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The 5th anniversary of the "Universal Protocol": pitfalls and pearls revisited. | PSNet

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December 21, 2014 - Commentary The 5th anniversary of the "Universal Protocol": pitfalls and pearls revisited. Citation Text: Stahel PF, Mehler PS, Clarke TJ, et al. The 5th anniversary of the "Universal Protocol": pitfalls and pearls revisited. Patient Saf Surg. 2009;3(1):14. doi:10.1186/1754-9493-3-14. …

You can't understand something you hide: transparency as a path to improve patient safety. | PSNet

psnet.ahrq.gov/issue/you-cant-understand-something-you-hide-transparency-path-improve-patient-safety

October 04, 2006 - Newspaper/Magazine Article You can't understand something you hide: transparency as a path to improve patient safety. Citation Text: You can't understand something you hide: transparency as a path to improve patient safety. Wachter R, Kaplan GS, Gandhi T, et al. Health Affairs Blog. June…

Exploring barriers and facilitators to the use of computerized clinical reminders. | PSNet

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November 05, 2015 - Study Exploring barriers and facilitators to the use of computerized clinical reminders. Citation Text: Saleem JJ, Patterson ES, Militello LG, et al. Exploring barriers and facilitators to the use of computerized clinical reminders. J Am Med Inform Assoc. 2005;12(4):438-47. Copy Cita…

Addressing healthcare-associated infections and antimicrobial resistance from an organizational perspective: progress and challenges. | PSNet

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January 31, 2024 - Commentary Addressing healthcare-associated infections and antimicrobial resistance from an organizational perspective: progress and challenges. Citation Text: Murray E, Holmes A. Addressing healthcare-associated infections and antimicrobial resistance from an organizational perspectiv…

A practical approach to measure the quality of handwritten medication orders: a tool for improvement. | PSNet

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September 24, 2010 - Study A practical approach to measure the quality of handwritten medication orders: a tool for improvement. Citation Text: Garbutt J, Milligan P, McNaughton C, et al. A Practical Approach to Measure the Quality of Handwritten Medication Orders. J Patient Saf. 2008;1(4). doi:10.1097/01.…

We know what they did wrong, but not why: the case for 'frame-based' feedback. | PSNet

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December 21, 2014 - Newspaper/Magazine Article We know what they did wrong, but not why: the case for 'frame-based' feedback. Citation Text: Rudolph JW, Raemer D, Shapiro J. We knowwhatthey did wrong, but notwhy: the case for ‘frame-based’ feedback. Clin Teach. 2013;10(3):186-189. doi:10.1111/j.1743-498x.2…

Remaking surgical socialization: work hour restrictions, rites of passage, and occupational identity. | PSNet

psnet.ahrq.gov/issue/remaking-surgical-socialization-work-hour-restrictions-rites-passage-and-occupational

March 15, 2023 - Study Remaking surgical socialization: work hour restrictions, rites of passage, and occupational identity. Citation Text: Veazey Brooks J, Bosk CL. Remaking surgical socialization: Work hour restrictions, rites of passage, and occupational identity. Soc Sci Med. 2012;75(9). doi:10.1016…

When there's no one to whom an error can be disclosed, how should an error be handled? | PSNet

psnet.ahrq.gov/issue/when-theres-no-one-whom-error-can-be-disclosed-how-should-error-be-handled

March 19, 2018 - Commentary When there's no one to whom an error can be disclosed, how should an error be handled? Citation Text: Chiu RG. When There's No One to Whom an Error Can Be Disclosed, How Should an Error Be Handled? AMA J Ethics. 2019;21(7):E553-558. doi:10.1001/amajethics.2019.553. Copy Cita…

Adverse drug event trigger tool: a practical methodology for measuring medication related harm. | PSNet

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January 05, 2017 - Study Classic Adverse drug event trigger tool: a practical methodology for measuring medication related harm. Citation Text: Rozich JD, Haraden CR, Resar RK. Adverse drug event trigger tool: a practical methodology for measuring medication related harm. Qual S…

Patient expectations of fair complaint handling in hospitals: empirical data. | PSNet

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September 25, 2024 - Study Patient expectations of fair complaint handling in hospitals: empirical data. Citation Text: Friele RD, Sluijs EM. Patient expectations of fair complaint handling in hospitals: empirical data. BMC Health Serv Res. 2006;6:106. Copy Citation Format: Google Scholar Pub…

ADEs and automation. | PSNet

psnet.ahrq.gov/issue/ades-and-automation

January 15, 2014 - Commentary ADEs and automation. Citation Text: Kloppenborg E, Wheeler A, Luria J. ADEs and automation. Nurs Manage. 2009;40(1):43-7. doi:10.1097/01.NUMA.0000343983.46376.31. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged…

The role of documents and documentation in communication failure across the perioperative pathway. A literature review. | PSNet

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November 06, 2015 - Review The role of documents and documentation in communication failure across the perioperative pathway. A literature review. Citation Text: Braaf S, Manias E, Riley R. The role of documents and documentation in communication failure across the perioperative pathway. A literature revi…

Analysis of laboratory critical value reporting at a large academic medical center. | PSNet

psnet.ahrq.gov/issue/analysis-laboratory-critical-value-reporting-large-academic-medical-center

December 05, 2013 - Study Analysis of laboratory critical value reporting at a large academic medical center. Citation Text: Dighe AS, Rao A, Coakley AB, et al. Analysis of laboratory critical value reporting at a large academic medical center. Am J Clin Pathol. 2006;125(5):758-64. Copy Citation For…

Intrahospital patient transport: checklists, adverse events, and other considerations for the anesthesia professional. | PSNet

psnet.ahrq.gov/issue/intrahospital-patient-transport-checklists-adverse-events-and-other-considerations-anesthesia

April 24, 2019 - Newspaper/Magazine Article Intrahospital patient transport: checklists, adverse events, and other considerations for the anesthesia professional. Citation Text: Andrew C, Fitzsimons M. Intrahospital patient transport: checklists, adverse events, and other considerations for the anesthesi…

AHRQ Communication and Optimal Resolution (CANDOR) Toolkit. | PSNet

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May 25, 2016 - Toolkit AHRQ Communication and Optimal Resolution (CANDOR) Toolkit. Citation Text: AHRQ Communication and Optimal Resolution (CANDOR) Toolkit. Rockville, MD: Agency for Healthcare Research and Quality; May 2016. Copy Citation Save Save to your library Print …

Delivering high reliability in maternity care: in situ simulation as a source of organisational resilience. | PSNet

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April 05, 2023 - Commentary Emerging Classic Delivering high reliability in maternity care: in situ simulation as a source of organisational resilience. Citation Text: Macrae C, Draycott T. Delivering high reliability in maternity care: In situ simulation as a source of organisa…

Parenteral nutrition errors and potential errors reported over the past 10 years. | PSNet

psnet.ahrq.gov/issue/parenteral-nutrition-errors-and-potential-errors-reported-over-past-10-years

June 20, 2018 - Study Parenteral nutrition errors and potential errors reported over the past 10 years. Citation Text: Guenter P, Ayers P, Boullata JI, et al. Parenteral Nutrition Errors and Potential Errors Reported Over the Past 10 Years. Nutr Clin Pract. 2017;32(6):826-830. doi:10.1177/08845336177158…

Evaluation of a redesign initiative in an internal-medicine residency. | PSNet

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February 17, 2011 - Study Evaluation of a redesign initiative in an internal-medicine residency. Citation Text: McMahon GT, Katz JT, Thorndike ME, et al. Evaluation of a redesign initiative in an internal-medicine residency. N Engl J Med. 2010;362(14):1304-1311. doi:10.1056/NEJMsa0908136. Copy Citation …

Using a survey of incident reporting and learning practices to improve organisational learning at a cancer care centre. | PSNet

psnet.ahrq.gov/issue/using-survey-incident-reporting-and-learning-practices-improve-organisational-learning-cancer

June 30, 2011 - Study Using a survey of incident reporting and learning practices to improve organisational learning at a cancer care centre. Citation Text: Cooke DL, Dunscombe PB, Lee R. Using a survey of incident reporting and learning practices to improve organisational learning at a cancer care ce…

Peer Review of a Report on Strategies to Improve Patient Safety. | PSNet

psnet.ahrq.gov/issue/peer-review-report-strategies-improve-patient-safety

May 19, 2021 - Book/Report Peer Review of a Report on Strategies to Improve Patient Safety. Citation Text: Peer Review of a Report on Strategies to Improve Patient Safety. Washington DC: National Academies of Sciences, Engineering, and Medicine; 2021. ISBN: 9780309462808. Copy Citation …

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