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psnet.ahrq.gov/issue/hiding-plain-sight-resurrecting-power-inspecting-patient
September 16, 2020 - Commentary
Hiding in plain sight—resurrecting the power of inspecting the patient.
Citation Text:
Gupta S, Saint S, Detsky AS. Hiding in Plain Sight-Resurrecting the Power of Inspecting the Patient. JAMA Intern Med. 2017;177(6):757-758. doi:10.1001/jamainternmed.2017.0634.
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psnet.ahrq.gov/issue/effectiveness-random-and-focused-review-detecting-surgical-pathology-error
August 04, 2021 - Study
Effectiveness of random and focused review in detecting surgical pathology error.
Citation Text:
Raab SS, Grzybicki DM, Mahood LK, et al. Effectiveness of random and focused review in detecting surgical pathology error. Am J Clin Pathol. 2008;130(6):905-12. doi:10.1309/AJCPPIA5…
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psnet.ahrq.gov/issue/adverse-events-following-emergency-department-visit
April 22, 2011 - Study
Adverse events following an emergency department visit.
Citation Text:
Forster AJ, Rose NGW, van Walraven C, et al. Adverse events following an emergency department visit. Qual Saf Health Care. 2007;16(1):17-22.
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psnet.ahrq.gov/issue/wisdom-patients-and-families-ignore-it-our-peril
March 13, 2013 - Commentary
The wisdom of patients and families: ignore it at our peril.
Citation Text:
Donaldson LJ. The wisdom of patients and families: ignore it at our peril. BMJ Qual Saf. 2015;24(10):603-604. doi:10.1136/bmjqs-2015-004573.
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psnet.ahrq.gov/issue/evidence-based-red-cell-transfusion-critically-ill-quality-improvement-using-computerized
February 15, 2017 - Study
Evidence-based red cell transfusion in the critically ill: quality improvement using computerized physician order entry.
Citation Text:
Rana R, Afessa B, Keegan MT, et al. Evidence-based red cell transfusion in the critically ill: quality improvement using computerized physician …
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psnet.ahrq.gov/issue/interorganizational-complexity-and-organizational-accident-risk-literature-review
June 02, 2021 - Review
Interorganizational complexity and organizational accident risk: a literature review.
Citation Text:
Milch V, Laumann K. Interorganizational complexity and organizational accident risk: A literature review. Safety Sci. 2015;82:9-17. doi:10.1016/j.ssci.2015.08.010.
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psnet.ahrq.gov/issue/intraoperative-adverse-events-and-related-postoperative-complications-spine-surgery
March 20, 2013 - Study
Intraoperative adverse events and related postoperative complications in spine surgery: implications for enhancing patient safety founded on evidence-based protocols.
Citation Text:
Intraoperative adverse events and related postoperative complications in spine surgery: implicatio…
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psnet.ahrq.gov/issue/failure-notify-reportable-test-results-significance-medical-malpractice
April 29, 2020 - Study
Failure to notify reportable test results: significance in medical malpractice.
Citation Text:
Gale BD, Bissett-Siegel DP, Davidson SJ, et al. Failure to notify reportable test results: significance in medical malpractice. J Am Coll Radiol. 2011;8(11):776-9. doi:10.1016/j.jacr.20…
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psnet.ahrq.gov/issue/countering-cognitive-biases-minimising-low-value-care
May 11, 2019 - Review
Countering cognitive biases in minimising low value care.
Citation Text:
Scott IA, Soon J, Elshaug AG, et al. Countering cognitive biases in minimising low value care. Med J Aust. 2017;206(9):407-411.
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psnet.ahrq.gov/issue/framework-encouraging-patient-engagement-medical-decision-making
September 17, 2010 - Commentary
A framework for encouraging patient engagement in medical decision making.
Citation Text:
Holzmueller CG, Wu AW, Pronovost P. A framework for encouraging patient engagement in medical decision making. J Patient Saf. 2012;8(4):161-164. doi:10.1097/PTS.0b013e318267c56e.
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psnet.ahrq.gov/issue/observation-assessment-clinician-performance-narrative-review
September 09, 2015 - Review
Observation for assessment of clinician performance: a narrative review.
Citation Text:
Yanes AF, McElroy LM, Abecassis ZA, et al. Observation for assessment of clinician performance: a narrative review. BMJ Qual Saf. 2016;25(1):46-55. doi:10.1136/bmjqs-2015-004171.
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psnet.ahrq.gov/issue/public-reporting-patient-safety-metrics-ready-or-not
July 14, 2010 - Commentary
Public reporting of patient safety metrics: ready or not?
Citation Text:
Podolsky DK, Nagarkar PA, Reed G, et al. Public reporting of patient safety metrics: ready or not? Plast Reconstr Surg. 2014;134(6):981e-5e. doi:10.1097/PRS.0000000000000713.
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psnet.ahrq.gov/issue/case-simulation-part-comprehensive-patient-safety-program
September 02, 2015 - Review
The case for simulation as part of a comprehensive patient safety program.
Citation Text:
Argani CH, Eichelberger M, Deering S, et al. The case for simulation as part of a comprehensive patient safety program. Am J Obstet Gynecol. 2012;206(6):451-5. doi:10.1016/j.ajog.2011.09.01…
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psnet.ahrq.gov/issue/characteristics-and-outcomes-patients-receiving-medical-emergency-team-review-respiratory
February 13, 2008 - Study
Characteristics and outcomes of patients receiving a medical emergency team review for respiratory distress or hypotension.
Citation Text:
Quach J, Downey A, Haase M, et al. Characteristics and outcomes of patients receiving a medical emergency team review for respiratory distres…
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psnet.ahrq.gov/issue/learning-defects-enhance-morbidity-and-mortality-conferences
May 20, 2009 - Commentary
Learning from defects to enhance morbidity and mortality conferences.
Citation Text:
Berenholtz SM, Hartsell TL, Pronovost P. Learning from defects to enhance morbidity and mortality conferences. Am J Med Qual. 2009;24(3):192-5. doi:10.1177/1062860609332370.
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psnet.ahrq.gov/issue/establishing-rapid-response-team-rrt-academic-hospital-one-years-experience
September 28, 2010 - Study
Establishing a rapid response team (RRT) in an academic hospital: one year's experience.
Citation Text:
King E, Horvath R, Shulkin DJ. Establishing a rapid response team (RRT) in an academic hospital: One year's experience. J Hosp Med. 2006;1(5). doi:10.1002/jhm.114.
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psnet.ahrq.gov/issue/hope-modified-association-between-distress-and-incidence-self-perceived-medical-errors-among
June 07, 2018 - Study
Hope modified the association between distress and incidence of self-perceived medical errors among practicing physicians: prospective cohort study.
Citation Text:
Hayashino Y, Utsugi-Ozaki M, Feldman MD, et al. Hope modified the association between distress and incidence of self-…
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psnet.ahrq.gov/issue/childrens-hospital-investigated-five-patient-deaths-deadly-fungal-disease-2009
June 14, 2017 - Newspaper/Magazine Article
Children's Hospital investigated five patient deaths from deadly fungal disease in 2009.
Citation Text:
Duffy J, Harris J, Gade L, et al. Mucormycosis outbreak associated with hospital linens. The Pediatric infectious disease journal. 2014;33(5):472-6. doi:10.1…
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psnet.ahrq.gov/issue/organisational-paradoxes-speaking-safety-implications-interprofessional-field
March 08, 2023 - Commentary
Organisational paradoxes in speaking up for safety: implications for the interprofessional field.
Citation Text:
Rowland P. Organisational paradoxes in speaking up for safety: Implications for the interprofessional field. J Interprof Care. 2017;31(5):553-556. doi:10.1080/13561…
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psnet.ahrq.gov/issue/ashp-guidelines-managing-drug-product-shortages
September 06, 2023 - Commentary
ASHP guidelines on managing drug product shortages.
Citation Text:
Fox ER, McLaughlin MM. ASHP guidelines on managing drug product shortages. Am J Health Syst Pharm. 2018;75(21):1742-1750. doi:10.2146/ajhp180441.
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