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To Err Is Human: Building a Safer Health System. | PSNet

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July 08, 2016 - Book/Report Classic To Err Is Human: Building a Safer Health System. Citation Text: To Err Is Human: Building a Safer Health System. Kohn KT, Corrigan JM, Donaldson MS, eds. Washington, DC: Committee on Quality Health Care in America, Institute of Medicine: Nati…

Understanding principles of high reliability organizations through the eyes of VIONE: a clinical program to improve patient safety by deprescribing potentially inappropriate medications and reducing polypharmacy. | PSNet

psnet.ahrq.gov/issue/understanding-principles-high-reliability-organizations-through-eyes-vione-clinical-program

November 15, 2023 - Study Understanding principles of high reliability organizations through the eyes of VIONE: a clinical program to improve patient safety by deprescribing potentially inappropriate medications and reducing polypharmacy. Citation Text: Battar S, Dickerson KRW, Sedgwick C, et al. Understand…

Adverse events and burnout: the moderating effects of workgroup identification and safety climate. | PSNet

psnet.ahrq.gov/issue/adverse-events-and-burnout-moderating-effects-workgroup-identification-and-safety-climate

February 09, 2022 - Study Adverse events and burnout: the moderating effects of workgroup identification and safety climate. Citation Text: Vogus TJ, Ramanujam R, Novikov Z, et al. Adverse events and burnout: the moderating effects of workgroup identification and safety climate. Med Care. 2020;58(7):594-600…

Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. | PSNet

psnet.ahrq.gov/issue/incidence-adverse-events-and-negligence-hospitalized-patients-results-harvard-medical

February 18, 2011 - Study Classic Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. Citation Text: Brennan TA, Leape LL, Laird NM, et al. Incidence of Adverse Events and Negligence in Hospitalized Patients. N Eng…

Adopting the Fall Tailoring Interventions for Patient Safety (TIPS) program to engage older adults in fall prevention in a nursing home. | PSNet

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December 08, 2021 - Commentary Adopting the Fall Tailoring Interventions for Patient Safety (TIPS) program to engage older adults in fall prevention in a nursing home. Citation Text: Tzeng H-M, Jansen LS, Okpalauwaekwe U, et al. Adopting the Fall Tailoring Interventions for Patient Safety (TIPS) program to …

How health systems decide to use artificial intelligence for clinical decision support. | PSNet

psnet.ahrq.gov/issue/how-health-systems-decide-use-artificial-intelligence-clinical-decision-support

March 30, 2022 - Study How health systems decide to use artificial intelligence for clinical decision support. Citation Text: Gonzalez-Smith J, Shen H, Singletary E, et al. How health systems decide to use artificial intelligence for clinical decision support. NEJM Catal Innov Care Deliv. 2022;3(4). doi:…

Implementation science: a neglected opportunity to accelerate improvements in the safety and quality of surgical care. | PSNet

psnet.ahrq.gov/issue/implementation-science-neglected-opportunity-accelerate-improvements-safety-and-quality

February 14, 2018 - Review Implementation science: a neglected opportunity to accelerate improvements in the safety and quality of surgical care. Citation Text: Hull L, Athanasiou T, Russ S. Implementation Science: A Neglected Opportunity to Accelerate Improvements in the Safety and Quality of Surgical Care…

Mind the gap between recommendation and implementation—principles and lessons in the aftermath of incident investigations: a semi-quantitative and qualitative study of factors leading to the successful implementation of recommendations. | PSNet

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March 11, 2020 - Study Mind the gap between recommendation and implementation—principles and lessons in the aftermath of incident investigations: a semi-quantitative and qualitative study of factors leading to the successful implementation of recommendations. Citation Text: Wrigstad J, Bergström J, Gusta…

A qualitative positive deviance study to explore exceptionally safe care on medical wards for older people. | PSNet

psnet.ahrq.gov/issue/qualitative-positive-deviance-study-explore-exceptionally-safe-care-medical-wards-older

March 02, 2016 - Study A qualitative positive deviance study to explore exceptionally safe care on medical wards for older people. Citation Text: Baxter R, Taylor N, Kellar I, et al. A qualitative positive deviance study to explore exceptionally safe care on medical wards for older people. BMJ Qual Saf. …

Integrated approach to reduce perinatal adverse events: standardized processes, interdisciplinary teamwork training, and performance feedback. | PSNet

psnet.ahrq.gov/issue/integrated-approach-reduce-perinatal-adverse-events-standardized-processes-interdisciplinary

September 01, 2018 - Study Integrated approach to reduce perinatal adverse events: standardized processes, interdisciplinary teamwork training, and performance feedback. Citation Text: Riley W, Begun JW, Meredith L, et al. Integrated Approach to Reduce Perinatal Adverse Events: Standardized Processes, Interd…

Cost–benefit analysis of a support program for nursing staff. | PSNet

psnet.ahrq.gov/issue/cost-benefit-analysis-support-program-nursing-staff

October 26, 2016 - Study Classic Cost–benefit analysis of a support program for nursing staff. Citation Text: Moran D, Wu AW, Connors C, et al. Cost-Benefit Analysis of a Support Program for Nursing Staff. J Patient Saf. 2020;16(4):e250-e254. doi:10.1097/pts.0000000000000376. Co…

Relationship between nurse burnout, patient and organizational outcomes: systematic review. | PSNet

psnet.ahrq.gov/issue/relationship-between-nurse-burnout-patient-and-organizational-outcomes-systematic-review

December 01, 2021 - Review Relationship between nurse burnout, patient and organizational outcomes: systematic review. Citation Text: Jun J, Ojemeni MM, Kalamani R, et al. Relationship between nurse burnout, patient and organizational outcomes: systematic review. Int J Nurs Stud. 2021;119:103933. doi:10.101…

Radiographers' experience of preventing patient safety incidents in the context of radiological examinations. | PSNet

psnet.ahrq.gov/issue/radiographers-experience-preventing-patient-safety-incidents-context-radiological

December 20, 2017 - Study Radiographers' experience of preventing patient safety incidents in the context of radiological examinations. Citation Text: Wallin A, Ringdal M, Ahlberg K, et al. Radiographers' experience of preventing patient safety incidents in the context of radiological examinations. Scand J …

Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. | PSNet

psnet.ahrq.gov/issue/resident-duty-hours-enhancing-sleep-supervision-and-safety

July 12, 2016 - Book/Report Classic Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. Citation Text: Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. Ulmer C, Wolman DM, Johns MME, eds. Committee on Optimizing Graduate Medical Trainee (Resident) Hours…

Toward a safer health care system: the critical need to improve measurement. | PSNet

psnet.ahrq.gov/issue/toward-safer-health-care-system-critical-need-improve-measurement

November 03, 2015 - Commentary Classic Toward a safer health care system: the critical need to improve measurement. Citation Text: Jha AK, Pronovost P. Toward a Safer Health Care System: The Critical Need to Improve Measurement. JAMA. 2016;315(17):1831-2. doi:10.1001/jama.2016.3448…

Anesthesia-related closed claims in free-standing ambulatory surgery centers. | PSNet

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. C…

Didactic and simulation nontechnical skills team training to improve perinatal patient outcomes in a community hospital. | PSNet

psnet.ahrq.gov/issue/didactic-and-simulation-nontechnical-skills-team-training-improve-perinatal-patient-outcomes

October 21, 2011 - Study Didactic and simulation nontechnical skills team training to improve perinatal patient outcomes in a community hospital. Citation Text: Riley W, Davis SE, Miller KK, et al. Didactic and simulation nontechnical skills team training to improve perinatal patient outcomes in a commun…

Adverse-event-reporting practices by US hospitals: results of a national survey. | PSNet

psnet.ahrq.gov/issue/adverse-event-reporting-practices-us-hospitals-results-national-survey

December 30, 2014 - Study Adverse-event-reporting practices by US hospitals: results of a national survey. Citation Text: Farley DO, Haviland A, Champagne S, et al. Adverse-event-reporting practices by US hospitals: results of a national survey. Qual Saf Health Care. 2008;17(6):416-23. doi:10.1136/qshc.20…

Effectiveness and efficiency of root cause analysis in medicine. | PSNet

psnet.ahrq.gov/issue/effectiveness-and-efficiency-root-cause-analysis-medicine

July 11, 2012 - Commentary Classic Effectiveness and efficiency of root cause analysis in medicine. Citation Text: Wu AW. Effectiveness and Efficiency of Root Cause Analysis in Medicine. JAMA. 2008;299(6):685-687. doi:10.1001/jama.299.6.685. Copy Citation Format: …

Implementing strategies to identify and mitigate adverse safety events: a case study with unplanned extubations. | PSNet

psnet.ahrq.gov/issue/implementing-strategies-identify-and-mitigate-adverse-safety-events-case-study-unplanned

May 24, 2012 - Study Implementing strategies to identify and mitigate adverse safety events: a case study with unplanned extubations. Citation Text: Hatch D, Rivard M, Bolton J, et al. Implementing Strategies to Identify and Mitigate Adverse Safety Events: A Case Study with Unplanned Extubations. Jt Co…

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