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The culture of safety: results of an organization-wide survey in 15 California hospitals. | PSNet

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November 18, 2009 - Study Classic The culture of safety: results of an organization-wide survey in 15 California hospitals. Citation Text: Singer SJ, Gaba DM, Geppert JJ, et al. The culture of safety: results of an organization-wide survey in 15 California hospitals. Qual Saf Hea…

Preventable errors in the operating room--part 2: retained foreign objects, sharps injuries, and wrong site surgery. | PSNet

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April 25, 2018 - Review Preventable errors in the operating room--part 2: retained foreign objects, sharps injuries, and wrong site surgery. Citation Text: Dagi F, Berguer R, Moore S, et al. Preventable errors in the operating room--part 2: retained foreign objects, sharps injuries, and wrong site surg…

Patient safety: latex allergy. | PSNet

psnet.ahrq.gov/issue/patient-safety-latex-allergy

October 07, 2013 - Commentary Patient safety: latex allergy. Citation Text: Reines D, Seifert PC. Patient safety: latex allergy. Surg Clin North Am. 2005;85(6):1329-40, xiv. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

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…

A system analysis of a suboptimal surgical experience. | PSNet

psnet.ahrq.gov/issue/system-analysis-suboptimal-surgical-experience

March 23, 2011 - Study A system analysis of a suboptimal surgical experience. Citation Text: Lee R, Cooke DL, Richards MR. A system analysis of a suboptimal surgical experience. Patient Saf Surg. 2009;3(1):1. doi:10.1186/1754-9493-3-1. Copy Citation Format: DOI Google Scholar PubMed BibTe…

Speaking across the drapes: communication strategies of anesthesiologists and obstetricians during a simulated maternal crisis. | PSNet

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May 08, 2017 - Study Speaking across the drapes: communication strategies of anesthesiologists and obstetricians during a simulated maternal crisis. Citation Text: Minehart RD, Pian-Smith MCM, Walzer TB, et al. Speaking across the drapes: communication strategies of anesthesiologists and obstetrician…

Safety with nebulized medications requires an interdisciplinary team approach. | PSNet

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December 27, 2018 - Newspaper/Magazine Article Safety with nebulized medications requires an interdisciplinary team approach. Citation Text: Safety with nebulized medications requires an interdisciplinary team approach. ISMP Medication Safety Alert! Acute care edition. February 22, 2018;23(4):1-5. Copy Ci…

Improving diagnosis in health care—the next imperative for patient safety. | PSNet

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July 15, 2015 - Commentary Classic Improving diagnosis in health care—the next imperative for patient safety. Citation Text: Singh H, Graber ML. Improving Diagnosis in Health Care--The Next Imperative for Patient Safety. New Engl J Med. 2015;373(26):2493-2495. doi:10.1056/NEJMp…

The nuclear power industry as an alternative analogy for safety in anaesthesia and a novel approach for the conceptualisation of safety goals. | PSNet

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February 13, 2019 - Commentary The nuclear power industry as an alternative analogy for safety in anaesthesia and a novel approach for the conceptualisation of safety goals. Citation Text: Webster CS. The nuclear power industry as an alternative analogy for safety in anaesthesia and a novel approach for t…

Reducing preventable medication safety events by recognizing renal risk. | PSNet

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June 27, 2011 - Study Reducing preventable medication safety events by recognizing renal risk. Citation Text: Fields W, Tedeschi C, Foltz J, et al. Reducing preventable medication safety events by recognizing renal risk. Clin Nurse Spec. 2008;22(2):73-8; quiz 79-80. doi:10.1097/01.NUR.0000311795.69476…

Towards an organization with a memory: exploring the organizational generation of adverse events in health care. | PSNet

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February 22, 2010 - Commentary Towards an organization with a memory: exploring the organizational generation of adverse events in health care. Citation Text: Smith D, Toft B. Towards an organization with a memory: exploring the organizational generation of adverse events in health care. Health Serv Manag…

Using fault trees to advance understanding of diagnostic errors. | PSNet

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November 11, 2020 - Commentary Using fault trees to advance understanding of diagnostic errors. Citation Text: Rogith D, Iyengar S, Singh H. Using Fault Trees to Advance Understanding of Diagnostic Errors. Jt Comm J Qual Patient Saf. 2017;43(11):598-605. doi:10.1016/j.jcjq.2017.06.007. Copy Citation F…

Hand-off Communications. | PSNet

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January 04, 2017 - Multi-use Website Hand-off Communications. Citation Text: DeRosier JM, Stalhandske E, Bagian JP, et al. Using health care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective risk analysis system. Copy Citation Format: Google Scholar P…

Injection practices among clinicians in United States health care settings. | PSNet

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January 06, 2017 - Study Injection practices among clinicians in United States health care settings. Citation Text: Pugliese G, Gosnell C, Bartley JM, et al. Injection practices among clinicians in United States health care settings. Am J Infect Control. 2010;38(10):789-798. doi:10.1016/j.ajic.2010.09.00…

Eradicating medical student mistreatment: a longitudinal study of one institution's efforts. | PSNet

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August 28, 2019 - Study Eradicating medical student mistreatment: a longitudinal study of one institution's efforts. Citation Text: Fried JM, Vermillion M, Parker NH, et al. Eradicating medical student mistreatment: a longitudinal study of one institution's efforts. Acad Med. 2012;87(9):1191-1198. Copy …

Lehigh Valley Hospital: engaging patients and families. | PSNet

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January 04, 2017 - Award Recipient Lehigh Valley Hospital: engaging patients and families. Citation Text: Anthony R, Ritter M, Davis R, et al. Lehigh Valley Hospital: engaging patients and families. Jt Comm J Qual Patient Saf. 2005;31(10):566-72. Copy Citation Format: Google Scholar PubMed Bi…

Fall risk and prevention agreement: engaging patients and families with a partnership for patient safety. | PSNet

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November 13, 2024 - Commentary Fall risk and prevention agreement: engaging patients and families with a partnership for patient safety. Citation Text: Vonnes C, Wolf D. Fall risk and prevention agreement: engaging patients and families with a partnership for patient safety. BMJ Open Qual. 2017;6(2):e000038…

Diagnostic errors: impact of an educational intervention on pediatric primary care. | PSNet

psnet.ahrq.gov/issue/diagnostic-errors-impact-educational-intervention-pediatric-primary-care

July 22, 2020 - Study Diagnostic errors: impact of an educational intervention on pediatric primary care. Citation Text: Walsh JN, Knight M, Lee AJ. Diagnostic Errors: Impact of an Educational Intervention on Pediatric Primary Care. Journal of Pediatric Health Care. 2017;32(1). doi:10.1016/j.pedhc.2017.…

Residual anaesthesia drugs in intravenous lines—a silent threat? | PSNet

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July 13, 2010 - Commentary Residual anaesthesia drugs in intravenous lines—a silent threat? Citation Text: Bowman S, Raghavan K, Walker IA. Residual anaesthesia drugs in intravenous lines--a silent threat? Anaesthesia. 2013;68(6):557-61. doi:10.1111/anae.12287. Copy Citation Format: DOI G…

Knowledge-based errors in anesthesia: a paired, controlled trial of learning and retention. | PSNet

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December 06, 2023 - Study Knowledge-based errors in anesthesia: a paired, controlled trial of learning and retention. Citation Text: Goldhaber-Fiebert SN, Goldhaber-Fiebert JD, Rosow CE. Knowledge-based errors in anesthesia: a paired, controlled trial of learning and retention. Can J Anaesth. 2009;56(1):3…

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