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psnet.ahrq.gov/issue/automated-detection-look-alikesound-alike-medication-errors
August 28, 2019 - Study
Automated detection of look-alike/sound-alike medication errors.
Citation Text:
Rash-Foanio C, Galanter W, Bryson M, et al. Automated detection of look-alike/sound-alike medication errors. Am J Health Syst Pharm. 2017;74(7):521-527. doi:10.2146/ajhp150690.
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psnet.ahrq.gov/issue/quality-improvement-ambulatory-surgery-centers-major-national-effort-aimed-reducing
September 23, 2020 - Study
Quality improvement in ambulatory surgery centers: a major national effort aimed at reducing infections and other surgical complications.
Citation Text:
Davis KK, Mahishi V, Singal R, et al. Quality Improvement in Ambulatory Surgery Centers: A Major National Effort Aimed at Reducin…
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psnet.ahrq.gov/issue/reducing-failures-daily-medical-practice-healthcare-failure-mode-and-effect-analysis-combined
August 10, 2022 - Study
Reducing failures in daily medical practice: healthcare failure mode and effect analysis combined with computer simulation.
Citation Text:
Leeftink AG, Visser J, de Laat JM, et al. Reducing failures in daily medical practice: healthcare failure mode and effect analysis combined wit…
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psnet.ahrq.gov/issue/navigating-ship-broken-compass-evaluating-standard-algorithms-measure-patient-safety
January 23, 2017 - Study
Navigating a ship with a broken compass: evaluating standard algorithms to measure patient safety.
Citation Text:
Hefner JL, Huerta T, McAlearney AS, et al. Navigating a ship with a broken compass: evaluating standard algorithms to measure patient safety. J Am Med Inform Assoc. 201…
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psnet.ahrq.gov/issue/impact-fatigue-and-insufficient-sleep-physician-and-patient-outcomes-systematic-review
October 19, 2022 - Review
Emerging Classic
Impact of fatigue and insufficient sleep on physician and patient outcomes: a systematic review.
Citation Text:
Gates M, Wingert A, Featherstone R, et al. Impact of fatigue and insufficient sleep on physician and patient outcomes: a syste…
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psnet.ahrq.gov/issue/data-driven-quality-improvement-culture-change-and-high-reliability-journey-special-hospital
March 24, 2021 - Commentary
Data-driven quality improvement, culture change, and the high reliability journey at a special hospital for people with medically complex developmental disabilities.
Citation Text:
Barba V, Foreman K, Robey K. Data-driven quality improvement, culture change, and the high relia…
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psnet.ahrq.gov/issue/dilemma-patient-safety-work-perceptions-hospital-middle-managers
February 03, 2015 - Study
The dilemma of patient safety work: perceptions of hospital middle managers.
Citation Text:
Sanner M, Halford C, Vengberg S, et al. The dilemma of patient safety work: Perceptions of hospital middle managers. J Healthc Risk Manag. 2018;38(2):47-55. doi:10.1002/jhrm.21325.
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psnet.ahrq.gov/issue/risk-factors-retained-instruments-and-sponges-after-surgery
February 17, 2011 - Study
Classic
Risk factors for retained instruments and sponges after surgery.
Citation Text:
Gawande AA, Studdert DM, Orav J, et al. Risk factors for retained instruments and sponges after surgery. N Engl J Med. 2003;348(3):229-35.
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psnet.ahrq.gov/issue/addressing-systemic-racism-nursing-homes-time-action
November 18, 2020 - Commentary
Emerging Classic
Addressing systemic racism in nursing homes: a time for action.
Citation Text:
Sloane PD, Yearby R, Konetzka RT, et al. Addressing systemic racism in nursing homes: a time for action. J Am Med Dir Assoc. 2021;22(4):886-892. doi:10.101…
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psnet.ahrq.gov/issue/mitigating-patient-and-consumer-safety-risks-when-using-conversational-assistants-medical
September 19, 2018 - Study
Mitigating patient and consumer safety risks when using conversational assistants for medical information: exploratory mixed methods experiment.
Citation Text:
Bickmore TW, Olafsson S, O'Leary TK. Mitigating patient and consumer safety risks when using conversational assistants for…
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psnet.ahrq.gov/issue/online-patient-feedback-safety-valve-automated-language-analysis-unnoticed-and-unresolved
August 05, 2020 - Study
Online patient feedback as a safety valve: an automated language analysis of unnoticed and unresolved safety incidents.
Citation Text:
Gillespie A, Reader TW. Online patient feedback as a safety valve: an automated language analysis of unnoticed and unresolved safety incidents. Ris…
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psnet.ahrq.gov/issue/adopting-high-reliability-organization-principles-lead-large-scale-clinical-transformation
November 21, 2021 - Commentary
Adopting high reliability organization principles to lead a large scale clinical transformation.
Citation Text:
Pozzobon LD, Lam J, Chimonides E, et al. Adopting high reliability organization principles to lead a large scale clinical transformation. Healthc Manage Forum. 2023;…
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psnet.ahrq.gov/issue/why-and-how-approach-user-experience-safety-critical-domains-example-health-care
May 05, 2021 - Commentary
Why and how to approach user experience in safety-critical domains: the example of health care.
Citation Text:
Grundgeiger T, Hurtienne J, Happel O. Why and how to approach user experience in safety-critical domains: the example of health care. Hum Factors. 2020;63(5):821-832.…
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psnet.ahrq.gov/issue/ehr-related-medication-errors-two-icus
March 15, 2017 - Study
EHR-related medication errors in two ICUs.
Citation Text:
Carayon P, Du S, Brown RL, et al. EHR-related medication errors in two ICUs. J Healthc Risk Manag. 2017;36(3):6-15. doi:10.1002/jhrm.21259.
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psnet.ahrq.gov/issue/health-care-quality-and-safety-correctional-system-creating-goals-and-performance-measures
May 18, 2022 - Commentary
Health care quality and safety in a correctional system: creating goals and performance measures for improvement.
Citation Text:
Neely J, Sampath R, Kirkbride G, et al. Health care quality and safety in a correctional system: creating goals and performance measures for improve…
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psnet.ahrq.gov/issue/advance-care-planning-documentation-practices-and-accessibility-electronic-health-record
December 05, 2012 - Study
Emerging Classic
Advance care planning documentation practices and accessibility in the electronic health record: implications for patient safety.
Citation Text:
Walker E, McMahan R, Barnes D, et al. Advance Care Planning Documentation Practices and Access…
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psnet.ahrq.gov/issue/impact-automated-email-notification-system-results-tests-pending-discharge-cluster-randomized
December 31, 2014 - Study
Impact of an automated email notification system for results of tests pending at discharge: a cluster-randomized controlled trial.
Citation Text:
Dalal A, Roy CL, Poon EG, et al. Impact of an automated email notification system for results of tests pending at discharge: a cluster-r…
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psnet.ahrq.gov/issue/huddling-high-reliability-and-situation-awareness
January 29, 2014 - Study
Huddling for high reliability and situation awareness.
Citation Text:
Goldenhar LM, Brady PW, Sutcliffe K, et al. Huddling for high reliability and situation awareness. BMJ Qual Saf. 2013;22(11):899-906. doi:10.1136/bmjqs-2012-001467.
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psnet.ahrq.gov/issue/uncertain-diagnoses-childrens-hospital-patient-characteristics-and-outcomes
March 17, 2021 - Study
Uncertain diagnoses in a children's hospital: patient characteristics and outcomes.
Citation Text:
Sump CA, Marshall TL, Ipsaro AJ, et al. Uncertain diagnoses in a children’s hospital: patient characteristics and outcomes. Diagnosis. 2021;8(3):353-357. doi:10.1515/dx-2019-0058.
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psnet.ahrq.gov/issue/surgical-safety-checklist-audits-may-be-misleading-improving-implementation-and-adherence
November 24, 2021 - Study
Surgical safety checklist audits may be misleading! Improving the implementation and adherence of the surgical safety checklist: a quality improvement project.
Citation Text:
Brown B, Bermingham S, Vermeulen M, et al. Surgical safety checklist audits may be misleading! Improving th…