AHRQ Search | Home Page

PEARLS for systems integration: a modified PEARLS framework for debriefing systems-focused simulations. | PSNet

psnet.ahrq.gov/issue/pearls-systems-integration-modified-pearls-framework-debriefing-systems-focused-simulations

October 29, 2017 - Commentary PEARLS for systems integration: a modified PEARLS framework for debriefing systems-focused simulations. Citation Text: Dubé MM, Reid J, Kaba A, et al. PEARLS for Systems Integration: A Modified PEARLS Framework for Debriefing Systems-Focused Simulations. Simul Healthc. 2019;14…

Prevalence of harmful diagnostic errors in hospitalised adults: a systematic review and meta-analysis. | PSNet

psnet.ahrq.gov/issue/prevalence-harmful-diagnostic-errors-hospitalised-adults-systematic-review-and-meta-analysis

April 01, 2020 - Review Emerging Classic Prevalence of harmful diagnostic errors in hospitalised adults: a systematic review and meta-analysis. Citation Text: Gunderson CG, Bilan VP, Holleck JL, et al. Prevalence of harmful diagnostic errors in hospitalised adults: a systematic …

Identifying boundary spanning reporter roles in patient safety events. | PSNet

psnet.ahrq.gov/issue/identifying-boundary-spanning-reporter-roles-patient-safety-events

December 07, 2022 - Study Identifying boundary spanning reporter roles in patient safety events. Citation Text: Hurley VB, Boxley C, Sloss EA, et al. Identifying boundary spanning reporter roles in patient safety events. J Patient Saf Risk Manag. 2022;27(4):181-187. doi:10.1177/25160435221103096. Copy Cit…

Improving safety outcomes through medical error reduction via virtual reality-based clinical skills training. | PSNet

psnet.ahrq.gov/issue/improving-safety-outcomes-through-medical-error-reduction-virtual-reality-based-clinical

July 27, 2022 - Study Improving safety outcomes through medical error reduction via virtual reality-based clinical skills training. Citation Text: Kennedy GAL, Pedram S, Sanzone S. Improving safety outcomes through medical error reduction via virtual reality-based clinical skills training. Safety Sci. 2…

Intensive care medicine in 2050: preventing harm. | PSNet

psnet.ahrq.gov/issue/intensive-care-medicine-2050-preventing-harm

November 25, 2020 - Commentary Intensive care medicine in 2050: preventing harm. Citation Text: Beet C, Benoit D, Bion J. Intensive care medicine in 2050: preventing harm. Intensive Care Med. 2019;45(4):505-507. doi:10.1007/s00134-018-5353-z. Copy Citation Format: DOI Google Scholar PubMed Bib…

Are temporary staff associated with more severe emergency department medication errors? | PSNet

psnet.ahrq.gov/issue/are-temporary-staff-associated-more-severe-emergency-department-medication-errors

June 29, 2011 - Study Are temporary staff associated with more severe emergency department medication errors? Citation Text: Pham JC, Andrawis M, Shore AD, et al. Are temporary staff associated with more severe emergency department medication errors? J Healthc Qual. 2011;33(4):9-18. doi:10.1111/j.1945…

Health care quality and safety in a correctional system: creating goals and performance measures for improvement. | PSNet

psnet.ahrq.gov/issue/health-care-quality-and-safety-correctional-system-creating-goals-and-performance-measures

May 18, 2022 - Commentary Health care quality and safety in a correctional system: creating goals and performance measures for improvement. Citation Text: Neely J, Sampath R, Kirkbride G, et al. Health care quality and safety in a correctional system: creating goals and performance measures for improve…

Surgical safety checklist audits may be misleading! Improving the implementation and adherence of the surgical safety checklist: a quality improvement project. | PSNet

psnet.ahrq.gov/issue/surgical-safety-checklist-audits-may-be-misleading-improving-implementation-and-adherence

November 24, 2021 - Study Surgical safety checklist audits may be misleading! Improving the implementation and adherence of the surgical safety checklist: a quality improvement project. Citation Text: Brown B, Bermingham S, Vermeulen M, et al. Surgical safety checklist audits may be misleading! Improving th…

Effects of individual nurse and hospital characteristics on patient adverse events and quality of care: a multilevel analysis. | PSNet

psnet.ahrq.gov/issue/effects-individual-nurse-and-hospital-characteristics-patient-adverse-events-and-quality-care

February 08, 2019 - Study Effects of individual nurse and hospital characteristics on patient adverse events and quality of care: a multilevel analysis. Citation Text: Lee SE, Vincent C, Dahinten S, et al. Effects of Individual Nurse and Hospital Characteristics on Patient Adverse Events and Quality of Care…

Initiatives to identify and mitigate medication errors in England. | PSNet

psnet.ahrq.gov/issue/initiatives-identify-and-mitigate-medication-errors-england

July 22, 2020 - Commentary Initiatives to identify and mitigate medication errors in England. Citation Text: Cousins D, Gerrett D, Richards N, et al. Initiatives to identify and mitigate medication errors in England. Drug Saf. 2015;38(4):349-357. doi:10.1007/s40264-015-0270-3. Copy Citation Format…

Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 2003. | PSNet

psnet.ahrq.gov/issue/probabilistic-risk-assessment-accidental-abo-incompatible-thoracic-organ-transplantation-and

June 24, 2020 - Study Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 2003. Citation Text: Cook RI, Wreathall J, Smith A, et al. Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 200…

The effects of leadership for self-worth, inclusion, trust, and psychological safety on medical error reporting. | PSNet

psnet.ahrq.gov/issue/effects-leadership-self-worth-inclusion-trust-and-psychological-safety-medical-error

March 30, 2022 - Study The effects of leadership for self-worth, inclusion, trust, and psychological safety on medical error reporting. Citation Text: Brimhall KC, Tsai C-Y, Eckardt R, et al. The effects of leadership for self-worth, inclusion, trust, and psychological safety on medical error reporting. …

Multiple points of system failure underpin continuous subcutaneous infusion safety incidents in palliative care: a mixed methods analysis. | PSNet

psnet.ahrq.gov/issue/multiple-points-system-failure-underpin-continuous-subcutaneous-infusion-safety-incidents

December 16, 2020 - Study Multiple points of system failure underpin continuous subcutaneous infusion safety incidents in palliative care: a mixed methods analysis. Citation Text: Brown AJ, Yardley S, Bowers B, et al. Multiple points of system failure underpin continuous subcutaneous infusion safety inciden…

The application of strong matrix management and PDCA cycle in the management of severe COVID-19 patients. | PSNet

psnet.ahrq.gov/issue/application-strong-matrix-management-and-pdca-cycle-management-severe-covid-19-patients

March 24, 2019 - Commentary The application of strong matrix management and PDCA cycle in the management of severe COVID-19 patients. Citation Text: Li Y, Wang H, Jiao J. The application of strong matrix management and PDCA cycle in the management of severe COVID-19 patients. Crit Care. 2020;24(1):157. d…

Potentially inappropriate prescribing in long-term care and its relationship with probable delirium. | PSNet

psnet.ahrq.gov/issue/potentially-inappropriate-prescribing-long-term-care-and-its-relationship-probable-delirium

September 23, 2020 - Study Potentially inappropriate prescribing in long-term care and its relationship with probable delirium. Citation Text: Webber C, Milani C, Bjerre LM, et al. Potentially inappropriate prescribing in long-term care and its relationship with probable delirium. J Am Med Dir Assoc. 2024;25…

Organizational conditions for engagement in quality and safety improvement: a longitudinal qualitative study of community pharmacies. | PSNet

psnet.ahrq.gov/issue/organizational-conditions-engagement-quality-and-safety-improvement-longitudinal-qualitative

November 25, 2020 - Study Organizational conditions for engagement in quality and safety improvement: a longitudinal qualitative study of community pharmacies. Citation Text: Phipps D, Jones CEL, Parker D, et al. Organizational conditions for engagement in quality and safety improvement: a longitudinal qual…

Enhancing patient safety: a national standard for cyber resiliency in healthcare. | PSNet

psnet.ahrq.gov/issue/enhancing-patient-safety-national-standard-cyber-resiliency-healthcare

September 23, 2020 - Commentary Enhancing patient safety: a national standard for cyber resiliency in healthcare. Citation Text: Samuelson-Kiraly C, Mitchell JI, Kingston D, et al. Enhancing patient safety: A national standard for cyber resiliency in healthcare. Healthc Manage Forum. 2024;37(1):9-12. doi:10.…

It depends who you ask: divergences in staff and external stakeholder narratives about the causes of a healthcare failure. | PSNet

psnet.ahrq.gov/issue/it-depends-who-you-ask-divergences-staff-and-external-stakeholder-narratives-about-causes

August 05, 2020 - Study It depends who you ask: divergences in staff and external stakeholder narratives about the causes of a healthcare failure. Citation Text: Hald EJ, Gillespie A, Reader TW. It depends who you ask: divergences in staff and external stakeholder narratives about the causes of a healthca…

From reporting to improving: how root cause analysis in teams shape patient safety culture. | PSNet

psnet.ahrq.gov/issue/reporting-improving-how-root-cause-analysis-teams-shape-patient-safety-culture

July 31, 2024 - Study From reporting to improving: how root cause analysis in teams shape patient safety culture. Citation Text: Tsamasiotis C, Fiard G, Bouzat P, et al. From reporting to improving: how root cause analysis in teams shape patient safety culture. Risk Manag Healthc Policy. 2024;17:1847-18…

A comprehensive quality assurance program for personnel and procedures in radiation oncology: value of voluntary error reporting and checklists. | PSNet

psnet.ahrq.gov/issue/comprehensive-quality-assurance-program-personnel-and-procedures-radiation-oncology-value

November 18, 2020 - Study A comprehensive quality assurance program for personnel and procedures in radiation oncology: value of voluntary error reporting and checklists. Citation Text: Kalapurakal JA, Zafirovski A, Smith J, et al. A comprehensive quality assurance program for personnel and procedures in …

Search AHRQ

Results