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psnet.ahrq.gov/issue/impact-standardized-incident-reporting-system-perioperative-setting-single-center-experience
February 09, 2022 - Study
The impact of a standardized incident reporting system in the perioperative setting: a single center experience on 2,563 'near-misses' and adverse events.
Citation Text:
Heideveld-Chevalking AJ, Calsbeek H, Damen J, et al. The impact of a standardized incident reporting system in t…
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psnet.ahrq.gov/issue/why-do-people-sue-doctors-study-patients-and-relatives-taking-legal-action
August 04, 2021 - Study
Classic
Why do people sue doctors? A study of patients and relatives taking legal action.
Citation Text:
Vincent C, Young M, Phillips A. Why do people sue doctors? A study of patients and relatives taking legal action. Lancet. 1994;343(8913):1609-1613.
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psnet.ahrq.gov/issue/unintended-discontinuation-medication-following-hospitalisation-retrospective-cohort-study
September 05, 2018 - Study
Unintended discontinuation of medication following hospitalisation: a retrospective cohort study.
Citation Text:
Redmond P, McDowell R, Grimes TC, et al. Unintended discontinuation of medication following hospitalisation: a retrospective cohort study. BMJ Open. 2019;9(6):e024747. d…
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psnet.ahrq.gov/issue/medication-reconciliation-failures-children-and-young-adults-chronic-disease-during-intensive
June 22, 2022 - Study
Medication reconciliation failures in children and young adults with chronic disease during intensive and intermediate care.
Citation Text:
DeCourcey DD, Silverman M, Chang E, et al. Medication reconciliation failures in children and young adults with chronic disease during intensi…
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psnet.ahrq.gov/issue/distractions-cardiac-catheterisation-laboratory-impact-cardiologists-and-patient-safety
June 07, 2023 - Study
Distractions in the cardiac catheterisation laboratory: impact for cardiologists and patient safety.
Citation Text:
Mahadevan K, Cowan E, Kalsi N, et al. Distractions in the cardiac catheterisation laboratory: impact for cardiologists and patient safety. Open Heart. 2020;7(2). doi:…
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psnet.ahrq.gov/issue/measuring-overall-development-patient-safety-new-hospital-using-trigger-tools
April 12, 2019 - Study
Measuring the overall development of patient safety in a new hospital using trigger tools.
Citation Text:
Adamovic I, Dahlem P, Brachmann J. Measuring the overall development of patient safety in a new hospital using trigger tools. Int J Qual Health Care. 2024;36(3):mzae064. doi:10…
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psnet.ahrq.gov/issue/exploring-relationship-between-hospital-patient-safety-culture-and-performance-measures
August 28, 2024 - Commentary
Exploring the relationship between hospital patient safety culture and performance on measures of hospital-acquired conditions.
Citation Text:
Noghrehchi P, Hefner JL, Stegall H, et al. Exploring the relationship between hospital patient safety culture and performance on measu…
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psnet.ahrq.gov/issue/qualitative-study-senior-hospital-managers-views-current-and-innovative-strategies-improve
March 08, 2023 - Study
A qualitative study of senior hospital managers' views on current and innovative strategies to improve hand hygiene.
Citation Text:
McInnes E, Phillips R, Middleton S, et al. A qualitative study of senior hospital managers' views on current and innovative strategies to improve hand…
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psnet.ahrq.gov/issue/prevalence-and-factors-associated-patient-nondisclosure-medically-relevant-information
May 31, 2017 - Study
Emerging Classic
Prevalence of and factors associated with patient nondisclosure of medically relevant information to clinicians.
Citation Text:
Levy AG, Scherer AM, Zikmund-Fisher BJ, et al. Prevalence of and Factors Associated With Patient Nondisclosure …
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psnet.ahrq.gov/issue/preventing-nosocomial-bloodstream-infections-nbsis-implementing-hospitalwide-department-level
February 03, 2011 - Study
Preventing nosocomial bloodstream infections (NBSIs) by implementing hospitalwide, department-level, self-investigations: a NBSIs frontline ownership intervention.
Citation Text:
Mudrik-Zohar H, Chowers M, Temkin E, et al. Preventing nosocomial bloodstream infections (NBSIs) by imp…
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psnet.ahrq.gov/issue/detection-rates-mild-cognitive-impairment-primary-care-united-states-medicare-population
February 16, 2022 - Study
Detection rates of mild cognitive impairment in primary care for the United States Medicare population.
Citation Text:
Liu Y, Jun H, Becker A, et al. Detection rates of mild cognitive impairment in primary care for the United States Medicare population. J Prev Alz Dis. 2024;11:7–12…
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psnet.ahrq.gov/issue/interpersonal-and-organizational-dynamics-are-key-drivers-failure-rescue
June 18, 2019 - Study
Interpersonal and organizational dynamics are key drivers of failure to rescue.
Citation Text:
Smith ME, Wells EE, Friese CR, et al. Interpersonal And Organizational Dynamics Are Key Drivers Of Failure To Rescue. Health Aff (Millwood). 2018;37(11):1870-1876. doi:10.1377/hlthaff.201…
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psnet.ahrq.gov/issue/nursing-staffs-perceptions-patient-safety-psychiatric-inpatient-care
September 27, 2017 - Study
Nursing staff's perceptions of patient safety in psychiatric inpatient care.
Citation Text:
Kanerva A, Lammintakanen J, Kivinen T. Nursing Staff's Perceptions of Patient Safety in Psychiatric Inpatient Care. Perspect Psych Care. 2016;52(1):25-31. doi:10.1111/ppc.12098.
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psnet.ahrq.gov/issue/influence-psychological-safety-and-organizational-support-impact-humiliation-trainee-well
January 26, 2022 - Study
Influence of psychological safety and organizational support on the impact of humiliation on trainee well-being.
Citation Text:
Appelbaum NP, Santen SA, Perera RA, et al. Influence of psychological safety and organizational support on the impact of humiliation on trainee well-being…
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psnet.ahrq.gov/issue/speaking-same-language-international-variations-safety-information-accompanying-top-selling
September 25, 2008 - Study
Speaking the same language? International variations in the safety information accompanying top-selling prescription drugs.
Citation Text:
Kesselheim AS, Franklin JM, Avorn J, et al. Speaking the same language? International variations in the safety information accompanying top-se…
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psnet.ahrq.gov/issue/no-harm-found-when-nurse-anesthetists-work-without-supervision-physicians
August 04, 2021 - Study
No harm found when nurse anesthetists work without supervision by physicians.
Citation Text:
Dulisse B, Cromwell J. No harm found when nurse anesthetists work without supervision by physicians. Health Aff (Millwood). 2010;29(8):1469-1475. doi:10.1377/hlthaff.2008.0966.
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/sops-101-webcast-databases.pdf
January 01, 2022 - Understanding SOPS® Surveys: A Primer for New Users - Famolaro
The SOPS Databases
Theresa Famolaro, MPS, MS, MBA
Senior Study Director
User Network for the AHRQ Surveys on Patient Safety Culture (SOPS)
Westat
SOPS Databases
320
Hospitals
Version 1.0
(2021)
172
Hospitals
Version 2.0
(2021)
191
Nur…
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psnet.ahrq.gov/issue/variability-measurement-hospital-wide-mortality-rates
July 01, 2016 - Study
Classic
Variability in the measurement of hospital-wide mortality rates.
Citation Text:
Shahian DM, Wolf RE, Iezzoni LI, et al. Variability in the measurement of hospital-wide mortality rates. N Engl J Med. 2010;363(26):2530-9. doi:10.1056/NEJMsa1006396. …
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_3_Physician_HO_508.docx
January 01, 2010 - Strategy 4: IDEA Discharge Planning (Tool 3)
Strategy 4: IDEAL Discharge Planning (Tool 3)
Improving Discharge Outcomes with Patients and Families
Strategy 1: Working with Patients & Families as Advisors
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Strategy 4: IDEAL Discharge Planning (Tool 3)
O Guide to Patient and Family …
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management/visual-slides.html
June 01, 2017 - Management Practices for Sustainability Module 5: Visual Management
Slide 1: Management Practices for Sustainability Module 5: Visual Management
Management Practices for Sustainability
Module 5: Visual Management
Slide 2: A Frontline Management System To Promote Safety Standard Work
Image: This imag…