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Adverse event reporting priorities: an integrative review. | PSNet

psnet.ahrq.gov/issue/adverse-event-reporting-priorities-integrative-review

March 10, 2021 - Review Adverse event reporting priorities: an integrative review. Citation Text: Falcone ML, Van Stee SK, Tokac U, et al. Adverse event reporting priorities: an integrative review. J Patient Saf. 2022;18(4):e727-e740. doi:10.1097/pts.0000000000000945. Copy Citation Format: …

A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional change. | PSNet

psnet.ahrq.gov/issue/case-transfusion-error-trauma-patient-subsequent-root-cause-analysis-leading-institutional

March 30, 2022 - Commentary A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional change. Citation Text: Clifford SP, Mick PB, Derhake BM. A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional ch…

A prospective study of paediatric cardiac surgical microsystems: assessing the relationships between non-routine events, teamwork and patient outcomes. | PSNet

psnet.ahrq.gov/issue/prospective-study-paediatric-cardiac-surgical-microsystems-assessing-relationships-between

February 14, 2024 - Study A prospective study of paediatric cardiac surgical microsystems: assessing the relationships between non-routine events, teamwork and patient outcomes. Citation Text: Schraagen JM, Schouten T, Smit M, et al. A prospective study of paediatric cardiac surgical microsystems: assessi…

Looking back on the history of patient safety: an opportunity to reflect and ponder future challenges. | PSNet

psnet.ahrq.gov/issue/looking-back-history-patient-safety-opportunity-reflect-and-ponder-future-challenges

July 10, 2019 - Commentary Looking back on the history of patient safety: an opportunity to reflect and ponder future challenges. Citation Text: Schiff G, Shojania KG. Looking back on the history of patient safety: an opportunity to reflect and ponder future challenges. BMJ Qual Saf. 2022;31(2):148-152.…

Humanizing harm: using a restorative approach to heal and learn from adverse events. | PSNet

psnet.ahrq.gov/issue/humanizing-harm-using-restorative-approach-heal-and-learn-adverse-events

November 30, 2022 - Commentary Humanizing harm: using a restorative approach to heal and learn from adverse events. Citation Text: Wailling J, Kooijman A, Hughes J, et al. Humanizing harm: Using a restorative approach to heal and learn from adverse events. Health Expect. 2022;25(4):1192-1199. doi:10.1111/he…

A trigger tool to identify adverse events in the intensive care unit. | PSNet

psnet.ahrq.gov/issue/trigger-tool-identify-adverse-events-intensive-care-unit

April 08, 2011 - Study A trigger tool to identify adverse events in the intensive care unit. Citation Text: Resar RK, Rozich JD, Simmonds T, et al. A Trigger Tool to Identify Adverse Events in the Intensive Care Unit. The Joint Commission Journal on Quality and Patient Safety. 2016;32(10). doi:10.1016/s…

An evaluation of shared mental models and mutual trust on general medical units: implications for collaboration, teamwork, and patient safety. | PSNet

psnet.ahrq.gov/issue/evaluation-shared-mental-models-and-mutual-trust-general-medical-units-implications

November 08, 2012 - Study An evaluation of shared mental models and mutual trust on general medical units: implications for collaboration, teamwork, and patient safety. Citation Text: McComb SA, Lemaster M, Henneman EA, et al. An Evaluation of Shared Mental Models and Mutual Trust on General Medical Units: …

Anesthesiology patient handoff education interventions: a systematic review. | PSNet

psnet.ahrq.gov/issue/anesthesiology-patient-handoff-education-interventions-systematic-review

April 28, 2021 - Review Anesthesiology patient handoff education interventions: a systematic review. Citation Text: Riesenberg LA, Davis R, Heng A, et al. Anesthesiology patient handoff education interventions: a systematic review. Jt Comm J Qual Patient Saf. 2023;49(8):394-404. doi:10.1016/j.jcjq.2022.1…

Crisis recovery in surgery: error management and problem solving in safety-critical situations. | PSNet

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November 30, 2022 - Study Crisis recovery in surgery: error management and problem solving in safety-critical situations. Citation Text: Gogalniceanu P, Kunduzi B, Ruckley C, et al. Crisis recovery in surgery: error management and problem solving in safety-critical situations. Surgery. 2022;172(2):537-545. …

Using an online quiz-based reinforcement system to teach healthcare quality and patient safety and care transitions at the University of California. | PSNet

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December 07, 2011 - Study Using an online quiz-based reinforcement system to teach healthcare quality and patient safety and care transitions at the University of California. Citation Text: Shaikh U, Afsar-Manesh N, Amin AN, et al. Using an online quiz-based reinforcement system to teach healthcare quality …

Outpatient adverse drug events identified by screening electronic health records. | PSNet

psnet.ahrq.gov/issue/outpatient-adverse-drug-events-identified-screening-electronic-health-records

June 08, 2016 - Study Outpatient adverse drug events identified by screening electronic health records. Citation Text: Gandhi TK, Seger AC, Overhage M, et al. Outpatient adverse drug events identified by screening electronic health records. J Patient Saf. 2010;6(2):91-6. doi:10.1097/PTS.0b013e3181dcae06…

Developing standardized "receiver-driven" handoffs between referring providers and the emergency department: results of a multidisciplinary needs assessment. | PSNet

psnet.ahrq.gov/issue/developing-standardized-receiver-driven-handoffs-between-referring-providers-and-emergency

June 03, 2020 - Study Developing standardized "receiver-driven" handoffs between referring providers and the emergency department: results of a multidisciplinary needs assessment. Citation Text: Huth K, Stack AM, Chi G, et al. Developing Standardized "Receiver-Driven" Handoffs Between Referring Provider…

A simulation systems testing program using HFMEA methodology can effectively identify and mitigate latent safety threats for a new on-site helipad. | PSNet

psnet.ahrq.gov/issue/simulation-systems-testing-program-using-hfmea-methodology-can-effectively-identify-and

January 03, 2017 - Study A simulation systems testing program using HFMEA methodology can effectively identify and mitigate latent safety threats for a new on-site helipad. Citation Text: Holmes J, Chipman M, Barbour T, et al. A simulation systems testing program using HFMEA methodology can effectively ide…

Naming the "baby" or the "beast"? The importance of concepts and labels in healthcare safety investigation. | PSNet

psnet.ahrq.gov/issue/naming-baby-or-beast-importance-concepts-and-labels-healthcare-safety-investigation

April 14, 2021 - Commentary Naming the "baby" or the "beast"? The importance of concepts and labels in healthcare safety investigation. Citation Text: Wiig S, Macrae C, Frich J, et al. Naming the “baby” or the “beast”? The importance of concepts and labels in healthcare safety investigation. Front Public…

Educational levels of hospital nurses and surgical patient mortality. | PSNet

psnet.ahrq.gov/issue/educational-levels-hospital-nurses-and-surgical-patient-mortality

February 09, 2011 - Study Classic Educational levels of hospital nurses and surgical patient mortality. Citation Text: Aiken LH, Clarke S, Cheung RB, et al. Educational levels of hospital nurses and surgical patient mortality. JAMA. 2003;290(12):1617-1623. Copy Citation For…

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

psnet.ahrq.gov/issue/learning-preventable-deaths-exploring-case-record-reviewers-narratives-using-change-analysis

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…

Surgical safety does not happen by accident: learning from perioperative near miss case studies. | PSNet

psnet.ahrq.gov/issue/surgical-safety-does-not-happen-accident-learning-perioperative-near-miss-case-studies

August 04, 2021 - Commentary Surgical safety does not happen by accident: learning from perioperative near miss case studies. Citation Text: Stucky CH, Michael Hartmann J, Yauger YJ, et al. Surgical safety does not happen by accident: learning from perioperative near miss case studies. J Perianesth Nurs. …

Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. | PSNet

psnet.ahrq.gov/issue/medication-reconciliation-during-transitions-care-patient-safety-strategy-systematic-review

January 12, 2022 - Review Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Citation Text: Kwan JL, Lo L, Sampson M, et al. Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158…

The impacts of a pharmacist-managed outpatient clinic and chemotherapy-directed electronic order sets for monitoring oral chemotherapy. | PSNet

psnet.ahrq.gov/issue/impacts-pharmacist-managed-outpatient-clinic-and-chemotherapy-directed-electronic-order-sets

June 18, 2014 - Study The impacts of a pharmacist-managed outpatient clinic and chemotherapy-directed electronic order sets for monitoring oral chemotherapy. Citation Text: Battis B, Clifford L, Huq M, et al. The impacts of a pharmacist-managed outpatient clinic and chemotherapy-directed electronic orde…

Development and reliability of the explicit professional oral communication observation tool to quantify the use of non-technical skills in healthcare. | PSNet

psnet.ahrq.gov/issue/development-and-reliability-explicit-professional-oral-communication-observation-tool

April 23, 2014 - Study Development and reliability of the explicit professional oral communication observation tool to quantify the use of non-technical skills in healthcare. Citation Text: Kemper PF, van Noord I, de Bruijne M, et al. Development and reliability of the explicit professional oral communi…

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