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psnet.ahrq.gov/issue/unintentionally-retained-foreign-objects-descriptive-study-308-sentinel-events-and
March 20, 2019 - Study
Emerging Classic
Unintentionally retained foreign objects: a descriptive study of 308 sentinel events and contributing factors.
Citation Text:
Steelman VM, Shaw C, Shine L, et al. Unintentionally Retained Foreign Objects: A Descriptive Study of 308 Sentine…
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psnet.ahrq.gov/issue/introducing-safety-score-audit-staff-member-and-patient-safety
April 16, 2014 - Commentary
Introducing the safety score audit for staff member and patient safety.
Citation Text:
Sinnott M, Eley R, Winch S. Introducing the safety score audit for staff member and patient safety. AORN J. 2014;100(1):91-5. doi:10.1016/j.aorn.2014.05.006.
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psnet.ahrq.gov/issue/classification-adverse-events-occurring-surgical-intensive-care-unit
May 01, 2013 - Study
Classification of adverse events occurring in a surgical intensive care unit.
Citation Text:
Frankel H, Sperry J, Kaplan L, et al. Classification of adverse events occurring in a surgical intensive care unit. Am J Surg. 2007;194(3):328-32.
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psnet.ahrq.gov/issue/adopting-national-quality-forum-medication-safe-practices-progress-and-barriers-hospital
December 16, 2011 - Study
Adopting National Quality Forum medication safe practices: progress and barriers to hospital implementation.
Citation Text:
Rask KJ, Culler SD, Scott T, et al. Adopting National Quality Forum medication safe practices: Progress and barriers to hospital implementation. J Hosp Med.…
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psnet.ahrq.gov/issue/adoption-order-entry-decision-support-chronic-care-physician-organizations
October 06, 2011 - Study
Adoption of order entry with decision support for chronic care by physician organizations.
Citation Text:
Simon JS, Rundall TG, Shortell SM. Adoption of order entry with decision support for chronic care by physician organizations. J Am Med Inform Assoc. 2007;14(4):432-9.
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psnet.ahrq.gov/issue/quality-improvement-through-implementation-discharge-order-reconciliation
September 23, 2020 - Commentary
Quality improvement through implementation of discharge order reconciliation.
Citation Text:
Lu Y, Clifford P, Bjorneby A, et al. Quality improvement through implementation of discharge order reconciliation. Am J Health Syst Pharm. 2013;70(9):815-20. doi:10.2146/ajhp120050. …
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psnet.ahrq.gov/issue/opportunities-enhance-laboratory-professionals-role-diagnostic-team
April 13, 2022 - Study
Opportunities to enhance laboratory professionals' role on the diagnostic team.
Citation Text:
Taylor JR, Thompson PJ, Genzen JR, et al. Opportunities to enhance laboratory professionals' role on the diagnostic team. Lab Med. 2017;48(1):97-103. doi:10.1093/labmed/lmw048.
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psnet.ahrq.gov/issue/harvey-cushings-open-and-thorough-documentation-surgical-mishaps-dawn-neurologic-surgery
November 16, 2022 - Study
Harvey Cushing's open and thorough documentation of surgical mishaps at the dawn of neurologic surgery.
Citation Text:
Latimer K, Pendleton C, Olivi A, et al. Harvey Cushing's open and thorough documentation of surgical mishaps at the dawn of neurologic surgery. Arch Surg. 2011;1…
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psnet.ahrq.gov/issue/ce-nursings-evolving-role-patient-safety
July 19, 2023 - Review
CE: nursing's evolving role in patient safety.
Citation Text:
Kowalski SL, Anthony M. CE: Nursing's Evolving Role in Patient Safety. Am J Nurs. 2017;117(2):34-48. doi:10.1097/01.NAJ.0000512274.79629.3c.
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psnet.ahrq.gov/issue/proactive-risk-assessment-surgical-site-infections-ambulatory-surgery-centers
April 13, 2022 - Study
Proactive risk assessment of surgical site infections in ambulatory surgery centers.
Citation Text:
Bish EK, Azadeh-Fard N, Steighner LA, et al. Proactive Risk Assessment of Surgical Site Infections in Ambulatory Surgery Centers. J Patient Saf. 2014;13(2). doi:10.1097/pts.000000000…
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psnet.ahrq.gov/issue/patient-safety-features-clinical-computer-systems-questionnaire-survey-gp-views
May 31, 2011 - Study
Patient safety features of clinical computer systems: questionnaire survey of GP views.
Citation Text:
Morris CJ, Savelyich BSP, Avery A, et al. Patient safety features of clinical computer systems: questionnaire survey of GP views. Qual Saf Health Care. 2005;14(3):164-8.
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psnet.ahrq.gov/issue/mental-models-basic-concept-human-factors-design-infection-prevention
April 26, 2017 - Commentary
Mental models: a basic concept for human factors design in infection prevention.
Citation Text:
Sax H, Clack L. Mental models: a basic concept for human factors design in infection prevention. J Hosp Infect. 2015;89(4):335-9. doi:10.1016/j.jhin.2014.12.008.
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psnet.ahrq.gov/issue/mandatory-presuit-mediation-5-year-results-medical-malpractice-resolution-program
February 02, 2022 - Study
Mandatory presuit mediation: 5-year results of a medical malpractice resolution program.
Citation Text:
Jenkins RC, Smillov AE, Goodwin MA. Mandatory presuit mediation: 5-year results of a medical malpractice resolution program. J Healthc Risk Manag. 2014;33(4):15-22. doi:10.1002/j…
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psnet.ahrq.gov/issue/team-based-care-changing-face-cardiothoracic-surgery
October 07, 2013 - Review
Team-based care: the changing face of cardiothoracic surgery.
Citation Text:
Crawford TC, Conte J, Sanchez JA. Team-Based Care: The Changing Face of Cardiothoracic Surgery. Surg Clin North Am. 2017;97(4):801-810. doi:10.1016/j.suc.2017.03.003.
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psnet.ahrq.gov/issue/surgical-fire-united-states-2000-2020
March 03, 2021 - Study
Surgical fire in the United States: 2000-2020.
Citation Text:
Grauer JS, Kana LA, Alzouhayli SJ, et al. Surgical fire in the United States: 2000–2020. Surgery. 2022;173(2):357-364. doi:10.1016/j.surg.2022.10.015.
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psnet.ahrq.gov/issue/reducing-delay-diagnosis-multistage-recommendation-tracking
June 19, 2012 - Study
Reducing delay in diagnosis: multistage recommendation tracking.
Citation Text:
Wandtke B, Gallagher S. Reducing Delay in Diagnosis: Multistage Recommendation Tracking. AJR Am J Roentgenol. 2017;209(5):970-975. doi:10.2214/AJR.17.18332.
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psnet.ahrq.gov/issue/fixed-dose-combination-antihypertensives-and-risk-medication-errors
September 28, 2016 - Study
Fixed-dose combination antihypertensives and risk of medication errors.
Citation Text:
Moriarty F, Bennett K, Fahey T. Fixed-dose combination antihypertensives and risk of medication errors. Heart. 2019;105(3):204-209. doi:10.1136/heartjnl-2018-313492.
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psnet.ahrq.gov/issue/errors-medication-process-frequency-type-and-potential-clinical-consequences
July 21, 2021 - Study
Errors in the medication process: frequency, type, and potential clinical consequences.
Citation Text:
Lisby M, Nielsen LP, Mainz J. Errors in the medication process: frequency, type, and potential clinical consequences. Int J Qual Health Care. 2005;17(1):15-22.
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psnet.ahrq.gov/issue/perceived-adverse-patient-outcomes-correlated-nurses-workload-medical-and-surgical-wards
February 01, 2013 - Study
Perceived adverse patient outcomes correlated to nurses' workload in medical and surgical wards of selected hospitals in Kuwait.
Citation Text:
Al-Kandari F, Thomas D. Perceived adverse patient outcomes correlated to nurses' workload in medical and surgical wards of selected ho…
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psnet.ahrq.gov/issue/review-current-evidence-base-significant-event-analysis
October 14, 2009 - Review
A review of the current evidence base for significant event analysis.
Citation Text:
Bowie P, Pope L, Lough M. A review of the current evidence base for significant event analysis. J Eval Clin Pract. 2008;14(4):520-36. doi:10.1111/j.1365-2753.2007.00908.x.
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