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Applying the high reliability health care maturity model to assess hospital performance: a VA case study. | PSNet

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December 19, 2014 - Study Applying the high reliability health care maturity model to assess hospital performance: a VA case study. Citation Text: Sullivan JL, Rivard PE, Shin MH, et al. Applying the High Reliability Health Care Maturity Model to Assess Hospital Performance: A VA Case Study. Jt Comm J Qual …

Understanding the factors influencing implementation of a new national patient safety policy in England: lessons from 'Learning from Deaths'. | PSNet

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August 18, 2021 - Study Understanding the factors influencing implementation of a new national patient safety policy in England: lessons from 'Learning from Deaths'. Citation Text: Lalani M, Morgan S, Basu A, et al. Understanding the factors influencing implementation of a new national patient safety pol…

Adverse event reviews in healthcare: what matters to patients and their family? A qualitative study exploring the perspective of patients and family. | PSNet

psnet.ahrq.gov/issue/adverse-event-reviews-healthcare-what-matters-patients-and-their-family-qualitative-study

March 24, 2021 - Study Adverse event reviews in healthcare: what matters to patients and their family? A qualitative study exploring the perspective of patients and family. Citation Text: McQueen JM, Gibson KR, Manson M, et al. Adverse event reviews in healthcare: what matters to patients and their famil…

Evaluating incident learning systems and safety culture in two radiation oncology departments. | PSNet

psnet.ahrq.gov/issue/evaluating-incident-learning-systems-and-safety-culture-two-radiation-oncology-departments

June 30, 2021 - Study Evaluating incident learning systems and safety culture in two radiation oncology departments. Citation Text: Adamson L, Beldham‐Collins R, Sykes J, et al. Evaluating incident learning systems and safety culture in two radiation oncology departments. J Med Radiat Sci. 2022;69(2):2…

Preliminary study of patient safety and quality use cases for ICD-11 MMS. | PSNet

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July 22, 2020 - Study Preliminary study of patient safety and quality use cases for ICD-11 MMS. Citation Text: Fenton SH, Giannangelo KL, Stanfill MH. Preliminary study of patient safety and quality use cases for ICD-11 MMS. J Am Med Inform Assoc. 2021;28(11):2346-2353. doi:10.1093/jamia/ocab163. Copy…

Filling a gap in safety metrics: development of a patient-centred framework to identify and categorise patient-reported breakdowns related to the diagnostic process in ambulatory care. | PSNet

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February 15, 2023 - Study Filling a gap in safety metrics: development of a patient-centred framework to identify and categorise patient-reported breakdowns related to the diagnostic process in ambulatory care. Citation Text: Bell SK, Bourgeois FC, DesRoches CM, et al. Filling a gap in safety metrics: devel…

To make or buy patient safety solutions: a resource dependence and transaction cost economics perspective. | PSNet

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April 08, 2008 - Study To make or buy patient safety solutions: a resource dependence and transaction cost economics perspective. Citation Text: Fareed N, Mick SS. To make or buy patient safety solutions: a resource dependence and transaction cost economics perspective. Health Care Manage Rev. 2011;36(…

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

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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…

Effect of a pediatric early warning system on all-cause mortality in hospitalized pediatric patients. | PSNet

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April 24, 2018 - Study Classic Effect of a pediatric early warning system on all-cause mortality in hospitalized pediatric patients. Citation Text: Parshuram CS, Dryden-Palmer K, Farrell C, et al. Effect of a Pediatric Early Warning System on All-Cause Mortality in Hospitalized …

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…

Designing an intervention to improve medication safety for nursing home residents based on experiential knowledge related to patient safety culture at the nursing home front line: cocreative process study. | PSNet

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February 14, 2024 - Commentary Designing an intervention to improve medication safety for nursing home residents based on experiential knowledge related to patient safety culture at the nursing home front line: cocreative process study. Citation Text: Juhl MH, Soerensen AL, Vardinghus-Nielsen H, et al. Desi…

A cross-sectional study on the relationship between utilization of root cause analysis and patient safety at 139 Department of Veterans Affairs medical centers. | PSNet

psnet.ahrq.gov/issue/cross-sectional-study-relationship-between-utilization-root-cause-analysis-and-patient-safety

January 11, 2017 - Study A cross-sectional study on the relationship between utilization of root cause analysis and patient safety at 139 Department of Veterans Affairs medical centers. Citation Text: Percarpio KB, Watts V. A cross-sectional study on the relationship between utilization of root cause ana…

Interventions into reliability-seeking health care organizations: a systematic review of their goals and measuring methods. | PSNet

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October 19, 2022 - Review Interventions into reliability-seeking health care organizations: a systematic review of their goals and measuring methods. Citation Text: Auschra C, Asaad E, Sydow J, et al. Interventions into reliability-seeking health care organizations: a systematic review of their goals and m…

What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study. | PSNet

psnet.ahrq.gov/issue/what-works-medication-reconciliation-treatment-and-site-analysis-marquis2-study

May 19, 2021 - Study What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study. Citation Text: Schnipper JL, Reyes Nieva H, Yoon CS, et al. What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study. BMJ Qual Saf. 2023;32(8):4…

The impact of an intervention to improve intrapartum maternal vital sign monitoring and reduce alarm fatigue. | PSNet

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September 23, 2020 - Study The impact of an intervention to improve intrapartum maternal vital sign monitoring and reduce alarm fatigue. Citation Text: Kern-Goldberger AR, Nicholls EM, Plastino N, et al. The impact of an intervention to improve intrapartum maternal vital sign monitoring and reduce alarm fati…

The 'go-between' study: a simulation study comparing the 'Traffic Lights' and 'SBAR' tools as a means of communication between anaesthetic staff. | PSNet

psnet.ahrq.gov/issue/go-between-study-simulation-study-comparing-traffic-lights-and-sbar-tools-means-communication

March 01, 2023 - Study The 'go-between' study: a simulation study comparing the 'Traffic Lights' and 'SBAR' tools as a means of communication between anaesthetic staff. Citation Text: MacDougall-Davis SR, Kettley L, Cook TM. The 'go-between' study: a simulation study comparing the 'Traffic Lights' and 'S…

National improvements in resident physician-reported patient safety after limiting first-year resident physicians' extended duration work shifts: a pooled analysis of prospective cohort studies. | PSNet

psnet.ahrq.gov/issue/national-improvements-resident-physician-reported-patient-safety-after-limiting-first-year

July 15, 2020 - Study National improvements in resident physician-reported patient safety after limiting first-year resident physicians' extended duration work shifts: a pooled analysis of prospective cohort studies. Citation Text: Weaver MD, Landrigan CP, Sullivan JP, et al. National improvements in re…

Implementing situation-background-assessment-recommendation in an anaesthetic clinic and subsequent information retention among receivers: a prospective interventional study of postoperative handovers. | PSNet

psnet.ahrq.gov/issue/implementing-situation-background-assessment-recommendation-anaesthetic-clinic-and-subsequent

December 30, 2014 - Study Implementing situation-background-assessment-recommendation in an anaesthetic clinic and subsequent information retention among receivers: a prospective interventional study of postoperative handovers. Citation Text: Randmaa M, Swenne CL, Mårtensson G, et al. Implementing situation…

Culture change in infection control: applying psychological principles to improve hand hygiene. | PSNet

psnet.ahrq.gov/issue/culture-change-infection-control-applying-psychological-principles-improve-hand-hygiene

November 21, 2021 - Study Culture change in infection control: applying psychological principles to improve hand hygiene. Citation Text: Cumbler E, Castillo L, Satorie L, et al. Culture change in infection control: applying psychological principles to improve hand hygiene. J Nurs Care Qual. 2013;28(4):304…

Operating room–to-ICU patient handovers: a multidisciplinary human-centered design approach. | PSNet

psnet.ahrq.gov/issue/operating-room-icu-patient-handovers-multidisciplinary-human-centered-design-approach

June 27, 2012 - Study Operating room–to-ICU patient handovers: a multidisciplinary human-centered design approach. Citation Text: Segall N, Bonifacio AS, Barbeito A, et al. Operating Room-to-ICU Patient Handovers: A Multidisciplinary Human-Centered Design Approach. Jt Comm J Qual Patient Saf. 2016;42(9)…

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