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A mixed methods study exploring patient safety culture at 4 VHA Hospitals. | PSNet

psnet.ahrq.gov/issue/mixed-methods-study-exploring-patient-safety-culture-4-vha-hospitals

September 25, 2019 - Study A mixed methods study exploring patient safety culture at 4 VHA Hospitals. Citation Text: Sullivan JL, Shin MH, Ranusch A, et al. A mixed methods study exploring patient safety culture at 4 VHA Hospitals. Jt Comm J Qual Patient Saf. 2024;50(11):791-800. doi:10.1016/j.jcjq.2024.07.0…

Performance variability in perioperative sentinel events: report on a nationwide data set. | PSNet

psnet.ahrq.gov/issue/performance-variability-perioperative-sentinel-events-report-nationwide-data-set

November 04, 2020 - Study Performance variability in perioperative sentinel events: report on a nationwide data set. Citation Text: Reijmerink IM, Bos K, Leistikow IP, et al. Performance variability in perioperative sentinel events: report on a nationwide data set. Br J Surg. 2022;109(7):573-575. doi:10.109…

Accurate measurement in California's safety-net health systems has gaps and barriers. | PSNet

psnet.ahrq.gov/issue/accurate-measurement-californias-safety-net-health-systems-has-gaps-and-barriers

April 04, 2018 - Study Accurate measurement in California's safety-net health systems has gaps and barriers. Citation Text: Khoong EC, Cherian R, Rivadeneira NA, et al. Accurate Measurement In California's Safety-Net Health Systems Has Gaps And Barriers. Health Aff (Millwood). 2018;37(11):1760-1769. doi:…

Adherence to national guidelines for timeliness of test results communication to patients in the Veterans Affairs health care system. | PSNet

psnet.ahrq.gov/issue/adherence-national-guidelines-timeliness-test-results-communication-patients-veterans-affairs

March 03, 2019 - Study Adherence to national guidelines for timeliness of test results communication to patients in the Veterans Affairs health care system. Citation Text: Meyer AND, Scott TMT, Singh H. Adherence to national guidelines for timeliness of test results communication to patients in the Veter…

Factors associated with workarounds in barcode-assisted medication administration in hospitals. | PSNet

psnet.ahrq.gov/issue/factors-associated-workarounds-barcode-assisted-medication-administration-hospitals

January 23, 2019 - Study Factors associated with workarounds in barcode-assisted medication administration in hospitals. Citation Text: Veen W, Taxis K, Wouters H, et al. Factors associated with workarounds in barcode‐assisted medication administration in hospitals. J Clin Nurs. 2020;29(13-14):2239-2250. d…

The effect of contact precautions on frequency of hospital adverse events. | PSNet

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September 30, 2015 - Study The effect of contact precautions on frequency of hospital adverse events. Citation Text: Croft LD, Liquori M, Ladd J, et al. The Effect of Contact Precautions on Frequency of Hospital Adverse Events. Infect Control Hosp Epidemiol. 2015;36(11):1268-74. doi:10.1017/ice.2015.192. C…

From box ticking to the black box: the evolution of operating room safety. | PSNet

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October 29, 2017 - Commentary From box ticking to the black box: the evolution of operating room safety. Citation Text: Goldenberg MG, Elterman D. From box ticking to the black box: the evolution of operating room safety. World J Urol. 2019;38(6):1369-1372. doi:10.1007/s00345-019-02886-5. Copy Citation …

Discrepancies between clinical and autopsy diagnosis and the value of post mortem histology: a meta-analysis and review. | PSNet

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September 22, 2021 - Review Discrepancies between clinical and autopsy diagnosis and the value of post mortem histology: a meta-analysis and review. Citation Text: Roulson J, Benbow EW, Hasleton PS. Discrepancies between clinical and autopsy diagnosis and the value of post mortem histology; a meta-analysis a…

Controversies in diagnosis: contemporary debates in the diagnostic safety literature. | PSNet

psnet.ahrq.gov/issue/controversies-diagnosis-contemporary-debates-diagnostic-safety-literature

December 21, 2018 - Review Controversies in diagnosis: contemporary debates in the diagnostic safety literature. Citation Text: Bergl PA, Wijesekera TP, Nassery N, et al. Controversies in diagnosis: contemporary debates in the diagnostic safety literature. Diagnosis (Berl). 2020;7(1):3-9. doi:10.1515/dx-201…

Organisational culture: variation across hospitals and connection to patient safety climate. | PSNet

psnet.ahrq.gov/issue/organisational-culture-variation-across-hospitals-and-connection-patient-safety-climate

March 17, 2010 - Study Organisational culture: variation across hospitals and connection to patient safety climate. Citation Text: Speroff T, Nwosu S, Greevy R, et al. Organisational culture: variation across hospitals and connection to patient safety climate. Qual Saf Health Care. 2010;19(6):592-6. do…

The National Healthcare Safety Network's digital quality measures: CDC's automated measures for surveillance of patient safety. | PSNet

psnet.ahrq.gov/issue/national-healthcare-safety-networks-digital-quality-measures-cdcs-automated-measures

September 23, 2020 - Study The National Healthcare Safety Network's digital quality measures: CDC's automated measures for surveillance of patient safety. Citation Text: Shehab N, Alschuler L, McILvenna S, et al. The National Healthcare Safety Network’s digital quality measures: CDC’s automated measures for …

Improving handoffs in the perioperative environment: a conceptual framework of key theories, system factors, methods, and core interventions to ensure success. | PSNet

psnet.ahrq.gov/issue/improving-handoffs-perioperative-environment-conceptual-framework-key-theories-system-factors

November 16, 2022 - Commentary Improving handoffs in the perioperative environment: a conceptual framework of key theories, system factors, methods, and core interventions to ensure success. Citation Text: Starmer AJ, Michael MM, Spector ND, et al. Improving handoffs in the perioperative environment: a conc…

Adherence to black box warnings for prescription medications in outpatients. | PSNet

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September 29, 2017 - Study Adherence to black box warnings for prescription medications in outpatients. Citation Text: Lasser KE, Seger DL, Yu T, et al. Adherence to black box warnings for prescription medications in outpatients. Arch Intern Med. 2006;166(3):338-44. Copy Citation Format: Goog…

Rapid response teams as a patient safety practice for failure to rescue. | PSNet

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January 26, 2022 - Commentary Rapid response teams as a patient safety practice for failure to rescue. Citation Text: Fischer CP, Bilimoria KY, Ghaferi AA. Rapid Response Teams as a Patient Safety Practice for Failure to Rescue. JAMA. 2021;326(2):179-180. doi:10.1001/jama.2021.7510. Copy Citation For…

Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions. | PSNet

psnet.ahrq.gov/issue/enabling-learning-healthcare-system-automated-computer-protocols-produce-replicable-and

September 23, 2020 - Commentary Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions. Citation Text: Morris AH, Stagg B, Lanspa M, et al. Enabling a learning healthcare system with automated computer protocols that produce replicab…

Advancing the science of patient safety. | PSNet

psnet.ahrq.gov/issue/advancing-science-patient-safety

March 13, 2013 - Commentary Classic Advancing the science of patient safety. Citation Text: Shekelle PG, Pronovost P, Wachter R, et al. Advancing the science of patient safety. Ann Intern Med. 2011;154(10):693-6. doi:10.7326/0003-4819-154-10-201105170-00011. Copy Citation …

Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. | PSNet

psnet.ahrq.gov/issue/missed-and-delayed-diagnoses-emergency-department-study-closed-malpractice-claims-4-liability

March 02, 2011 - Study Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. Citation Text: Kachalia A, Gandhi TK, Puopolo AL, et al. Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4…

TeamGAINS: a tool for structured debriefings for simulation-based team trainings. | PSNet

psnet.ahrq.gov/issue/teamgains-tool-structured-debriefings-simulation-based-team-trainings

October 08, 2016 - Study TeamGAINS: a tool for structured debriefings for simulation-based team trainings. Citation Text: Kolbe M, Weiss M, Grote G, et al. TeamGAINS: a tool for structured debriefings for simulation-based team trainings. BMJ Qual Saf. 2013;22(7):541-53. doi:10.1136/bmjqs-2012-000917. Co…

Resident duty hours and resident and patient outcomes: systematic review and meta-analysis. | PSNet

psnet.ahrq.gov/issue/resident-duty-hours-and-resident-and-patient-outcomes-systematic-review-and-meta-analysis

July 14, 2021 - Review Resident duty hours and resident and patient outcomes: systematic review and meta-analysis. Citation Text: Sephien A, Reljic T, Jordan J, et al. Resident duty hours and resident and patient outcomes: systematic review and meta‐analysis. Med Educ. 2023;57(3):221-232. doi:10.1111/me…

Debrief it all: a tool for inclusion of Safety-II. | PSNet

psnet.ahrq.gov/issue/debrief-it-all-tool-inclusion-safety-ii

June 08, 2022 - Study Debrief it all: a tool for inclusion of Safety-II. Citation Text: Bentley SK, McNamara S, Meguerdichian MJ, et al. Debrief it all: a tool for inclusion of Safety-II. Adv Simul (Lond). 2021;6(1):9. doi:10.1186/s41077-021-00163-3. Copy Citation Format: DOI Google Schola…

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