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  1. The problem with root cause analysis. | PSNet

    psnet.ahrq.gov/issue/problem-root-cause-analysis
    August 28, 2024 - Commentary The problem with root cause analysis. Citation Text: Peerally MF, Carr S, Waring J, et al. The problem with root cause analysis. BMJ Qual Saf. 2017;26(5):417-422. doi:10.1136/bmjqs-2016-005511. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML…

  2. Care transition of trauma patients: processes with articulation work before and after handoff. | PSNet

    psnet.ahrq.gov/issue/care-transition-trauma-patients-processes-articulation-work-and-after-handoff
    June 22, 2022 - Study Care transition of trauma patients: processes with articulation work before and after handoff. Citation Text: Wooldridge AR, Carayon P, Hoonakker PLT, et al. Care transition of trauma patients: processes with articulation work before and after handoff. Appl Ergon. 2022;98:103606. d…

  3. Does one size fit all? Assessing the need for organizational second victim support programs. | PSNet

    psnet.ahrq.gov/issue/does-one-size-fit-all-assessing-need-organizational-second-victim-support-programs
    January 14, 2011 - Study Emerging Classic Does one size fit all? Assessing the need for organizational second victim support programs. Citation Text: Edrees HH, Wu AW. Does one size fit all? Assessing the need for organizational second victim support programs. J Patient Saf. 2021;…

  4. The business case for quality: economic analysis of the Michigan Keystone Patient Safety Program in ICUs. | PSNet

    psnet.ahrq.gov/issue/business-case-quality-economic-analysis-michigan-keystone-patient-safety-program-icus
    September 20, 2011 - Study Classic The business case for quality: economic analysis of the Michigan Keystone Patient Safety Program in ICUs. Citation Text: Waters HR, Korn R, Colantuoni E, et al. The business case for quality: economic analysis of the Michigan Keystone Patient Saf…

  5. "Sorry" is never enough: how state apology laws fail to reduce medical malpractice liability risk. | PSNet

    psnet.ahrq.gov/issue/sorry-never-enough-how-state-apology-laws-fail-reduce-medical-malpractice-liability-risk
    January 07, 2022 - Study "Sorry" is never enough: how state apology laws fail to reduce medical malpractice liability risk. Citation Text: McMichael BJ, Van Horn L, Viscusi K. "Sorry” Is Never Enough: How State Apology Laws Fail to Reduce Medical Malpractice Liability Risk. Stanford Law Rev. 2019;71(2):341…

  6. The application of the Global Trigger Tool: a systematic review. | PSNet

    psnet.ahrq.gov/issue/application-global-trigger-tool-systematic-review
    December 06, 2023 - Review The application of the Global Trigger Tool: a systematic review. Citation Text: Hibbert PD, Molloy CJ, Hooper TD, et al. The application of the Global Trigger Tool: a systematic review. Int J Qual Health Care. 2016;28(6):640-649. doi:10.1093/intqhc/mzw115. Copy Citation For…

  7. High-reliability health care: getting there from here. | PSNet

    psnet.ahrq.gov/issue/high-reliability-health-care-getting-there-here
    January 23, 2012 - Study Classic High-reliability health care: getting there from here. Citation Text: Chassin MR, Loeb JM. High-reliability health care: getting there from here. Milbank Q. 2013;91(3):459-490. doi:10.1111/1468-0009.12023. Copy Citation Format: DOI Go…

  8. Developing and aligning a safety event taxonomy for inpatient psychiatry. | PSNet

    psnet.ahrq.gov/issue/developing-and-aligning-safety-event-taxonomy-inpatient-psychiatry
    September 14, 2022 - Study Developing and aligning a safety event taxonomy for inpatient psychiatry. Citation Text: Barnes T, Fontaine T, Bautista C, et al. Developing and aligning a safety event taxonomy for inpatient psychiatry. J Patient Saf. 2022;18(4):e704-e713. doi:10.1097/pts.0000000000000935. Copy …

  9. Impact of the Accreditation Council for Graduate Medical Education work-hour regulations on neurosurgical resident education and productivity. | PSNet

    psnet.ahrq.gov/issue/impact-accreditation-council-graduate-medical-education-work-hour-regulations-neurosurgical
    June 03, 2020 - Study Impact of the Accreditation Council for Graduate Medical Education work-hour regulations on neurosurgical resident education and productivity. Citation Text: Jagannathan J, Vates E, Pouratian N, et al. Impact of the Accreditation Council for Graduate Medical Education work-hour r…

  10. Impact of medical education on patient safety: finding the signal through the noise. | PSNet

    psnet.ahrq.gov/issue/impact-medical-education-patient-safety-finding-signal-through-noise
    December 31, 2018 - Commentary Impact of medical education on patient safety: finding the signal through the noise. Citation Text: Hwang J, Kelz RR. Impact of medical education on patient safety: finding the signal through the noise. BMJ Qual Saf. 2023;32(2):61-64. doi:10.1136/bmjqs-2022-015054. Copy Cita…

  11. Shift change handovers and subsequent interruptions: potential impacts on quality of care. | PSNet

    psnet.ahrq.gov/issue/shift-change-handovers-and-subsequent-interruptions-potential-impacts-quality-care
    February 04, 2009 - Study Shift change handovers and subsequent interruptions: potential impacts on quality of care. Citation Text: Estryn-Behar MR, Milanini-Magny G, Chaumon E, et al. Shift change handovers and subsequent interruptions: potential impacts on quality of care. J Patient Saf. 2014;10(1):29-44.…

  12. Characterising physician listening behaviour during hospitalist handoffs using the HEAR checklist. | PSNet

    psnet.ahrq.gov/issue/characterising-physician-listening-behaviour-during-hospitalist-handoffs-using-hear-checklist
    March 11, 2013 - Study Characterising physician listening behaviour during hospitalist handoffs using the HEAR checklist. Citation Text: Greenstein EA, Arora V, Staisiunas PG, et al. Characterising physician listening behaviour during hospitalist handoffs using the HEAR checklist. BMJ Qual Saf. 2013;22…

  13. Pharmacy leadership amid the pandemic: maintaining patient safety during uncertain times. | PSNet

    psnet.ahrq.gov/issue/pharmacy-leadership-amid-pandemic-maintaining-patient-safety-during-uncertain-times
    March 29, 2023 - Commentary Pharmacy leadership amid the pandemic: maintaining patient safety during uncertain times. Citation Text: Derrong Lin I, Hertig JB. Pharmacy leadership amid the pandemic: maintaining patient safety during uncertain times. Hosp Pharm. 2022;57(3):323-328. doi:10.1177/001857872110…

  14. Identifying a list of healthcare 'never events' to effect system change: a systematic review and narrative synthesis. | PSNet

    psnet.ahrq.gov/issue/identifying-list-healthcare-never-events-effect-system-change-systematic-review-and-narrative
    April 24, 2019 - Review Identifying a list of healthcare 'never events' to effect system change: a systematic review and narrative synthesis. Citation Text: Bowman CL, De Gorter R, Zaslow J, et al. Identifying a list of healthcare ‘never events’ to effect system change: a systematic review and narrative …

  15. Using the Assessment of Reasoning Tool to facilitate feedback about diagnostic reasoning. | PSNet

    psnet.ahrq.gov/issue/using-assessment-reasoning-tool-facilitate-feedback-about-diagnostic-reasoning
    February 23, 2022 - Study Using the Assessment of Reasoning Tool to facilitate feedback about diagnostic reasoning. Citation Text: Cohen AL, Sur M, Falco C, et al. Using the Assessment of Reasoning Tool to facilitate feedback about diagnostic reasoning. Diagnosis (Berl). 2022;9(4):476-484. doi:10.1515/dx-20…

  16. American College of Surgeons' Committee on Trauma performance improvement and patient safety program: maximal impact in a mature trauma center. | PSNet

    psnet.ahrq.gov/issue/american-college-surgeons-committee-trauma-performance-improvement-and-patient-safety-program
    September 23, 2020 - Study American College of Surgeons' Committee on Trauma performance improvement and patient safety program: maximal impact in a mature trauma center. Citation Text: Sarkar B, Brunsvold ME, Cherry-Bukoweic JR, et al. American College of Surgeons' Committee on Trauma Performance Improvem…

  17. Society for Maternal-Fetal Medicine Special Statement: cognitive bias and medical error in obstetrics-challenges and opportunities. | PSNet

    psnet.ahrq.gov/issue/society-maternal-fetal-medicine-special-statement-cognitive-bias-and-medical-error-obstetrics
    May 18, 2022 - Organizational Policy/Guidelines Society for Maternal-Fetal Medicine Special Statement: cognitive bias and medical error in obstetrics-challenges and opportunities. Citation Text: Atallah F, Hamm RF, Davidson CM, et al. Society for Maternal-Fetal Medicine Special Statement: Cognitive bia…

  18. Publication of inspection frameworks: a qualitative study exploring the impact on quality improvement and regulation in three healthcare settings. | PSNet

    psnet.ahrq.gov/issue/publication-inspection-frameworks-qualitative-study-exploring-impact-quality-improvement-and
    August 10, 2022 - Study Publication of inspection frameworks: a qualitative study exploring the impact on quality improvement and regulation in three healthcare settings. Citation Text: Weenink J-W, Wallenburg I, Leistikow I, et al. Publication of inspection frameworks: a qualitative study exploring the i…

  19. Contributors to diagnostic error or delay in the acute care setting: a survey of clinical stakeholders. | PSNet

    psnet.ahrq.gov/issue/contributors-diagnostic-error-or-delay-acute-care-setting-survey-clinical-stakeholders
    May 26, 2021 - Study Contributors to diagnostic error or delay in the acute care setting: a survey of clinical stakeholders. Citation Text: Redmond S, Barwise A, Zornes S, et al. Contributors to diagnostic error or delay in the acute care setting: a survey of clinical stakeholders. Health Serv Insights…

  20. Frequency of diagnostic errors in the neonatal intensive care unit: a retrospective cohort study. | PSNet

    psnet.ahrq.gov/issue/frequency-diagnostic-errors-neonatal-intensive-care-unit-retrospective-cohort-study
    April 13, 2022 - Study Frequency of diagnostic errors in the neonatal intensive care unit: a retrospective cohort study. Citation Text: Shafer GJ, Singh H, Thomas EJ, et al. Frequency of diagnostic errors in the neonatal intensive care unit: a retrospective cohort study. J Perinatol. 2022;42(10):1312-131…
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