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psnet.ahrq.gov/issue/identifying-systems-failures-pathway-catastrophic-event-analysis-national-incident-report
January 22, 2014 - Study
Identifying systems failures in the pathway to a catastrophic event: an analysis of national incident report data relating to vinca alkaloids.
Citation Text:
Franklin BD, Panesar S, Vincent CA, et al. Identifying systems failures in the pathway to a catastrophic event: an analysis …
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psnet.ahrq.gov/issue/whistleblowing-over-patient-safety-and-care-quality-review-literature
April 08, 2019 - Review
Emerging Classic
Whistleblowing over patient safety and care quality: a review of the literature.
Citation Text:
Blenkinsopp J, Snowden N, Mannion R, et al. Whistleblowing over patient safety and care quality: a review of the literature. J Health Org Mana…
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psnet.ahrq.gov/issue/missed-nursing-care-emergency-departments-scoping-review
November 03, 2021 - Review
Missed nursing care in emergency departments: a scoping review.
Citation Text:
Duhalde H, Bjuresäter K, Karlsson I, et al. Missed nursing care in emergency departments: a scoping review. Int Emerg Nurs. 2023;69:101296. doi:10.1016/j.ienj.2023.101296.
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psnet.ahrq.gov/issue/ashp-national-survey-pharmacy-practice-hospital-settings-dispensing-and-administration-2011
September 30, 2020 - Study
ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2011.
Citation Text:
Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: Dispensing and administration—2011. American Journal of H…
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psnet.ahrq.gov/issue/challenging-authority-during-life-threatening-crisis-effect-operating-theatre-hierarchy
December 02, 2015 - Study
Challenging authority during a life-threatening crisis: the effect of operating theatre hierarchy.
Citation Text:
Sydor DT, Bould MD, Naik VN, et al. Challenging authority during a life-threatening crisis: the effect of operating theatre hierarchy. Br J Anaesth. 2013;110(3):463-7…
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psnet.ahrq.gov/issue/retrospective-analysis-demonstrates-failure-document-key-comorbid-diseases-anesthesia
May 26, 2021 - Study
A retrospective analysis demonstrates that a failure to document key comorbid diseases in the anesthesia preoperative evaluation associates with increased length of stay and mortality.
Citation Text:
Hofer IS, Cheng D, Grogan T. A retrospective analysis demonstrates that a failure …
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psnet.ahrq.gov/issue/communication-failure-operating-room
February 25, 2009 - Study
Communication failure in the operating room.
Citation Text:
Halverson AL, Casey JT, Andersson J, et al. Communication failure in the operating room. Surgery. 2011;149(3):305-310. doi:10.1016/j.surg.2010.07.051.
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psnet.ahrq.gov/issue/state-health-burnout-healthy-behaviors-workplace-wellness-support-and-concerns-medication
July 14, 2021 - Study
The state of health, burnout, healthy behaviors, workplace wellness support, and concerns of medication errors in pharmacists during the COVID-19 pandemic.
Citation Text:
Melnyk BM, Hsieh AP, Tan A, et al. The state of health, burnout, healthy behaviors, workplace wellness support,…
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psnet.ahrq.gov/issue/do-physicians-clean-their-hands-insights-covert-observational-study
July 02, 2019 - Study
Do physicians clean their hands? Insights from a covert observational study.
Citation Text:
Kovacs-Litman A, Wong K, Shojania KG, et al. Do physicians clean their hands? Insights from a covert observational study. J Hosp Med. 2016;11(12):862-864. doi:10.1002/jhm.2632.
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psnet.ahrq.gov/issue/doctor-was-rude-toilets-are-dirty-utilizing-soft-signals-regulation-patient-safety
October 06, 2021 - Study
The doctor was rude, the toilets are dirty. Utilizing 'soft signals' in the regulation of patient safety.
Citation Text:
Kok J, Wallenburg I, Leistikow I, et al. The doctor was rude, the toilets are dirty. Utilizing ‘soft signals’ in the regulation of patient safety. Safety Sci. 20…
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psnet.ahrq.gov/issue/application-human-factors-analysis-and-classification-system-methodology-cardiovascular
January 06, 2012 - Study
Application of the human factors analysis and classification system methodology to the cardiovascular surgery operating room.
Citation Text:
Elbardissi AW, Wiegmann DA, Dearani JA, et al. Application of the human factors analysis and classification system methodology to the cardi…
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psnet.ahrq.gov/issue/reductions-sepsis-mortality-and-costs-after-design-and-implementation-nurse-based-early
March 09, 2016 - Study
Reductions in sepsis mortality and costs after design and implementation of a nurse-based early recognition and response program.
Citation Text:
Jones SL, Ashton CM, Kiehne L, et al. Reductions in sepsis mortality and costs after design and implementation of a nurse-based early rec…
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psnet.ahrq.gov/issue/outcomes-quality-improvement-project-educating-nurses-medication-administration-and-errors
April 24, 2018 - Study
Outcomes of a quality improvement project for educating nurses on medication administration and errors in nursing homes.
Citation Text:
Tenhunen ML, Tanner EK, Dahlen R. Outcomes of a quality improvement project for educating nurses on medication administration and errors in nursin…
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psnet.ahrq.gov/issue/diagnostic-error-emergency-department-learning-national-patient-safety-incident-report
January 12, 2022 - Study
Diagnostic error in the emergency department: learning from national patient safety incident report analysis.
Citation Text:
Hussain F, Cooper A, Carson-Stevens A, et al. Diagnostic error in the emergency department: learning from national patient safety incident report analysis. B…
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psnet.ahrq.gov/issue/inpatient-ehr-user-experience-and-hospital-ehr-safety-performance
April 24, 2018 - Study
Inpatient EHR user experience and hospital EHR safety performance.
Citation Text:
Classen DC, Longhurst CA, Davis T, et al. Inpatient EHR user experience and hospital EHR safety performance. JAMA Netw Open. 2023;6(9):e2333152. doi:10.1001/jamanetworkopen.2023.33152.
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psnet.ahrq.gov/issue/exploring-nurses-attitudes-skills-and-beliefs-medication-safety-practices
October 21, 2020 - Study
Exploring nurses' attitudes, skills, and beliefs of medication safety practices.
Citation Text:
Arkin L, Schuermann A, Penoyer D, et al. Exploring nurses' attitudes, skills, and beliefs of medication safety practices. J Nurs Care Qual. 2022;37(4):319-326. doi:10.1097/ncq.0000000000…
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psnet.ahrq.gov/issue/impact-nurse-shortage-hospital-patient-care-comparative-perspectives
March 23, 2011 - Study
Impact of the nurse shortage on hospital patient care: comparative perspectives.
Citation Text:
Buerhaus P, Donelan K, Ulrich BT, et al. Impact of the nurse shortage on hospital patient care: comparative perspectives. Health Aff (Millwood). 2007;26(3):853-62.
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psnet.ahrq.gov/issue/safety-ground-using-critical-incident-technique-explore-factors-influencing-medical
April 19, 2023 - Study
Safety on the ground: using critical incident technique to explore the factors influencing medical registrars' provision of safe care.
Citation Text:
Ralston K, Smith SE, Kerins J, et al. Safety on the ground: using critical incident technique to explore the factors influencing med…
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psnet.ahrq.gov/issue/long-term-effects-teamwork-training-communication-and-teamwork-climate-ambulatory
May 01, 2019 - Study
Long-term effects of teamwork training on communication and teamwork climate in ambulatory reproductive health care.
Citation Text:
Dodge LE, Nippita S, Hacker MR, et al. Long‐term effects of teamwork training on communication and teamwork climate in ambulatory reproductive health …
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psnet.ahrq.gov/issue/association-between-clinic-opioid-administration-and-discharge-opioid-prescription-urgent
May 19, 2021 - Study
Association between in-clinic opioid administration and discharge opioid prescription in urgent care: a retrospective cohort study.
Citation Text:
Calcaterra SL, Lou Y, Everhart RM, et al. Association between in-clinic opioid administration and discharge opioid prescription in urge…