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Reasons for repeat rapid response team calls, and associations with in-hospital mortality. | PSNet

psnet.ahrq.gov/issue/reasons-repeat-rapid-response-team-calls-and-associations-hospital-mortality

March 03, 2020 - Study Reasons for repeat rapid response team calls, and associations with in-hospital mortality. Citation Text: Chalwin R, Giles L, Salter A, et al. Reasons for Repeat Rapid Response Team Calls, and Associations with In-Hospital Mortality. Jt Comm J Qual Patient Saf. 2019;45(4):268-275. …

Changing cardiac arrest and hospital mortality rates through a medical emergency team takes time and constant review. | PSNet

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March 13, 2024 - Study Changing cardiac arrest and hospital mortality rates through a medical emergency team takes time and constant review. Citation Text: Santamaria J, Tobin A, Holmes J. Changing cardiac arrest and hospital mortality rates through a medical emergency team takes time and constant revi…

Policies and practices related to the role of board certification and recertification of pediatricians in hospital privileging. | PSNet

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February 03, 2011 - Study Policies and practices related to the role of board certification and recertification of pediatricians in hospital privileging. Citation Text: Freed GL, Uren RL, Hudson EJ, et al. Policies and practices related to the role of board certification and recertification of pediatricia…

Impact of diagnostic checklists on the interpretation of normal and abnormal electrocardiograms. | PSNet

psnet.ahrq.gov/issue/impact-diagnostic-checklists-interpretation-normal-and-abnormal-electrocardiograms

September 14, 2022 - Study Impact of diagnostic checklists on the interpretation of normal and abnormal electrocardiograms. Citation Text: Staal J, Zegers R, Caljouw-Vos J, et al. Impact of diagnostic checklists on the interpretation of normal and abnormal electrocardiograms. Diagnosis (Berl). 2022;10(2):121…

The clinical safety of disabled patients: proposal for a methodology for analysis of health care risks and specific measures for improvement. | PSNet

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January 17, 2012 - Review The clinical safety of disabled patients: proposal for a methodology for analysis of health care risks and specific measures for improvement. Citation Text: Perea-Pérez B, Labajo-González E, Bratos-Murillo M, et al. The clinical safety of disabled patients: proposal for a method…

Why do doctors make mistakes? A study of the role of salient distracting clinical features. | PSNet

psnet.ahrq.gov/issue/why-do-doctors-make-mistakes-study-role-salient-distracting-clinical-features

July 03, 2014 - Study Why do doctors make mistakes? A study of the role of salient distracting clinical features. Citation Text: Mamede S, Van Gog T, Van den Berge K, et al. Why do doctors make mistakes? A study of the role of salient distracting clinical features. Acad Med. 2014;89(1):114-20. doi:10.10…

Patient involvement in patient safety: how willing are patients to participate? | PSNet

psnet.ahrq.gov/issue/patient-involvement-patient-safety-how-willing-are-patients-participate

September 05, 2013 - Study Classic Patient involvement in patient safety: how willing are patients to participate? Citation Text: Davis R, Sevdalis N, Vincent C. Patient involvement in patient safety: How willing are patients to participate? BMJ Qual Saf. 2011;20(1):108-114. doi:…

Distractions in the operating room: a survey of the healthcare team. | PSNet

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November 16, 2022 - Study Distractions in the operating room: a survey of the healthcare team. Citation Text: Nasri B-N, Mitchell JD, Jackson C, et al. Distractions in the operating room: a survey of the healthcare team. Surg Endosc. 2023;37(3):2316-2325. doi:10.1007/s00464-022-09553-8. Copy Citation …

A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional change. | PSNet

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March 30, 2022 - Commentary A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional change. Citation Text: Clifford SP, Mick PB, Derhake BM. A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional ch…

VA Health Care: Actions Needed to Assess Decrease in Root Cause Analyses of Adverse Events. | PSNet

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November 22, 2017 - Book/Report VA Health Care: Actions Needed to Assess Decrease in Root Cause Analyses of Adverse Events. Citation Text: VA Health Care: Actions Needed to Assess Decrease in Root Cause Analyses of Adverse Events. Washington, DC: United States Government Accountability Office; July 29, 2015…

Association between hospital penalty status under the Hospital Readmission Reduction Program and readmission rates for target and nontarget conditions. | PSNet

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August 15, 2018 - Study Association between hospital penalty status under the Hospital Readmission Reduction Program and readmission rates for target and nontarget conditions. Citation Text: Desai NR, Ross JS, Kwon JY, et al. Association Between Hospital Penalty Status Under the Hospital Readmission Reduc…

High-fidelity, simulation-based, interdisciplinary operating room team training at the point of care. | PSNet

psnet.ahrq.gov/issue/high-fidelity-simulation-based-interdisciplinary-operating-room-team-training-point-care

September 16, 2009 - Study High-fidelity, simulation-based, interdisciplinary operating room team training at the point of care. Citation Text: Paige JT, Kozmenko V, Yang T, et al. High-fidelity, simulation-based, interdisciplinary operating room team training at the point of care. Surgery. 2009;145(2):138…

Technological distractions—part 1 and part 2. | PSNet

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April 24, 2018 - Review Technological distractions—part 1 and part 2. Citation Text: Kane-Gill SL, O'Connor MF, Rothschild JM, et al. Technologic Distractions (Part 1): Summary of Approaches to Manage Alert Quantity With Intent to Reduce Alert Fatigue and Suggestions for Alert Fatigue Metrics. Crit Care …

Reducing high-risk medication use through pharmacist-led interventions in an outpatient setting. | PSNet

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September 23, 2020 - Study Reducing high-risk medication use through pharmacist-led interventions in an outpatient setting. Citation Text: Deyo JC, Smith BH, Biola H, et al. Reducing high-risk medication use through pharmacist-led interventions in an outpatient setting. J Am Pharm Assoc. 2020. doi:10.1016/j.…

Older adults' awareness of deprescribing: a population-based survey. | PSNet

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June 22, 2009 - Study Older adults' awareness of deprescribing: a population-based survey. Citation Text: Turner JP, Tannenbaum C. Older adults' awareness of deprescribing: a population-based survey. J Am Geriatr Soc. 2017;65(12):2691-2696. doi:10.1111/jgs.15079. Copy Citation Format: DOI …

Preventable anesthesia-related adverse events at a large tertiary care center: a nine-year retrospective analysis. | PSNet

psnet.ahrq.gov/issue/preventable-anesthesia-related-adverse-events-large-tertiary-care-center-nine-year

November 12, 2014 - Study Preventable anesthesia-related adverse events at a large tertiary care center: a nine-year retrospective analysis. Citation Text: Curatolo CJ, McCormick PJ, Hyman JB, et al. Preventable Anesthesia-Related Adverse Events at a Large Tertiary Care Center: A Nine-Year Retrospective Ana…

A patient safety approach to setting pass/fail standards for basic procedural skills checklists. | PSNet

psnet.ahrq.gov/issue/patient-safety-approach-setting-passfail-standards-basic-procedural-skills-checklists

July 28, 2010 - Commentary A patient safety approach to setting pass/fail standards for basic procedural skills checklists. Citation Text: Yudkowsky R, Tumuluru S, Casey P, et al. A patient safety approach to setting pass/fail standards for basic procedural skills checklists. Simul Healthc. 2014;9(5):27…

Confronting safety gaps across labor and delivery teams. | PSNet

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December 04, 2013 - Study Confronting safety gaps across labor and delivery teams. Citation Text: Maxfield DG, Lyndon A, Kennedy HP, et al. Confronting safety gaps across labor and delivery teams. Am J Obstet Gynecol. 2013;209(5). doi:10.1016/j.ajog.2013.07.013. Copy Citation Format: DOI Googl…

Preventable morbidity and mortality among non-trauma emergency surgery patients: the role of personal performance and system flaws in adverse events. | PSNet

psnet.ahrq.gov/issue/preventable-morbidity-and-mortality-among-non-trauma-emergency-surgery-patients-role-personal

January 26, 2022 - Study Preventable morbidity and mortality among non-trauma emergency surgery patients: the role of personal performance and system flaws in adverse events. Citation Text: Velmahos CS, Kokoroskos N, Tarabanis C, et al. Preventable morbidity and mortality among non-trauma emergency surgery…

Tracking progress in improving diagnosis: a framework for defining undesirable diagnostic events. | PSNet

psnet.ahrq.gov/issue/tracking-progress-improving-diagnosis-framework-defining-undesirable-diagnostic-events

September 01, 2021 - Commentary Classic Tracking progress in improving diagnosis: a framework for defining undesirable diagnostic events. Citation Text: Olson A, Graber ML, Singh H. Tracking Progress in Improving Diagnosis: A Framework for Defining Undesirable Diagnostic Events. J G…

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