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psnet.ahrq.gov/issue/information-transfer-and-communication-surgery-systematic-review
September 26, 2012 - Review
Information transfer and communication in surgery: a systematic review.
Citation Text:
Nagpal K, Vats A, Lamb B, et al. Information transfer and communication in surgery: a systematic review. Ann Surg. 2010;252(2):225-39. doi:10.1097/SLA.0b013e3181e495c2.
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psnet.ahrq.gov/issue/patient-handover-surgery-intensive-care-using-formula-1-pit-stop-and-aviation-models-improve
October 03, 2011 - Study
Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality.
Citation Text:
Catchpole K, de Leval MR, McEwan A, et al. Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to …
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psnet.ahrq.gov/issue/how-often-are-potential-patient-safety-events-present-admission
January 26, 2022 - Study
Classic
How often are potential patient safety events present on admission?
Citation Text:
Houchens RL, Elixhauser A, Romano PS. How often are potential patient safety events present on admission? Jt Comm J Qual Patient Saf. 2008;34(3):154-63.
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psnet.ahrq.gov/issue/look-alikesound-alike-drugs-literature-review-causes-and-solutions
September 28, 2022 - Review
Look alike/sound alike drugs: a literature review on causes and solutions.
Citation Text:
Ciociano N, Bagnasco L. Look alike/sound alike drugs: a literature review on causes and solutions. Int J Clin Pharm. 2014;36(2):233-242. doi:10.1007/s11096-013-9885-6.
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psnet.ahrq.gov/issue/implementation-structured-hospital-wide-morbidity-and-mortality-rounds-model
January 20, 2015 - Study
Implementation of a structured hospital-wide morbidity and mortality rounds model.
Citation Text:
Kwok ESH, Calder LA, Barlow-Krelina E, et al. Implementation of a structured hospital-wide morbidity and mortality rounds model. BMJ Qual Saf. 2017;26(6):439-448. doi:10.1136/bmjqs-201…
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psnet.ahrq.gov/node/36185/psn-pdf
March 28, 2011 - Defining the technical skills of teamwork in surgery.
March 28, 2011
Healey A, Undre S, Vincent C. Defining the technical skills of teamwork in surgery. Qual Saf Health Care.
2006;15(4):231-4.
https://psnet.ahrq.gov/issue/defining-technical-skills-teamwork-surgery
The authors discuss a strategy for incorporating t…
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psnet.ahrq.gov/node/34579/psn-pdf
August 20, 2012 - Edgeware: Insights from Complexity Science for Health
Care Leaders. Second ed.
August 20, 2012
Zimmerman B, Lindberg C, Plsek P. Irving, TX: VHA Incorporated; 2008. ISBN: 9780966782806
https://psnet.ahrq.gov/issue/edgeware-insights-complexity-science-health-care-leaders
A workbook that presents a series of self-le…
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psnet.ahrq.gov/node/40003/psn-pdf
November 02, 2012 - Meeting the Joint Commission's 2013 National Patient
Safety Goals.
November 2, 2012
Oakbrook Terrace, IL: The Joint Commission; September 2012. ISBN: 9781599407555.
https://psnet.ahrq.gov/issue/meeting-joint-commissions-2013-national-patient-safety-goals
This e-book provides tips for incorporating activitie…
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psnet.ahrq.gov/node/60260/psn-pdf
April 22, 2020 - Joint Statement on Multiple Patients Per Ventilator.
April 22, 2020
The Anesthesia Patient Safety Foundation, Society of Critical Care Medicine, American Association for
Respiratory Care, American Society of Anesthesiologists, American Association of Critical?Care Nurses,
and American College of Chest Physicians. M…
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psnet.ahrq.gov/node/33809/psn-pdf
June 01, 2016 - And change our safety surveys to incorporate those types of questions and deliberately consider
burnout … Keeping up with this rapidly changing field is both an opportunity for us to incorporate new
knowledge
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psnet.ahrq.gov/web-mm/diagnosing-diagnostic-mistakes
April 30, 2014 - We believe that any attempt to determine cause and effect (preventability) must incorporate these factors … Do diagnostic plans incorporate the risk/benefit of finding one diagnosis rather than another?
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psnet.ahrq.gov/issue/dispensing-errors-community-pharmacy-perceived-influence-sociotechnical-factors
October 03, 2011 - Study
Dispensing errors in community pharmacy: perceived influence of sociotechnical factors.
Citation Text:
Szeinbach S, Seoane-Vazquez E, Parekh A, et al. Dispensing errors in community pharmacy: perceived influence of sociotechnical factors. Int J Qual Health Care. 2007;19(4):203-9.…
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psnet.ahrq.gov/node/854992/psn-pdf
November 01, 2023 - Failure to rescue as a patient safety indicator for
neurosurgical patients: are we there yet?
November 1, 2023
Roy JM, Rumalla K, Skandalakis GP, et al. Failure to rescue as a patient safety indicator for neurosurgical
patients: are we there yet? A systematic review. Neurosurg Rev. 2023;46(1):227. doi:10.1007/s1014…
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psnet.ahrq.gov/node/866555/psn-pdf
August 21, 2024 - Using behavioral insights to strengthen strategies for
change. Practical applications for quality improvement in
healthcare.
August 21, 2024
Johansen RLR, Tulloch S. Using behavioral insights to strengthen strategies for change. Practical
applications for quality improvement in healthcare. J Patient Saf. 2024;20(5…
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psnet.ahrq.gov/node/42480/psn-pdf
August 07, 2013 - A multi-tiered approach to safety education.
August 7, 2013
Oates K, Sammut J, Kennedy P. A multi-tiered approach to safety education. Clin Teach. 2013;10(4):214-
8. doi:10.1111/tct.12037.
https://psnet.ahrq.gov/issue/multi-tiered-approach-safety-education
This commentary describes an initiative that incorporated …
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psnet.ahrq.gov/node/37641/psn-pdf
March 10, 2011 - EHR safety: the way forward to safe and effective
systems.
March 10, 2011
Walker JM, Carayon P, Leveson N, et al. EHR safety: the way forward to safe and effective systems. J Am
Med Inform Assoc. 2008;15(3):272-7. doi:10.1197/jamia.M2618.
https://psnet.ahrq.gov/issue/ehr-safety-way-forward-safe-and-effective-syste…
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psnet.ahrq.gov/node/74703/psn-pdf
January 26, 2022 - Research to improve diagnosis: time to study the real
world.
January 26, 2022
Ranji SR, Thomas EJ. Research to improve diagnosis: time to study the real world. BMJ Qual Saf.
2022;31(4):255-258. doi:10.1136/bmjqs-2021-014071.
https://psnet.ahrq.gov/issue/research-improve-diagnosis-time-study-real-world
Diagnostic …
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psnet.ahrq.gov/node/60796/psn-pdf
August 12, 2020 - The challenges and opportunities for shared decision
making highlighted by COVID-19.
August 12, 2020
Abrams EM, Shaker M, Oppenheimer J, et al. The challenges and opportunities for shared decision making
highlighted by COVID-19. J Allergy Clin Immunol Pract. 2020;8(8):2474-2480.e1.
doi:10.1016/j.jaip.2020.07.003.
…
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psnet.ahrq.gov/node/50575/psn-pdf
October 23, 2019 - Dynamic pocket card for implementing ISBAR in shift
handover communication.
October 23, 2019
Schmidt T, Kocher DR, Mahendran P, et al. Dynamic Pocket Card for Implementing ISBAR in Shift
Handover Communication. Stud Health Technol Inform. 2019;267:224-229. doi:10.3233/SHTI190831.
https://psnet.ahrq.gov/issue/dynam…
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psnet.ahrq.gov/node/48093/psn-pdf
July 24, 2019 - Failure to report poor care as a breach of moral and
professional expectation.
July 24, 2019
Ion R, Olivier S, Darbyshire P. Failure to report poor care as a breach of moral and professional
expectation. Nurs Inq. 2019;26(3):e12299. doi:10.1111/nin.12299.
https://psnet.ahrq.gov/issue/failure-report-poor-care-breac…