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psnet.ahrq.gov/issue/balancing-no-blame-accountability-patient-safety
March 13, 2013 - Commentary
Classic
Balancing "no blame" with accountability in patient safety.
Citation Text:
Wachter R, Pronovost P. Balancing "no blame" with accountability in patient safety. New Engl J Med. 2009;361(14):1401-1406. doi:10.1056/NEJMsb0903885.
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psnet.ahrq.gov/issue/integrating-incident-reporting-electronic-patient-record-system
June 08, 2010 - Study
Integrating incident reporting into an electronic patient record system.
Citation Text:
Haller G, Myles PS, Stoelwinder J, et al. Integrating incident reporting into an electronic patient record system. J Am Med Inform Assoc. 2007;14(2):175-81.
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psnet.ahrq.gov/issue/tele-rapid-response-team-tele-rrt-effect-implementing-patient-safety-network-system-outcomes
March 24, 2021 - Study
Tele-Rapid Response Team (Tele-RRT): the effect of implementing patient safety network system on outcomes of medical patients- a before and after cohort study.
Citation Text:
Balshi AN, Al-Odat MA, Alharthy AM, et al. Tele-Rapid Response Team (Tele-RRT): The effect of implementing …
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psnet.ahrq.gov/issue/identification-doctors-risk-recurrent-complaints-national-study-healthcare-complaints
September 07, 2011 - Study
Identification of doctors at risk of recurrent complaints: a national study of healthcare complaints in Australia.
Citation Text:
Bismark M, Spittal MJ, Gurrin LC, et al. Identification of doctors at risk of recurrent complaints: a national study of healthcare complaints in Aust…
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psnet.ahrq.gov/issue/characterization-adverse-events-detected-large-health-care-delivery-system-using-enhanced
May 25, 2013 - Study
Characterization of adverse events detected in a large health care delivery system using an enhanced Global Trigger Tool over a five-year interval.
Citation Text:
Kennerly DA, Kudyakov R, da Graca B, et al. Characterization of adverse events detected in a large health care delivery…
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psnet.ahrq.gov/issue/applying-high-reliability-health-care-maturity-model-assess-hospital-performance-va-case
December 19, 2014 - Study
Applying the high reliability health care maturity model to assess hospital performance: a VA case study.
Citation Text:
Sullivan JL, Rivard PE, Shin MH, et al. Applying the High Reliability Health Care Maturity Model to Assess Hospital Performance: A VA Case Study. Jt Comm J Qual …
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psnet.ahrq.gov/issue/explaining-michigan-developing-ex-post-theory-quality-improvement-program
April 04, 2011 - Study
Classic
Explaining Michigan: developing an ex post theory of a quality improvement program.
Citation Text:
Dixon-Woods M, Bosk CL, Aveling EL, et al. Explaining Michigan: developing an ex post theory of a quality improvement program. Milbank Q. 2011;89(2):…
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psnet.ahrq.gov/issue/surveys-patient-safety-culture-sops-hospital-survey-20-user-database-report
December 18, 2024 - Book/Report
Surveys on Patient Safety Culture (SOPS) Hospital Survey 2.0: User Database Report.
Citation Text:
Tyler ER, Yalden O, Fan L, et al. Surveys On Patient Safety Culture (Sops) Hospital Survey 2.0: User Database Report. Rockville, MD: Agency for Healthcare Research and Quality; …
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psnet.ahrq.gov/issue/learning-safety-incidents-high-reliability-organizations-systematic-review-learning-tools
May 26, 2021 - Review
Learning from safety incidents in high reliability organizations: a systematic review of learning tools that could be adapted and used in healthcare.
Citation Text:
Serou N, Sahota LM, Husband AK, et al. Learning from safety incidents in high-reliability organizations: a systemati…
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psnet.ahrq.gov/issue/barriers-and-enhancers-trust-just-culture-hospital-settings-systematic-review
February 02, 2022 - Review
The barriers and enhancers to trust in a just culture in hospital settings: a systematic review.
Citation Text:
van Marum S, Verhoeven D, de Rooy D. The barriers and enhancers to trust in a just culture in hospital settings: a systematic review. J Patient Saf. 2022;18(7):e1067-e10…
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psnet.ahrq.gov/issue/ahrq-nursing-home-survey-patient-safety-culture-2014-user-comparative-database-report
May 11, 2016 - Book/Report
AHRQ Nursing Home Survey on Patient Safety Culture: 2014 User Comparative Database Report.
Citation Text:
AHRQ Nursing Home Survey on Patient Safety Culture: 2014 User Comparative Database Report. Sorra J, Famolaro T, Yount N, Burns W, Liu H, Shyy M. Rockville, MD: Agency for…
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psnet.ahrq.gov/issue/exposure-incivility-hinders-clinical-performance-simulated-operative-crisis
June 14, 2019 - Study
Emerging Classic
Exposure to incivility hinders clinical performance in a simulated operative crisis.
Citation Text:
Katz D, Blasius K, Isaak R, et al. Exposure to incivility hinders clinical performance in a simulated operative crisis. BMJ Qual Saf. 2019;…
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psnet.ahrq.gov/issue/evaluating-incident-learning-systems-and-safety-culture-two-radiation-oncology-departments
June 30, 2021 - Study
Evaluating incident learning systems and safety culture in two radiation oncology departments.
Citation Text:
Adamson L, Beldham‐Collins R, Sykes J, et al. Evaluating incident learning systems and safety culture in two radiation oncology departments. J Med Radiat Sci. 2022;69(2):2…
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psnet.ahrq.gov/issue/blinded-prospective-study-error-detection-during-physician-chart-rounds-radiation-oncology
November 16, 2022 - Study
A blinded, prospective study of error detection during physician chart rounds in radiation oncology.
Citation Text:
Talcott WJ, Lincoln H, Kelly JR, et al. A blinded, prospective study of error detection during physician chart rounds in radiation oncology. Pract Radiat Oncol. 2020;…
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psnet.ahrq.gov/issue/effectiveness-barcode-medication-administration-system-reducing-preventable-adverse-drug
December 14, 2022 - Study
Effectiveness of a barcode medication administration system in reducing preventable adverse drug events in a neonatal intensive care unit: a prospective cohort study.
Citation Text:
Morriss FH, Abramowitz PW, Nelson S, et al. Effectiveness of a barcode medication administration s…
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psnet.ahrq.gov/issue/preliminary-study-patient-safety-and-quality-use-cases-icd-11-mms
July 22, 2020 - Study
Preliminary study of patient safety and quality use cases for ICD-11 MMS.
Citation Text:
Fenton SH, Giannangelo KL, Stanfill MH. Preliminary study of patient safety and quality use cases for ICD-11 MMS. J Am Med Inform Assoc. 2021;28(11):2346-2353. doi:10.1093/jamia/ocab163.
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psnet.ahrq.gov/issue/speaking-about-patient-safety-concerns-and-unprofessional-behaviour-among-residents
December 21, 2017 - Study
'Speaking up' about patient safety concerns and unprofessional behaviour among residents: validation of two scales.
Citation Text:
Martinez W, Etchegaray J, Thomas EJ, et al. 'Speaking up' about patient safety concerns and unprofessional behaviour among residents: validation of two…
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psnet.ahrq.gov/issue/incorrect-surgical-procedures-within-and-outside-operating-room-follow-report
April 30, 2014 - Study
Incorrect surgical procedures within and outside of the operating room: a follow-up report.
Citation Text:
Neily J, Mills PD, Eldridge N, et al. Incorrect surgical procedures within and outside of the operating room: a follow-up report. Arch Surg. 2011;146(11):1235-9. doi:10.1001…
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psnet.ahrq.gov/issue/mitigating-imperfect-data-validity-administrative-data-psis-method-estimating-true-adverse
March 17, 2021 - Study
Mitigating imperfect data validity in administrative data PSIs: a method for estimating true adverse event rates.
Citation Text:
Boussat B, Quan H, Labarere J, et al. Mitigating imperfect data validity in administrative data PSIs: a method for estimating true adverse event rates. I…
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psnet.ahrq.gov/issue/make-or-buy-patient-safety-solutions-resource-dependence-and-transaction-cost-economics
April 08, 2008 - Study
To make or buy patient safety solutions: a resource dependence and transaction cost economics perspective.
Citation Text:
Fareed N, Mick SS. To make or buy patient safety solutions: a resource dependence and transaction cost economics perspective. Health Care Manage Rev. 2011;36(…