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psnet.ahrq.gov/issue/reducing-errors-resulting-commonly-missed-chest-radiography-findings
August 20, 2018 - Commentary
Reducing errors resulting from commonly missed chest radiography findings.
Citation Text:
Gefter WB, Hatabu H. Reducing errors resulting from commonly missed chest radiography findings. Chest. 2023;163(3):634-649. doi:10.1016/j.chest.2022.12.003.
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psnet.ahrq.gov/issue/body-ct-technical-advances-improving-safety
September 28, 2022 - Review
Body CT: technical advances for improving safety.
Citation Text:
Marin D, Nelson RC, Rubin GD, et al. Body CT: technical advances for improving safety. AJR Am J Roentgenol. 2011;197(1):33-41. doi:10.2214/AJR.11.6755.
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psnet.ahrq.gov/issue/prevention-wrong-location-misadministration-through-use-intradepartmental-incident-learning
January 22, 2017 - Study
Prevention of a wrong-location misadministration through the use of an intradepartmental incident learning system.
Citation Text:
Ford E, Smith K, Harris K, et al. Prevention of a wrong-location misadministration through the use of an intradepartmental incident learning system. M…
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psnet.ahrq.gov/issue/frequency-and-severity-parenteral-nutrition-medication-errors-large-childrens-hospital-after
April 11, 2011 - Study
Frequency and severity of parenteral nutrition medication errors at a large children's hospital after implementation of electronic ordering and compounding.
Citation Text:
MacKay M, Anderson C, Boehme S, et al. Frequency and Severity of Parenteral Nutrition Medication Errors at a L…
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psnet.ahrq.gov/issue/safe-chemotherapy-administration-using-failure-mode-and-effects-analysis-computerized
October 19, 2022 - Commentary
Safe chemotherapy administration: using failure mode and effects analysis in computerized prescriber order entry.
Citation Text:
Kozakiewicz JM, Benis LJ, Fisher SM, et al. Safe chemotherapy administration: Using failure mode and effects analysis in computerized prescriber o…
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psnet.ahrq.gov/issue/reducing-readmission-academic-medical-center-results-pharmacy-facilitated-discharge
August 04, 2021 - Study
Reducing readmission at an academic medical center: results of a pharmacy-facilitated discharge counseling and medication reconciliation program.
Citation Text:
Zemaitis CT, Morris G, Cabie M, et al. Reducing Readmission at an Academic Medical Center: Results of a Pharmacy-Facilita…
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psnet.ahrq.gov/issue/disruptions-surgical-flow-and-their-relationship-surgical-errors-exploratory-investigation
August 26, 2011 - Study
Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation.
Citation Text:
Wiegmann DA, Elbardissi AW, Dearani JA, et al. Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation. Surgery. 2007;…
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psnet.ahrq.gov/issue/prescriber-barriers-and-enablers-minimising-potentially-inappropriate-medications-adults
September 23, 2020 - Review
Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis.
Citation Text:
Anderson K, Stowasser D, Freeman C, et al. Prescriber barriers and enablers to minimising potentially inappropriate medication…
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psnet.ahrq.gov/issue/relationships-among-psychological-safety-principles-high-reliability-and-safety-reporting
September 16, 2015 - Study
Relationships among psychological safety, the principles of high reliability, and safety reporting intentions in pediatric nursing.
Citation Text:
Pfeifer L, Vessey J, Cazzell M, et al. Relationships among psychological safety, the principles of high reliability, and safety reporti…
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psnet.ahrq.gov/issue/effect-rapid-response-team-incidence-hospital-mortality
March 15, 2023 - Study
Effect of a rapid response team on the incidence of in-hospital mortality.
Citation Text:
Factora F, Maheshwari K, Khanna S, et al. Effect of a rapid response team on the incidence of in-hospital mortality. Anesth Analg. 2022;135(3):595-604. doi:10.1213/ane.0000000000006005.
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psnet.ahrq.gov/issue/patient-falls-while-under-supervision-trends-incident-reporting
January 11, 2023 - Study
Patient falls while under supervision: trends from incident reporting.
Citation Text:
Roberts M. Patient falls while under supervision: trends from incident reporting. Br J Nurs. 2023;32(11):508-513. doi:10.12968/bjon.2023.32.11.508.
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psnet.ahrq.gov/issue/provencare-quality-improvement-model-designing-highly-reliable-care-cardiac-surgery
February 09, 2011 - Study
ProvenCare: quality improvement model for designing highly reliable care in cardiac surgery.
Citation Text:
Berry SA, Doll MC, McKinley KE, et al. ProvenCare: quality improvement model for designing highly reliable care in cardiac surgery. Qual Saf Health Care. 2009;18(5):360-8. d…
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psnet.ahrq.gov/issue/health-care-worker-fatigue
July 08, 2020 - Commentary
Health care worker fatigue.
Citation Text:
Gardner LA, Dubeck D. Health Care Worker Fatigue. Am J Nurs. 2016;116(8):58-62. doi:10.1097/01.NAJ.0000490182.21432.85.
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psnet.ahrq.gov/issue/hospitals-cultures-entrapment-re-analysis-bristol-royal-infirmary
May 21, 2019 - Commentary
Classic
Hospitals as cultures of entrapment: a re-analysis of the Bristol Royal Infirmary.
Citation Text:
Weick KE, Sutcliffe KM. Hospitals as Cultures of Entrapment: A Re-Analysis of the Bristol Royal Infirmary. Calif Manage Rev. 2012;45(2):73-84. do…
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psnet.ahrq.gov/issue/oxford-notechs-system-reliability-and-validity-tool-measuring-teamwork-behaviour-operating
March 03, 2011 - Study
The Oxford NOTECHS System: reliability and validity of a tool for measuring teamwork behaviour in the operating theatre.
Citation Text:
Mishra A, Catchpole K, McCulloch P. The Oxford NOTECHS System: reliability and validity of a tool for measuring teamwork behaviour in the operat…
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psnet.ahrq.gov/issue/inpatient-notes-human-factors-engineering-and-inpatient-care-new-ways-solve-old-problems
December 27, 2018 - Commentary
Inpatient Notes: human factors engineering and inpatient care—new ways to solve old problems.
Citation Text:
Clack L, Sax H. Web Exclusives. Annals for Hospitalists Inpatient Notes - Human Factors Engineering and Inpatient Care-New Ways to Solve Old Problems. Ann Intern Med. 2…
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psnet.ahrq.gov/issue/effectiveness-interventions-improve-patient-handover-surgery-systematic-review
June 25, 2018 - Review
Effectiveness of interventions to improve patient handover in surgery: a systematic review.
Citation Text:
Pucher PH, Johnston MJ, Aggarwal R, et al. Effectiveness of interventions to improve patient handover in surgery: A systematic review. Surgery. 2015;158(1):85-95. doi:10.1016…
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psnet.ahrq.gov/issue/team-management-training-using-crisis-resource-management-results-perceived-benefits
October 03, 2011 - Study
Team management training using crisis resource management results in perceived benefits by healthcare workers.
Citation Text:
Rudy SJ, Polomano R, Murray WB, et al. Team management training using crisis resource management results in perceived benefits by healthcare workers. J Co…
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psnet.ahrq.gov/issue/assessment-safety-enhancement-hospital-medication-reconciliation-process-elderly-patients
August 04, 2021 - Study
Assessment of a safety enhancement to the hospital medication reconciliation process for elderly patients.
Citation Text:
Gizzi LA, Slain D, Hare JT, et al. Assessment of a safety enhancement to the hospital medication reconciliation process for elderly patients. Am J Geriatr Phar…
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psnet.ahrq.gov/issue/safer-care-improving-caregiver-comprehension-discharge-instructions
October 26, 2022 - Study
SAFER Care: improving caregiver comprehension of discharge instructions.
Citation Text:
Uong A, Philips K, Hametz P, et al. SAFER care: improving caregiver comprehension of discharge instructions. Pediatrics. 2021;147(4):e20200031. doi:10.1542/peds.2020-0031.
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