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psnet.ahrq.gov/issue/evaluation-information-transfer-through-continuum-surgical-care-feasibility-study
December 21, 2014 - Study
An evaluation of information transfer through the continuum of surgical care: a feasibility study.
Citation Text:
Nagpal K, Vats A, Ahmed K, et al. An evaluation of information transfer through the continuum of surgical care: a feasibility study. Ann Surg. 2010;252(2):402-7. doi:1…
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psnet.ahrq.gov/issue/effect-safe-zone-nurse-interruptions-distractions-and-medication-administration-errors
October 19, 2022 - Study
The effect of a safe zone on nurse interruptions, distractions, and medication administration errors.
Citation Text:
Yoder M, Schadewald D, Dietrich K. The effect of a safe zone on nurse interruptions, distractions, and medication administration errors. J Infus Nurs. 2015;38(2):140…
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psnet.ahrq.gov/issue/medical-error-reduction-and-tort-reform-through-private-contractually-based-quality-medicine
October 13, 2010 - Commentary
Medical error reduction and tort reform through private contractually-based quality medicine societies.
Citation Text:
MacCourt D, Bernstein J. Medical error reduction and tort reform through private, contractually-based quality medicine societies. Am J Law Med. 2009;35(4):5…
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psnet.ahrq.gov/issue/recasting-rca-improved-model-performing-root-cause-analyses
November 10, 2010 - Commentary
ReCASTing the RCA: an improved model for performing root cause analyses.
Citation Text:
Pham JC, Kim GR, Natterman JP, et al. ReCASTing the RCA: An Improved Model for Performing Root Cause Analyses. American Journal of Medical Quality. 2010;25(3). doi:10.1177/1062860609359533…
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psnet.ahrq.gov/issue/beyond-see-one-do-one-teach-one-toward-different-training-paradigm
March 01, 2011 - Commentary
Beyond "see one, do one, teach one": toward a different training paradigm.
Citation Text:
Rodriguez-Paz JM, Kennedy M, Salas E, et al. Beyond "see one, do one, teach one": toward a different training paradigm. Qual Saf Health Care. 2009;18(1):63-8. doi:10.1136/qshc.2007.02…
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psnet.ahrq.gov/issue/towards-safer-better-healthcare-harnessing-natural-properties-complex-sociotechnical-systems
April 08, 2011 - Commentary
Towards safer, better healthcare: harnessing the natural properties of complex sociotechnical systems.
Citation Text:
Braithwaite J, Runciman WB, Merry AF. Towards safer, better healthcare: harnessing the natural properties of complex sociotechnical systems. Qual Saf Health …
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psnet.ahrq.gov/issue/case-study-getting-boards-board-allen-memorial-hospital-iowa-health-system
August 04, 2021 - Commentary
Case study: getting boards on board at Allen Memorial Hospital, Iowa Health System.
Citation Text:
Slessor SR, Crandall JB, Nielsen GA. Case study: getting boards on board at Allen Memorial Hospital, Iowa Health System. Jt Comm J Qual Patient Saf. 2008;34(4):221-227.
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psnet.ahrq.gov/issue/patient-safety-curriculum-surgical-residency-programs-results-national-consensus-conference
September 16, 2009 - Commentary
Patient safety curriculum for surgical residency programs: results of a national consensus conference.
Citation Text:
Sachdeva AK, Philibert I, Leach DC, et al. Patient safety curriculum for surgical residency programs: results of a national consensus conference. Surgery. 20…
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psnet.ahrq.gov/issue/reducing-diagnostic-error-through-medical-home-based-primary-care-reform
July 15, 2015 - Commentary
Reducing diagnostic error through medical home-based primary care reform.
Citation Text:
Singh H, Graber ML. Reducing diagnostic error through medical home-based primary care reform. JAMA. 2010;304(4):463-4. doi:10.1001/jama.2010.1035.
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psnet.ahrq.gov/issue/global-priorities-patient-safety-research
April 05, 2017 - Commentary
Global priorities for patient safety research.
Citation Text:
Bates DW, Larizgoitia I, Prasopa-Plaizier N, et al. Global priorities for patient safety research. BMJ. 2009;338:b1775. doi:10.1136/bmj.b1775.
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psnet.ahrq.gov/issue/teach-back-patients-perspective
March 27, 2024 - Commentary
"Teach-back" from a patient's perspective.
Citation Text:
Miller S, Lattanzio M, Cohen S. "Teach-back" from a patient's perspective. Nursing (Brux). 2016;46(2):63-4. doi:10.1097/01.NURSE.0000476249.18503.f5.
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psnet.ahrq.gov/issue/health-information-technology-leadership-panel-final-report
March 30, 2022 - Government Resource
Health Information Technology Leadership Panel: Final Report.
Citation Text:
Health Information Technology Leadership Panel: Final Report. Lewin Group: Falls Church, VA; March 2005.
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psnet.ahrq.gov/issue/changing-patient-safety-mindset-can-safety-cases-help
July 14, 2021 - Commentary
Changing the patient safety mindset: can safety cases help?
Citation Text:
Sujan M, Habli I. Changing the patient safety mindset: can safety cases help? BMJ Qual Saf. 2024;33(3):145-148. doi:10.1136/bmjqs-2023-016652.
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psnet.ahrq.gov/issue/incident-reporting-one-uk-accident-and-emergency-department
December 12, 2012 - Study
Incident reporting in one UK accident and emergency department.
Citation Text:
Tighe CM, Woloshynowych M, Brown R, et al. Incident reporting in one UK accident and emergency department. Accid Emerg Nurs. 2006;14(1):27-37.
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psnet.ahrq.gov/issue/racism-root-cause-approach-new-framework
December 17, 2020 - Commentary
Racism as a Root Cause approach: a new framework.
Citation Text:
Malawa Z, Gaarde J, Spellen S. Racism as a Root Cause approach: a new framework. Pediatrics. 2021;147(1):e2020015602. doi:10.1542/peds.2020-015602.
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psnet.ahrq.gov/issue/err-human-what-happens-when-surgeons-err
August 04, 2021 - Study
To err is human, but what happens when surgeons err?
Citation Text:
Lin JS, Olutoye OO, Samora JB. To err is human, but what happens when surgeons err? J Pediatr Surg. 2023;58(3):496-502. doi:10.1016/j.jpedsurg.2022.06.019.
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psnet.ahrq.gov/issue/medical-emergency-teams-strategy-improving-patient-care-and-nursing-work-environments
March 24, 2011 - Study
Medical emergency teams: a strategy for improving patient care and nursing work environments.
Citation Text:
Galhotra S, Scholle CC, Dew MA, et al. Medical emergency teams: a strategy for improving patient care and nursing work environments. J Adv Nurs. 2006;55(2):180-7.
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psnet.ahrq.gov/issue/legal-and-policy-interventions-improve-patient-safety
February 17, 2011 - Review
Legal and policy interventions to improve patient safety.
Citation Text:
Kachalia A, Mello MM, Nallamothu BK, et al. Legal and Policy Interventions to Improve Patient Safety. Circulation. 2016;133(7):661-71. doi:10.1161/CIRCULATIONAHA.115.015880.
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psnet.ahrq.gov/issue/preventable-mortality-after-common-urological-surgery-failing-rescue
July 17, 2013 - Study
Preventable mortality after common urological surgery: failing to rescue?
Citation Text:
Sammon JD, Pucheril D, Abdollah F, et al. Preventable mortality after common urological surgery: failing to rescue? BJU Int. 2015;115(4):666-674. doi:10.1111/bju.12833.
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psnet.ahrq.gov/issue/use-standardized-protocol-decrease-medication-errors-and-adverse-events-related-sliding-scale
January 05, 2017 - Study
Use of a standardized protocol to decrease medication errors and adverse events related to sliding scale insulin.
Citation Text:
Donihi AC, DiNardo MM, Devita MA, et al. Use of a standardized protocol to decrease medication errors and adverse events related to sliding scale insul…