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psnet.ahrq.gov/issue/anesthesia-related-closed-claims-free-standing-ambulatory-surgery-centers
March 29, 2023 - Study
Anesthesia-related closed claims in free-standing ambulatory surgery centers.
Citation Text:
Pimentel MPT, Chung S, Ross JM, et al. Anesthesia-related closed claims in free-standing ambulatory surgery centers. Anesth Analg. 2024;139(3):521-531. doi:10.1213/ane.0000000000006700.
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psnet.ahrq.gov/issue/medical-team-training-applying-crew-resource-management-veterans-health-administration
April 30, 2014 - Study
Classic
Medical team training: applying crew resource management in the Veterans Health Administration.
Citation Text:
Dunn EJ, Mills PD, Neily J, et al. Medical team training: applying crew resource management in the Veterans Health Administration. Jt Com…
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psnet.ahrq.gov/issue/sources-nurse-sensitive-inpatient-safety-improvement
July 07, 2021 - Study
Sources of nurse-sensitive inpatient safety improvement.
Citation Text:
Dynan L, Smith RB. Sources of nurse‐sensitive inpatient safety improvement. Health Serv Res. 2022;57(6):1235-1246. doi:10.1111/1475-6773.13979.
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DOI Google Scholar BibTeX EndN…
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psnet.ahrq.gov/issue/excess-dosing-antiplatelet-and-antithrombin-agents-treatment-non-st-segment-elevation-acute
November 10, 2015 - Study
Excess dosing of antiplatelet and antithrombin agents in the treatment of non–ST-segment elevation acute coronary syndromes.
Citation Text:
Alexander KP, Chen AY, Roe MT, et al. Excess dosing of antiplatelet and antithrombin agents in the treatment of non-ST-segment elevation acu…
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psnet.ahrq.gov/issue/bedside-computer-vision-moving-artificial-intelligence-driver-assistance-patient-safety
December 01, 2021 - Commentary
Emerging Classic
Bedside computer vision—moving artificial intelligence from driver assistance to patient safety.
Citation Text:
Yeung S, Downing L, Fei-Fei L, et al. Bedside Computer Vision - Moving Artificial Intelligence from Driver Assistance to P…
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psnet.ahrq.gov/issue/implementation-i-pass-handoff-program-diverse-clinical-environments-multicenter-prospective
April 24, 2018 - Study
Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study.
Citation Text:
Starmer AJ, Spector ND, O'Toole JK, et al. Implementation of the I‐PASS handoff program in diverse clinical environments: a mu…
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psnet.ahrq.gov/issue/contraindicated-medication-use-dialysis-patients-undergoing-percutaneous-coronary
February 03, 2011 - Study
Contraindicated medication use in dialysis patients undergoing percutaneous coronary intervention.
Citation Text:
Tsai TT, Maddox TM, Roe MT, et al. Contraindicated medication use in dialysis patients undergoing percutaneous coronary intervention. JAMA. 2009;302(22):2458-64. doi:…
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psnet.ahrq.gov/issue/diagnostic-performance-dashboards-tracking-diagnostic-errors-using-big-data
July 28, 2023 - Commentary
Diagnostic performance dashboards: tracking diagnostic errors using big data.
Citation Text:
Mane KK, Rubenstein KB, Nassery N, et al. Diagnostic performance dashboards: tracking diagnostic errors using big data. BMJ Qual Saf. 2018;27(7):567-570. doi:10.1136/bmjqs-2018-007945.…
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psnet.ahrq.gov/issue/classifying-errors-preventable-and-potentially-preventable-trauma-deaths-9-year-review-using
November 27, 2012 - Study
Classifying errors in preventable and potentially preventable trauma deaths: a 9-year review using the Joint Commission's standardized methodology.
Citation Text:
Vioque SM, Kim PK, McMaster J, et al. Classifying errors in preventable and potentially preventable trauma deaths: a 9-…
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psnet.ahrq.gov/issue/effect-multispecialty-faculty-handoff-initiative-safety-culture-and-handoff-quality
March 10, 2019 - Study
Effect of a multispecialty faculty handoff initiative on safety culture and handoff quality.
Citation Text:
Fitzgerald KM, Banerjee TR, Starmer AJ, et al. Effect of a multispecialty faculty handoff initiative on safety culture and handoff quality. Pediatr Qual Saf. 2022;7(2):e539. …
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psnet.ahrq.gov/issue/narrative-review-high-quality-literature-effects-resident-duty-hours-reforms
May 12, 2021 - Review
A narrative review of high-quality literature on the effects of resident duty hours reforms.
Citation Text:
Lin H, Lin E, Auditore S, et al. A Narrative Review of High-Quality Literature on the Effects of Resident Duty Hours Reforms. Acad Med. 2016;91(1):140-50. doi:10.1097/ACM.00…
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psnet.ahrq.gov/issue/patient-centered-insights-using-health-care-complaints-reveal-hot-spots-and-blind-spots
November 29, 2023 - Study
Emerging Classic
Patient-centered insights: using health care complaints to reveal hot spots and blind spots in quality and safety.
Citation Text:
Gillespie A, Reader TW. Patient-Centered Insights: Using Health Care Complaints to Reveal Hot Spots and Blind…
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psnet.ahrq.gov/issue/errors-adult-trauma-resuscitation-systematic-review
December 01, 2021 - Review
Errors in adult trauma resuscitation: a systematic review.
Citation Text:
Nikouline A, Quirion A, Jung JJ, et al. Errors in adult trauma resuscitation: a systematic review. CJEM. 2021;23:537–546. doi:10.1007/s43678-021-00118-7.
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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.…
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psnet.ahrq.gov/issue/anatomy-cyberattack-part-4-quality-assurance-and-error-reduction-billing-and-compliance
April 27, 2022 - Study
Anatomy of a cyberattack: part 4: quality assurance and error reduction, billing and compliance, transition to uptime.
Citation Text:
Frisch NK, Gibson PC, Stowman AM, et al. Anatomy of a cyberattack: part 4: quality assurance and error reduction, billing and compliance, transition…
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psnet.ahrq.gov/issue/randomised-controlled-trial-effect-continuous-electronic-physiological-monitoring-adverse
August 04, 2021 - Study
A randomised controlled trial of the effect of continuous electronic physiological monitoring on the adverse event rate in high risk medical and surgical patients.
Citation Text:
Watkinson PJ, Barber VS, Price JD, et al. A randomised controlled trial of the effect of continuous e…
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psnet.ahrq.gov/curated-library/diagnostic-error
August 10, 2025 - The majority of the diagnostic errors resulted in some form of clinical impact, including short-term … Missed or delayed diagnoses accounted for 21% of 55,377 claims analyzed, and the majority of these cases … Investigators found that three groups of diagnoses accounted for the majority of closed claims and high-severity
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psnet.ahrq.gov/node/33798/psn-pdf
January 01, 2015 - ineffective strategy for preventing further patient safety mishaps, particularly
considering that the majority … The majority of respondents, in all groups,
endorsed punitive measures such as fines, suspensions, or
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psnet.ahrq.gov/node/60362/psn-pdf
April 13, 2018 - High-Risk Pregnancy Program links clinicians and
patients across the state with UAMS, where the vast majority … Pregnancy Program links patients and clinicians across the state with the medical center,
where the vast majority … The majority of
referrals continue to be managed locally, but patients with abnormal findings may be … access to consultations: Since the implementation of the High-Risk Pregnancy
Program in 2003, the vast majority … Renewing annually, the program contract dedicates
the majority of funding toward the telemedicine infrastructure
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psnet.ahrq.gov/node/33853/psn-pdf
March 01, 2018 - But it is
disappointing that in the majority of hospitals there has been no change, and some hospitals … A majority of nurses say that they and other staff feel like their mistakes are held against them
and … RW: The majority of nurses in hospitals are working with and through technology.