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psnet.ahrq.gov/issue/implementation-protocol-reduce-occurrence-retained-sponges-after-vaginal-delivery
May 18, 2022 - Commentary
Implementation of a protocol to reduce occurrence of retained sponges after vaginal delivery.
Citation Text:
Lutgendorf MA, Schindler LL, Hill JB, et al. Implementation of a protocol to reduce occurrence of retained sponges after vaginal delivery. Mil Med. 2011;176(6):702-704.…
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psnet.ahrq.gov/issue/chemotherapy-medication-errors
May 19, 2014 - Review
Emerging Classic
Chemotherapy medication errors.
Citation Text:
Weingart SN, Zhang L, Sweeney M, et al. Chemotherapy medication errors. Lancet Oncol. 2018;19(4):e191-e199. doi:10.1016/S1470-2045(18)30094-9.
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psnet.ahrq.gov/issue/rapid-response-teams-improve-outcomes-part-1-part-2-and-part-3
November 30, 2016 - Commentary
Rapid response teams improve outcomes—Part 1, Part 2, and Part 3.
Citation Text:
Rapid response teams improve outcomes—Part 1, Part 2, and Part 3. Intensive Care Med. 2016;42(4):591-601.
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psnet.ahrq.gov/issue/disclosure-medical-errors-ethical-considerations-development-facility-policy-and
August 30, 2017 - Commentary
Disclosure of medical errors: ethical considerations for the development of a facility policy and organizational culture change.
Citation Text:
Henry LL. Disclosure of medical errors: ethical considerations for the development of a facility policy and organizational culture ch…
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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…
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psnet.ahrq.gov/issue/hospital-responses-leapfrog-group-local-markets
March 04, 2011 - Study
Hospital responses to the Leapfrog Group in local markets.
Citation Text:
Scanlon D, Christianson JB, Ford E. Hospital responses to the leapfrog group in local markets. Med Care Res Rev. 2008;65(2):207-31. doi:10.1177/1077558707312499.
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psnet.ahrq.gov/issue/failures-communication-through-documents-and-documentation-across-perioperative-pathway
August 07, 2013 - Study
Failures in communication through documents and documentation across the perioperative pathway.
Citation Text:
Braaf S, Riley R, Manias E. Failures in communication through documents and documentation across the perioperative pathway. J Clin Nurs. 2015;24(13-14):1874-1884. doi:10.1…
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psnet.ahrq.gov/issue/spike-people-dying-home-suggests-coronavirus-deaths-houston-may-be-higher-reported
January 30, 2019 - Newspaper/Magazine Article
A spike in people dying at home suggests coronavirus deaths in Houston may be higher than reported.
Citation Text:
Ornstein C, Hixenbaugh M. A spike in people dying at home suggests coronavirus deaths in Houston may be higher than reported. ProPublica and NBC N…
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psnet.ahrq.gov/issue/sleep-deprivation-physician-performance-and-patient-safety
November 13, 2024 - Commentary
Sleep deprivation, physician performance, and patient safety.
Citation Text:
Olson EJ, Drage LA, Auger R. Sleep deprivation, physician performance, and patient safety. Chest. 2009;136(5):1389-1396. doi:10.1378/chest.08-1952.
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psnet.ahrq.gov/issue/trigger-tool-fails-identify-serious-errors-and-adverse-events-pediatric-otolaryngology
May 06, 2009 - Study
A trigger tool fails to identify serious errors and adverse events in pediatric otolaryngology.
Citation Text:
Lander L, Roberson DW, Plummer KM, et al. A trigger tool fails to identify serious errors and adverse events in pediatric otolaryngology. Otolaryngol Head Neck Surg. 201…
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psnet.ahrq.gov/issue/second-victim-contested-term
December 08, 2021 - Study
The second victim: a contested term?
Citation Text:
Tumelty M-E. The second victim: a contested term? J Patient Saf. 2021;17(8):e1488-e1493. doi:10.1097/pts.0000000000000558.
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psnet.ahrq.gov/issue/jcaho-patient-safety-event-taxonomy-standardized-terminology-and-classification-schema-near
June 04, 2014 - Commentary
Classic
The JCAHO patient safety event taxonomy: a standardized terminology and classification schema for near misses and adverse events.
Citation Text:
Chang A, Schyve PM, Croteau RJ, et al. The JCAHO patient safety event taxonomy: a standardized t…
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psnet.ahrq.gov/issue/barriers-and-facilitators-related-implementation-surgical-safety-checklists-systematic-review
December 05, 2018 - Review
Barriers and facilitators related to the implementation of surgical safety checklists: a systematic review of the qualitative evidence.
Citation Text:
Bergs J, Lambrechts F, Simons P, et al. Barriers and facilitators related to the implementation of surgical safety checklists: a s…
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psnet.ahrq.gov/issue/automation-failures-and-patient-safety
November 21, 2012 - Review
Automation failures and patient safety.
Citation Text:
Ruskin KJ, Ruskin AC, O’Connor M. Automation failures and patient safety. Curr Opin Anaesthesiol. 2020;33(6):788-792. doi:10.1097/aco.0000000000000935.
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psnet.ahrq.gov/issue/enhancing-pediatric-perioperative-patient-safety
January 28, 2015 - Commentary
Enhancing pediatric perioperative patient safety.
Citation Text:
Johnson Q, McVey J. Enhancing Pediatric Perioperative Patient Safety. AORN J. 2017;106(5):434-442. doi:10.1016/j.aorn.2017.09.007.
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psnet.ahrq.gov/issue/impact-dedicated-medication-nurses-medication-administration-error-rate-randomized-controlled
September 24, 2010 - Study
Classic
The impact of dedicated medication nurses on the medication administration error rate: a randomized controlled trial.
Citation Text:
Greengold NL, Shane R, Schneider PJ, et al. The impact of dedicated medication nurses on the medication administr…
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psnet.ahrq.gov/issue/effect-surgical-safety-checklists-pediatric-surgical-complications-ontario
December 07, 2016 - Study
Effect of surgical safety checklists on pediatric surgical complications in Ontario.
Citation Text:
O'Leary JD, Wijeysundera DN, Crawford MW. Effect of surgical safety checklists on pediatric surgical complications in Ontario. CMAJ. 2016;188(9):E191-E198. doi:10.1503/cmaj.151333.
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psnet.ahrq.gov/issue/implementing-surgical-checklist-more-checking-box
July 16, 2014 - Study
Implementing a surgical checklist: more than checking a box.
Citation Text:
Levy SM, Senter CE, Hawkins RB, et al. Implementing a surgical checklist: more than checking a box. Surgery. 2012;152(3):331-6. doi:10.1016/j.surg.2012.05.034.
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psnet.ahrq.gov/issue/we-know-what-they-did-wrong-not-why-case-frame-based-feedback
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…
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psnet.ahrq.gov/issue/development-and-implementation-patient-safety-program-academic-urban-emergency-department
December 12, 2012 - Study
Development and implementation of a patient safety program in an academic, urban emergency department.
Citation Text:
Blank FSJ, Henneman PL, Maynard AM, et al. Development and implementation of a patient safety program in an academic, urban emergency department. Journal of emerg…