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A morbidity and mortality conference-based classification system for adverse events: surgical outcome analysis: part I. | PSNet

psnet.ahrq.gov/issue/morbidity-and-mortality-conference-based-classification-system-adverse-events-surgical

January 28, 2009 - Study A morbidity and mortality conference-based classification system for adverse events: surgical outcome analysis: part I. Citation Text: Antonacci AC, Lam S, Lavarias V, et al. A morbidity and mortality conference-based classification system for adverse events: surgical outcome ana…

How to improve the delivery of medication alerts within computerized physician order entry systems: an international Delphi study. | PSNet

psnet.ahrq.gov/issue/how-improve-delivery-medication-alerts-within-computerized-physician-order-entry-systems

October 30, 2013 - Study How to improve the delivery of medication alerts within computerized physician order entry systems: an international Delphi study. Citation Text: Riedmann D, Jung M, Hackl WO, et al. How to improve the delivery of medication alerts within computerized physician order entry systems:…

Repeat medication errors in nursing homes: contributing factors and their association with patient harm. | PSNet

psnet.ahrq.gov/issue/repeat-medication-errors-nursing-homes-contributing-factors-and-their-association-patient

August 07, 2013 - Study Repeat medication errors in nursing homes: contributing factors and their association with patient harm. Citation Text: Crespin DJ, Modi A, Wei D, et al. Repeat medication errors in nursing homes: Contributing factors and their association with patient harm. Am J Geriatr Pharmaco…

What do patients think about year-end resident continuity clinic handoffs?: a qualitative study. | PSNet

psnet.ahrq.gov/issue/what-do-patients-think-about-year-end-resident-continuity-clinic-handoffs-qualitative-study

March 28, 2018 - Study What do patients think about year-end resident continuity clinic handoffs?: a qualitative study. Citation Text: Pincavage A, Lee WW, Beiting KJ, et al. What do patients think about year-end resident continuity clinic handoffs? A qualitative study. J Gen Intern Med. 2013;28(8):999-1…

Improving our understanding of multi-tasking in healthcare: drawing together the cognitive psychology and healthcare literature. | PSNet

psnet.ahrq.gov/issue/improving-our-understanding-multi-tasking-healthcare-drawing-together-cognitive-psychology

July 19, 2018 - Review Improving our understanding of multi-tasking in healthcare: drawing together the cognitive psychology and healthcare literature. Citation Text: Douglas HE, Raban MZ, Walter SR, et al. Improving our understanding of multi-tasking in healthcare: Drawing together the cognitive psycho…

Patient safety and the problem of many hands. | PSNet

psnet.ahrq.gov/issue/patient-safety-and-problem-many-hands

June 16, 2021 - Commentary Patient safety and the problem of many hands. Citation Text: Dixon-Woods M, Pronovost P. Patient safety and the problem of many hands. BMJ Qual Saf. 2016;25(7):485-488. doi:10.1136/bmjqs-2016-005232. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote …

Improving team information sharing with a structured call-out in anaesthetic emergencies: a randomized controlled trial. | PSNet

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November 17, 2014 - Study Improving team information sharing with a structured call-out in anaesthetic emergencies: a randomized controlled trial. Citation Text: Weller JM, Torrie J, Boyd M, et al. Improving team information sharing with a structured call-out in anaesthetic emergencies: a randomized control…

Thresholds, rules and defensive strategies: how physicians learn from their prior diagnosis-related experiences. | PSNet

psnet.ahrq.gov/issue/thresholds-rules-and-defensive-strategies-how-physicians-learn-their-prior-diagnosis-related

April 15, 2020 - Study Thresholds, rules and defensive strategies: how physicians learn from their prior diagnosis-related experiences. Citation Text: Donner-Banzhoff N, Müller B, Beyer M, et al. Thresholds, rules and defensive strategies: how physicians learn from their prior diagnosis-related experienc…

The effects of patient handoff characteristics on subsequent care: a systematic review and areas for future research. | PSNet

psnet.ahrq.gov/issue/effects-patient-handoff-characteristics-subsequent-care-systematic-review-and-areas-future

January 19, 2011 - Review The effects of patient handoff characteristics on subsequent care: a systematic review and areas for future research. Citation Text: Foster S, Manser T. The effects of patient handoff characteristics on subsequent care: a systematic review and areas for future research. Acad Med.…

Seen through the patients' eyes: surgical safety and checklists. | PSNet

psnet.ahrq.gov/issue/seen-through-patients-eyes-surgical-safety-and-checklists

May 16, 2018 - Study Seen through the patients' eyes: surgical safety and checklists. Citation Text: Bergs J, Lambrechts F, Desmedt M, et al. Seen through the patients' eyes: surgical safety and checklists. Int J Qual Health Care. 2018;30(2):118-123. doi:10.1093/intqhc/mzx180. Copy Citation Forma…

More holes than cheese. What prevents the delivery of effective, high quality, and safe healthcare in England? | PSNet

psnet.ahrq.gov/issue/more-holes-cheese-what-prevents-delivery-effective-high-quality-and-safe-healthcare-england

December 18, 2017 - Study More holes than cheese. What prevents the delivery of effective, high quality, and safe healthcare in England? Citation Text: Hignett S, Lang A, Pickup L, et al. More holes than cheese. What prevents the delivery of effective, high quality and safe health care in England? Ergonomic…

Improving patient safety via automated laboratory-based adverse event grading. | PSNet

psnet.ahrq.gov/issue/improving-patient-safety-automated-laboratory-based-adverse-event-grading

October 19, 2022 - Study Improving patient safety via automated laboratory-based adverse event grading. Citation Text: Niland JC, Stiller T, Neat J, et al. Improving patient safety via automated laboratory-based adverse event grading. J Am Med Inform Assoc. 2012;19(1):111-5. doi:10.1136/amiajnl-2011-0005…

A guide to evaluation of quality improvement and patient safety educational programs: lessons from the VA Chief Resident in Quality and Safety Program. | PSNet

psnet.ahrq.gov/issue/guide-evaluation-quality-improvement-and-patient-safety-educational-programs-lessons-va-chief

February 26, 2020 - Commentary A guide to evaluation of quality improvement and patient safety educational programs: lessons from the VA Chief Resident in Quality and Safety Program. Citation Text: Butcher RL, Carluzzo KL, Watts B, et al. A Guide to Evaluation of Quality Improvement and Patient Safety Educa…

Uncovering, creating or constructing problems? Enacting a new role to support staff who raise concerns about quality and safety in the English National Health Service | PSNet

psnet.ahrq.gov/issue/uncovering-creating-or-constructing-problems-enacting-new-role-support-staff-who-raise

September 29, 2021 - Study Uncovering, creating or constructing problems? Enacting a new role to support staff who raise concerns about quality and safety in the English National Health Service Citation Text: Martin GP, Chew S, Dixon-Woods M. Uncovering, creating or constructing problems? Enacting a new role…

Improving ambulatory prescribing safety with a handheld decision support system: a randomized controlled trial. | PSNet

psnet.ahrq.gov/issue/improving-ambulatory-prescribing-safety-handheld-decision-support-system-randomized

July 30, 2014 - Study Improving ambulatory prescribing safety with a handheld decision support system: a randomized controlled trial. Citation Text: Berner ES, Houston TK, Ray MN, et al. Improving ambulatory prescribing safety with a handheld decision support system: a randomized controlled trial. J A…

Frequency and clinical importance of pages sent to the wrong physician. | PSNet

psnet.ahrq.gov/issue/frequency-and-clinical-importance-pages-sent-wrong-physician

October 31, 2011 - Study Frequency and clinical importance of pages sent to the wrong physician. Citation Text: Wong BM, Quan S, Cheung M, et al. Frequency and clinical importance of pages sent to the wrong physician. Arch Intern Med. 2009;169(11):1072-3. doi:10.1001/archinternmed.2009.117. Copy Citation…

Finding and fixing mistakes: do checklists work for clinicians with different levels of experience? | PSNet

psnet.ahrq.gov/issue/finding-and-fixing-mistakes-do-checklists-work-clinicians-different-levels-experience

February 06, 2014 - Study Finding and fixing mistakes: do checklists work for clinicians with different levels of experience? Citation Text: Sibbald M, de Bruin A, van Merrienboer JJG. Finding and fixing mistakes: do checklists work for clinicians with different levels of experience? Adv Health Sci Educ T…

Simulation-based assessment identifies longitudinal changes in cognitive skills in an anesthesiology residency training program. | PSNet

psnet.ahrq.gov/issue/simulation-based-assessment-identifies-longitudinal-changes-cognitive-skills-anesthesiology

August 11, 2021 - Study Simulation-based assessment identifies longitudinal changes in cognitive skills in an anesthesiology residency training program. Citation Text: Sidi A, Gravenstein N, Vasilopoulos T, et al. Simulation-based assessment identifies longitudinal changes in cognitive skills in an anesth…

Patient harm events and associated cost outcomes reported to a patient safety organization. | PSNet

psnet.ahrq.gov/issue/patient-harm-events-and-associated-cost-outcomes-reported-patient-safety-organization

July 18, 2017 - Study Patient harm events and associated cost outcomes reported to a patient safety organization. Citation Text: Miller S, Stockwell DC. Patient harm events and associated cost outcomes reported to a patient safety organization. J Patient Saf. 2024;20(7):e92-e96. doi:10.1097/pts.00000000…

Multidisciplinary simulation activity effectively prepares residents for participation in patient safety activities. | PSNet

psnet.ahrq.gov/issue/multidisciplinary-simulation-activity-effectively-prepares-residents-participation-patient

November 30, 2016 - Study Multidisciplinary simulation activity effectively prepares residents for participation in patient safety activities. Citation Text: Weis JJ, Croft CL, Bhoja R, et al. Multidisciplinary simulation activity effectively prepares residents for participation in patient safety activities…

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