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Implementation of a standardized tool for root cause analysis selection. | PSNet

psnet.ahrq.gov/issue/implementation-standardized-tool-root-cause-analysis-selection

November 06, 2024 - Study Implementation of a standardized tool for root cause analysis selection. Citation Text: Wahlstedt E, Levy BE, Scott E, et al. Implementation of a standardized tool for root cause analysis selection. J Patient Saf. 2025;21(2):101-105. doi:10.1097/pts.0000000000001291. Copy Citatio…

Assessing resident and attending error and adverse events in the emergency department. | PSNet

psnet.ahrq.gov/issue/assessing-resident-and-attending-error-and-adverse-events-emergency-department

November 25, 2020 - Study Assessing resident and attending error and adverse events in the emergency department. Citation Text: Adler JL, Gurley K, Rosen CL, et al. Assessing resident and attending error and adverse events in the emergency department. Am J Emerg Med. 2022;54:228-231. doi:10.1016/j.ajem.2022…

Factors influencing the reporting of medication errors and near misses among nurses: a systematic mixed methods review. | PSNet

psnet.ahrq.gov/issue/factors-influencing-reporting-medication-errors-and-near-misses-among-nurses-systematic-mixed

April 23, 2014 - Review Factors influencing the reporting of medication errors and near misses among nurses: a systematic mixed methods review. Citation Text: Braiki R, Douville F, Gagnon M‐P. Factors influencing the reporting of medication errors and near misses among nurses: a systematic mixed methods …

Using behavioral insights to strengthen strategies for change. Practical applications for quality improvement in healthcare. | PSNet

psnet.ahrq.gov/issue/using-behavioral-insights-strengthen-strategies-change-practical-applications-quality

April 06, 2022 - Commentary Using behavioral insights to strengthen strategies for change. Practical applications for quality improvement in healthcare. Citation Text: Johansen RLR, Tulloch S. Using behavioral insights to strengthen strategies for change. Practical applications for quality improvement in…

Accidental deaths, saved lives, and improved quality. | PSNet

psnet.ahrq.gov/issue/accidental-deaths-saved-lives-and-improved-quality

February 04, 2015 - Commentary Classic Accidental deaths, saved lives, and improved quality. Citation Text: Brennan TA, Gawande AA, Thomas EJ, et al. Accidental Deaths, Saved Lives, and Improved Quality. New England Journal of Medicine. 2005;353(13). doi:10.1056/nejmsb051157. C…

Design of an evidence-based "second victim" curriculum for nurse anesthetists. | PSNet

psnet.ahrq.gov/issue/design-evidence-based-second-victim-curriculum-nurse-anesthetists

February 15, 2023 - Commentary Design of an evidence-based "second victim" curriculum for nurse anesthetists. Citation Text: Daniels RG, McCorkle R. Design of an Evidence-Based "Second Victim" Curriculum for Nurse Anesthetists. AANA J. 2016;84(2):107-113. Copy Citation Format: Google Scholar P…

Hospital board checklist to improve culture and reduce central line–associated bloodstream infections. | PSNet

psnet.ahrq.gov/issue/hospital-board-checklist-improve-culture-and-reduce-central-line-associated-bloodstream

May 24, 2012 - Commentary Hospital board checklist to improve culture and reduce central line–associated bloodstream infections. Citation Text: Goeschel CA, Holzmueller CG, Pronovost P. Hospital Board Checklist to improve culture and reduce central line-associated bloodstream infections. Jt Comm J Qual…

Incidence and preventability of adverse events requiring intensive care admission: a systematic review. | PSNet

psnet.ahrq.gov/issue/incidence-and-preventability-adverse-events-requiring-intensive-care-admission-systematic

May 16, 2018 - Review Incidence and preventability of adverse events requiring intensive care admission: a systematic review. Citation Text: Vlayen A, Verelst S, Bekkering GE, et al. Incidence and preventability of adverse events requiring intensive care admission: a systematic review. J Eval Clin Pr…

Wisdom through adversity: learning and growing in the wake of an error. | PSNet

psnet.ahrq.gov/issue/wisdom-through-adversity-learning-and-growing-wake-error

October 08, 2016 - Study Wisdom through adversity: learning and growing in the wake of an error. Citation Text: Plews-Ogan M, Owens JE, May NB. Wisdom through adversity: learning and growing in the wake of an error. Patient Educ Couns. 2013;91(2):236-42. doi:10.1016/j.pec.2012.12.006. Copy Citation …

Effects of duty hour restrictions on core competencies, education, quality of life, and burnout among general surgery interns. | PSNet

psnet.ahrq.gov/issue/effects-duty-hour-restrictions-core-competencies-education-quality-life-and-burnout-among

December 21, 2014 - Study Effects of duty hour restrictions on core competencies, education, quality of life, and burnout among general surgery interns. Citation Text: Antiel RM, Reed DA, Van Arendonk K, et al. Effects of duty hour restrictions on core competencies, education, quality of life, and burnout a…

Advancing interprofessional patient safety education for medical, nursing, and pharmacy learners during clinical rotations. | PSNet

psnet.ahrq.gov/issue/advancing-interprofessional-patient-safety-education-medical-nursing-and-pharmacy-learners

May 18, 2022 - Commentary Advancing interprofessional patient safety education for medical, nursing, and pharmacy learners during clinical rotations. Citation Text: Thom KA, Heil EL, Croft LD, et al. Advancing interprofessional patient safety education for medical, nursing, and pharmacy learners during…

Information handoff and outcomes of critically ill patients transferred between hospitals. | PSNet

psnet.ahrq.gov/issue/information-handoff-and-outcomes-critically-ill-patients-transferred-between-hospitals

July 18, 2016 - Study Information handoff and outcomes of critically ill patients transferred between hospitals. Citation Text: Usher MG, Fanning C, Wu D, et al. Information handoff and outcomes of critically ill patients transferred between hospitals. J Crit Care. 2016;36:240-245. doi:10.1016/j.jcrc.20…

Using patient safety reporting systems to understand the clinical learning environment: a content analysis. | PSNet

psnet.ahrq.gov/issue/using-patient-safety-reporting-systems-understand-clinical-learning-environment-content

June 19, 2024 - Study Using patient safety reporting systems to understand the clinical learning environment: a content analysis. Citation Text: Sellers MM, Berger I, Myers JS, et al. Using Patient Safety Reporting Systems to Understand the Clinical Learning Environment: A Content Analysis. J Surg Educ.…

Actions and implementation strategies to reduce suicidal events in the Veterans Health Administration. | PSNet

psnet.ahrq.gov/issue/actions-and-implementation-strategies-reduce-suicidal-events-veterans-health-administration

January 05, 2017 - Study Actions and implementation strategies to reduce suicidal events in the Veterans Health Administration. Citation Text: Mills PD, Neily J, Luan D, et al. Actions and Implementation Strategies to Reduce Suicidal Events in the Veterans Health Administration. The Joint Commission Journa…

Are physicians safely prescribing opioids for chronic noncancer pain? A systematic review of current evidence. | PSNet

psnet.ahrq.gov/issue/are-physicians-safely-prescribing-opioids-chronic-noncancer-pain-systematic-review-current

November 07, 2018 - Review Are physicians safely prescribing opioids for chronic noncancer pain? A systematic review of current evidence. Citation Text: Tournebize J, Gibaja V, Muszczak A, et al. Are Physicians Safely Prescribing Opioids for Chronic Noncancer Pain? A Systematic Review of Current Evidence. P…

Overlooked guide wire: a multicomplicated Swiss Cheese Model example. Analysis of a case and review of the literature. | PSNet

psnet.ahrq.gov/issue/overlooked-guide-wire-multicomplicated-swiss-cheese-model-example-analysis-case-and-review

September 15, 2021 - Commentary Overlooked guide wire: a multicomplicated Swiss Cheese Model example. Analysis of a case and review of the literature. Citation Text: Thonon H, Espeel F, Frederic F, et al. Overlooked guide wire: a multicomplicated Swiss Cheese Model example. Analysis of a case and review of t…

Educational targets to reduce medication errors by general surgery residents. | PSNet

psnet.ahrq.gov/issue/educational-targets-reduce-medication-errors-general-surgery-residents

October 19, 2022 - Study Educational targets to reduce medication errors by general surgery residents. Citation Text: Chaitoff A, Strong AT, Bauer SR, et al. Educational Targets to Reduce Medication Errors by General Surgery Residents. J Surg Educ. 2019;76(6):1612-1621. doi:10.1016/j.jsurg.2019.04.009. C…

Risks of complications by attending physicians after performing nighttime procedures. | PSNet

psnet.ahrq.gov/issue/risks-complications-attending-physicians-after-performing-nighttime-procedures

February 14, 2018 - Study Classic Risks of complications by attending physicians after performing nighttime procedures. Citation Text: Rothschild JM. Risks of Complications by Attending Physicians After Performing Nighttime Procedures. JAMA. 2009;302(14):1565-1572. doi:10.1001/ja…

SBAR improves nurse–physician communication and reduces unexpected death: a pre and post intervention study. | PSNet

psnet.ahrq.gov/issue/sbar-improves-nurse-physician-communication-and-reduces-unexpected-death-pre-and-post

November 21, 2018 - Study SBAR improves nurse–physician communication and reduces unexpected death: a pre and post intervention study. Citation Text: De Meester K, Verspuy M, Monsieurs KG, et al. SBAR improves nurse-physician communication and reduces unexpected death: a pre and post intervention study. Re…

Should all duty hours be the same? Results of a national survey of surgical trainees. | PSNet

psnet.ahrq.gov/issue/should-all-duty-hours-be-same-results-national-survey-surgical-trainees

October 19, 2022 - Study Should all duty hours be the same? Results of a national survey of surgical trainees. Citation Text: Moalem J, Salzman P, Ruan DT, et al. Should All Duty Hours Be the Same? Results of a National Survey of Surgical Trainees. J Am Coll Surg. 2009;209(1). doi:10.1016/j.jamcollsurg.2…

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