interpreters-breast-imaging-clinic

October 16, 2024 - Commentary Appropriate use of medical interpreters in the breast imaging clinic. Citation Text: Feliciano-Rivera YZ, Yepes MM, Sanchez P, et al. Appropriate use of medical interpreters in the breast imaging clinic. J Breast Imaging. 2024;27(3):296-303. doi:10.1093/jbi/wbad109. Copy Cit…

In situ simulation as a quality improvement tool to identify and mitigate latent safety threats for emergency department SARS-CoV-2 airway management: a multi-institutional initiative. | PSNet

psnet.ahrq.gov/issue/situ-simulation-quality-improvement-tool-identify-and-mitigate-latent-safety-threats

February 22, 2023 - Study In situ simulation as a quality improvement tool to identify and mitigate latent safety threats for emergency department SARS-CoV-2 airway management: a multi-institutional initiative. Citation Text: Yang CJ, Saggar V, Seneviratne N, et al. In situ simulation as a quality improveme…

Adaption of a trigger tool to identify harmful incidents, no harm incidents, and near misses in prehospital emergency care of children. | PSNet

psnet.ahrq.gov/issue/adaption-trigger-tool-identify-harmful-incidents-no-harm-incidents-and-near-misses

May 25, 2022 - Study Adaption of a trigger tool to identify harmful incidents, no harm incidents, and near misses in prehospital emergency care of children. Citation Text: Packendorff N, Magnusson C, Axelsson C, et al. Adaption of a trigger tool to identify harmful incidents, no harm incidents, and nea…

Patient safety indicators during the initial COVID-19 pandemic surge in the United States. | PSNet

psnet.ahrq.gov/issue/patient-safety-indicators-during-initial-covid-19-pandemic-surge-united-states

August 03, 2022 - Study Patient safety indicators during the initial COVID-19 pandemic surge in the United States. Citation Text: Rodriguez JA, Samal L, Ganesan S, et al. Patient safety indicators during the initial COVID-19 pandemic surge in the United States. J Patient Saf. 2024;20(4):247-251. doi:10.10…

Clinical efficacy of combined surgical patient safety system and the World Health Organization's checklists in surgery: a nonrandomized clinical trial. | PSNet

psnet.ahrq.gov/issue/clinical-efficacy-combined-surgical-patient-safety-system-and-world-health-organizations

November 03, 2015 - Study Emerging Classic Clinical efficacy of combined surgical patient safety system and the World Health Organization's checklists in surgery: a nonrandomized clinical trial. Citation Text: Storesund A, Haugen AS, Flaatten H, et al. Clinical Efficacy of Combined…

Decreasing prescribing errors during pediatric emergencies: a randomized simulation trial. | PSNet

psnet.ahrq.gov/issue/decreasing-prescribing-errors-during-pediatric-emergencies-randomized-simulation-trial

October 08, 2013 - Study Decreasing prescribing errors during pediatric emergencies: a randomized simulation trial. Citation Text: Larose G, Levy A, Bailey B, et al. Decreasing Prescribing Errors During Pediatric Emergencies: A Randomized Simulation Trial. Pediatrics. 2017;139(3). doi:10.1542/peds.2016-320…

Patient safety monitoring in acute care in a decentralized national health care system: conceptual framework and initial set of actionable indicators. | PSNet

psnet.ahrq.gov/issue/patient-safety-monitoring-acute-care-decentralized-national-health-care-system-conceptual

July 27, 2022 - Study Patient safety monitoring in acute care in a decentralized national health care system: conceptual framework and initial set of actionable indicators. Citation Text: Barbara L, Roberta DB, Vanda R, et al. Patient safety monitoring in acute care in a decentralized national health ca…

Effectiveness of a 'Do not interrupt' bundled intervention to reduce interruptions during medication administration: a cluster randomised controlled feasibility study. | PSNet

psnet.ahrq.gov/issue/effectiveness-do-not-interrupt-bundled-intervention-reduce-interruptions-during-medication

August 26, 2020 - Study Classic Effectiveness of a 'Do not interrupt' bundled intervention to reduce interruptions during medication administration: a cluster randomised controlled feasibility study. Citation Text: Westbrook JI, Li L, Hooper TD, et al. Effectiveness of a 'Do not …

Association between workarounds and medication administration errors in bar-code-assisted medication administration in hospitals. | PSNet

psnet.ahrq.gov/issue/association-between-workarounds-and-medication-administration-errors-bar-code-assisted

August 26, 2020 - Study Classic Association between workarounds and medication administration errors in bar-code-assisted medication administration in hospitals. Citation Text: van der Veen W, van den Bemt PMLA, Wouters H, et al. Association between workarounds and medication adm…

Our current approach to root cause analysis: is it contributing to our failure to improve patient safety? | PSNet

psnet.ahrq.gov/issue/our-current-approach-root-cause-analysis-it-contributing-our-failure-improve-patient-safety

October 23, 2013 - Study Classic Our current approach to root cause analysis: is it contributing to our failure to improve patient safety? Citation Text: Kellogg KM, Hettinger Z, Shah M, et al. Our current approach to root cause analysis: is it contributing to our failure to impro…

Does root cause analysis improve patient safety? A systematic review at the Department of Veterans Affairs. | PSNet

psnet.ahrq.gov/issue/does-root-cause-analysis-improve-patient-safety-systematic-review-department-veterans-affairs

March 24, 2021 - Review Does root cause analysis improve patient safety? A systematic review at the Department of Veterans Affairs. Citation Text: Shah F, Falconer EA, Cimiotti JP. Does root cause analysis improve patient safety? A systematic review at the Department of Veterans Affairs. Qual Manag Healt…

Effect on patient safety of a resident physician schedule without 24-hour shifts. | PSNet

psnet.ahrq.gov/issue/effect-patient-safety-resident-physician-schedule-without-24-hour-shifts

March 10, 2021 - Study Emerging Classic Effect on patient safety of a resident physician schedule without 24-hour shifts. Citation Text: Landrigan CP, Rahman SA, Sullivan JP, et al. Effect on patient safety of a resident physician schedule without 24-hour shifts. N Engl J Med. 2…

Early experience of peer advocate program: using quality improvement to optimize behavioral and communication disconnect in the operating room. | PSNet

psnet.ahrq.gov/issue/early-experience-peer-advocate-program-using-quality-improvement-optimize-behavioral-and

September 23, 2020 - Study Early experience of peer advocate program: using quality improvement to optimize behavioral and communication disconnect in the operating room. Citation Text: Eckhouse SR, Huston M, Smith ER, et al. Early experience of peer advocate program: using quality improvement to optimize be…

Why is learning from patient safety incidents (still) so hard? A sociocultural perspective on learning from incidents in healthcare organizations. | PSNet

psnet.ahrq.gov/issue/why-learning-patient-safety-incidents-still-so-hard-sociocultural-perspective-learning

June 29, 2011 - Study Why is learning from patient safety incidents (still) so hard? A sociocultural perspective on learning from incidents in healthcare organizations. Citation Text: Rowland P, Lan MF, Wan C, et al. Why is learning from patient safety incidents (still) so hard? A sociocultural perspect…

Implicit bias in the patient descriptor "homeless" and its association with emergency department opioid administration and disposition. | PSNet

psnet.ahrq.gov/issue/implicit-bias-patient-descriptor-homeless-and-its-association-emergency-department-opioid

December 15, 2021 - Study Implicit bias in the patient descriptor "homeless" and its association with emergency department opioid administration and disposition. Citation Text: Lauricella M, Nene RV, Coyne CJ, et al. Implicit bias in the patient descriptor “homeless” and its association with emergency depar…

Surgeon perception and attitude towards the moral imperative of institutionally addressing second-victim syndrome in surgery. | PSNet

psnet.ahrq.gov/issue/surgeon-perception-and-attitude-towards-moral-imperative-institutionally-addressing-second

March 24, 2019 - Study Surgeon perception and attitude towards the moral imperative of institutionally addressing second-victim syndrome in surgery. Citation Text: Hsiao L-H, Kopar PK. Surgeon perception and attitude towards the moral imperative of institutionally addressing second-victim syndrome in sur…

Medical teamwork and the evolution of safety science: a critical review. | PSNet

psnet.ahrq.gov/issue/medical-teamwork-and-evolution-safety-science-critical-review

January 26, 2022 - Review Medical teamwork and the evolution of safety science: a critical review. Citation Text: Neuhaus C, Lutnæs DE, Bergström J. Medical teamwork and the evolution of safety science: a critical review. Cogn Technol Work. 2020;22(1):13-27. doi:10.1007/s10111-019-00545-8. Copy Citation …

Prevalence and characterisation of diagnostic error among 7-day all-cause hospital medicine readmissions: a retrospective cohort study. | PSNet

psnet.ahrq.gov/issue/prevalence-and-characterisation-diagnostic-error-among-7-day-all-cause-hospital-medicine

April 12, 2023 - Study Prevalence and characterisation of diagnostic error among 7-day all-cause hospital medicine readmissions: a retrospective cohort study. Citation Text: Raffel KE, Kantor MA, Barish P, et al. Prevalence and characterisation of diagnostic error among 7-day all-cause hospital medicine …

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