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Medical team training: applying crew resource management in the Veterans Health Administration. | PSNet

psnet.ahrq.gov/issue/medical-team-training-applying-crew-resource-management-veterans-health-administration

April 30, 2014 - Study Classic Medical team training: applying crew resource management in the Veterans Health Administration. Citation Text: Dunn EJ, Mills PD, Neily J, et al. Medical team training: applying crew resource management in the Veterans Health Administration. Jt Com…

Factors causing variation in World Health Organization surgical safety checklist effectiveness-a rapid scoping review. | PSNet

psnet.ahrq.gov/issue/factors-causing-variation-world-health-organization-surgical-safety-checklist-effectiveness

January 12, 2022 - Review Factors causing variation in World Health Organization surgical safety checklist effectiveness-a rapid scoping review. Citation Text: Wani MM, Gilbert JHV, Mohammed CA, et al. Factors causing variation in World Health Organization surgical safety checklist effectiveness-a rapid sc…

Putting the "action" in RCA(2): an analysis of intervention strength after adverse events. | PSNet

psnet.ahrq.gov/issue/putting-action-rca2-analysis-intervention-strength-after-adverse-events

April 17, 2024 - Study Putting the "action" in RCA(2): an analysis of intervention strength after adverse events. Citation Text: Zerillo JA, Tardiff SA, Flood D, et al. Putting the "action" in RCA(2): an analysis of intervention strength after adverse events. Jt Comm J Qual Patient Saf. 2024;50(7):492-49…

Adopting the Fall Tailoring Interventions for Patient Safety (TIPS) program to engage older adults in fall prevention in a nursing home. | PSNet

psnet.ahrq.gov/issue/adopting-fall-tailoring-interventions-patient-safety-tips-program-engage-older-adults-fall

December 08, 2021 - Commentary Adopting the Fall Tailoring Interventions for Patient Safety (TIPS) program to engage older adults in fall prevention in a nursing home. Citation Text: Tzeng H-M, Jansen LS, Okpalauwaekwe U, et al. Adopting the Fall Tailoring Interventions for Patient Safety (TIPS) program to …

A qualitative positive deviance study to explore exceptionally safe care on medical wards for older people. | PSNet

psnet.ahrq.gov/issue/qualitative-positive-deviance-study-explore-exceptionally-safe-care-medical-wards-older

March 02, 2016 - Study A qualitative positive deviance study to explore exceptionally safe care on medical wards for older people. Citation Text: Baxter R, Taylor N, Kellar I, et al. A qualitative positive deviance study to explore exceptionally safe care on medical wards for older people. BMJ Qual Saf. …

Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study. | PSNet

psnet.ahrq.gov/issue/implementation-i-pass-handoff-program-diverse-clinical-environments-multicenter-prospective

April 24, 2018 - Study Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study. Citation Text: Starmer AJ, Spector ND, O'Toole JK, et al. Implementation of the I‐PASS handoff program in diverse clinical environments: a mu…

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…

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…

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…

Diagnostic performance dashboards: tracking diagnostic errors using big data. | PSNet

psnet.ahrq.gov/issue/diagnostic-performance-dashboards-tracking-diagnostic-errors-using-big-data

July 28, 2023 - Commentary Diagnostic performance dashboards: tracking diagnostic errors using big data. Citation Text: Mane KK, Rubenstein KB, Nassery N, et al. Diagnostic performance dashboards: tracking diagnostic errors using big data. BMJ Qual Saf. 2018;27(7):567-570. doi:10.1136/bmjqs-2018-007945.…

The wisdom and justice of not paying for "preventable complications." | PSNet

psnet.ahrq.gov/issue/wisdom-and-justice-not-paying-preventable-complications

January 22, 2014 - Commentary Classic The wisdom and justice of not paying for "preventable complications." Citation Text: Pronovost P, Goeschel CA, Wachter R. The wisdom and justice of not paying for "preventable complications". JAMA. 2008;299(18):2197-9. doi:10.1001/jama.299.1…

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…

Shift change handovers and subsequent interruptions: potential impacts on quality of care. | PSNet

psnet.ahrq.gov/issue/shift-change-handovers-and-subsequent-interruptions-potential-impacts-quality-care

February 04, 2009 - Study Shift change handovers and subsequent interruptions: potential impacts on quality of care. Citation Text: Estryn-Behar MR, Milanini-Magny G, Chaumon E, et al. Shift change handovers and subsequent interruptions: potential impacts on quality of care. J Patient Saf. 2014;10(1):29-44.…

Systematic review and evaluation of physiological track and trigger warning systems for identifying at-risk patients on the ward. | PSNet

psnet.ahrq.gov/issue/systematic-review-and-evaluation-physiological-track-and-trigger-warning-systems-identifying

July 20, 2022 - Review Systematic review and evaluation of physiological track and trigger warning systems for identifying at-risk patients on the ward. Citation Text: Gao H, McDonnell A, Harrison DA, et al. Systematic review and evaluation of physiological track and trigger warning systems for identif…

Pharmacist-led program to improve transitions from acute care to skilled nursing facility care. | PSNet

psnet.ahrq.gov/issue/pharmacist-led-program-improve-transitions-acute-care-skilled-nursing-facility-care

December 09, 2020 - Study Pharmacist-led program to improve transitions from acute care to skilled nursing facility care. Citation Text: Achilleos M, McEwen J, Hoesly M, et al. Pharmacist-led program to improve transitions from acute care to skilled nursing facility care. Am J Health Syst Pharm. 2020;77(12)…

Burns surgery handover study: trainees' assessment of current practice in the British Isles. | PSNet

psnet.ahrq.gov/issue/burns-surgery-handover-study-trainees-assessment-current-practice-british-isles

February 01, 2013 - Study Burns surgery handover study: trainees' assessment of current practice in the British Isles. Citation Text: Al-Benna S, Al-Ajam Y, Alzoubaidi D. Burns surgery handover study: trainees' assessment of current practice in the British Isles. Burns. 2009;35(4):509-12. doi:10.1016/j.bu…

Linking acknowledgement to action: closing the loop on non-urgent, clinically significant test results in the electronic health record. | PSNet

psnet.ahrq.gov/issue/linking-acknowledgement-action-closing-loop-non-urgent-clinically-significant-test-results

July 02, 2019 - Study Linking acknowledgement to action: closing the loop on non-urgent, clinically significant test results in the electronic health record. Citation Text: Dalal A, Pesterev BM, Eibensteiner K, et al. Linking acknowledgement to action: closing the loop on non-urgent, clinically signific…

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…

Gaps in ambulatory patient safety for immunosuppressive specialty medications. | PSNet

psnet.ahrq.gov/issue/gaps-ambulatory-patient-safety-immunosuppressive-specialty-medications

November 19, 2018 - Study Gaps in ambulatory patient safety for immunosuppressive specialty medications. Citation Text: Patterson S, Schmajuk G, Evans M, et al. Gaps in Ambulatory Patient Safety for Immunosuppressive Specialty Medications. Jt Comm J Qual Patient Saf. 2019;45(5):348-357. doi:10.1016/j.jcjq.2…

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…

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