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psnet.ahrq.gov/issue/anatomy-incident-disclosure-importance-dialogue
February 20, 2012 - Commentary
Anatomy of an incident disclosure: the importance of dialogue.
Citation Text:
Iedema R, Allen S. Anatomy of an incident disclosure: the importance of dialogue. Jt Comm J Qual Patient Saf. 2012;38(10):435-42.
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psnet.ahrq.gov/issue/what-makes-hospitalized-patients-more-vulnerable-and-increases-their-risk-experiencing
March 23, 2011 - Study
What makes hospitalized patients more vulnerable and increases their risk of experiencing an adverse event?
Citation Text:
Aranaz-Andrés JM, Limón R, Mira JJ, et al. What makes hospitalized patients more vulnerable and increases their risk of experiencing an adverse event? Int J Qu…
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psnet.ahrq.gov/issue/effect-critical-access-hospital-conversion-patient-safety
October 19, 2022 - Study
Effect of critical access hospital conversion on patient safety.
Citation Text:
Li P, Schneider JE, Ward MM. Effect of critical access hospital conversion on patient safety. Health Serv Res. 2007;42(6 Pt 1):2089-108; discussion 2294-323.
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psnet.ahrq.gov/issue/assessment-simulated-case-based-measurement-physician-diagnostic-performance
May 20, 2019 - Study
Assessment of a simulated case-based measurement of physician diagnostic performance.
Citation Text:
Chatterjee S, Desai S, Manesh R, et al. Assessment of a Simulated Case-Based Measurement of Physician Diagnostic Performance. JAMA Netw Open. 2019;2(1):e187006. doi:10.1001/jamanetw…
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psnet.ahrq.gov/issue/lack-patient-knowledge-regarding-hospital-medications
September 20, 2006 - Study
Lack of patient knowledge regarding hospital medications.
Citation Text:
Lack of patient knowledge regarding hospital medications.
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psnet.ahrq.gov/issue/psychometric-properties-hospital-survey-patient-safety-culture-findings-uk
March 22, 2023 - Study
Psychometric properties of the Hospital Survey on Patient Safety Culture: findings from the UK.
Citation Text:
Waterson P, Griffiths P, Stride C, et al. Psychometric properties of the Hospital Survey on Patient Safety Culture: findings from the UK. Qual Saf Health Care. 2010;19(5…
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psnet.ahrq.gov/issue/move-toward-full-use-metric-dosing-eliminate-dosage-cups-measure-liquids-fluid-drams-use-cups
April 01, 2015 - Press Release/Announcement
Move toward full use of metric dosing: eliminate dosage cups that measure liquids in fluid drams. Use cups that measure mL.
Citation Text:
Move toward full use of metric dosing: eliminate dosage cups that measure liquids in fluid drams. Use cups that measure mL…
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psnet.ahrq.gov/issue/impact-pharmacist-medication-reconciliation-patient-admission-veterans-affairs-medical-center
July 22, 2020 - Study
Impact of a pharmacist on medication reconciliation on patient admission to a Veterans Affairs Medical Center.
Citation Text:
Strunk LB, Matson AW, Steinke DT. Impact of a Pharmacist on Medication Reconciliation on Patient Admission to a Veterans Affairs Medical Center. Hosp Pharm.…
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psnet.ahrq.gov/issue/using-situ-simulation-improve-hospital-cardiopulmonary-resuscitation
January 02, 2017 - Study
Using in situ simulation to improve in-hospital cardiopulmonary resuscitation.
Citation Text:
Lighthall GK, Poon T, Harrison K. Using in situ simulation to improve in-hospital cardiopulmonary resuscitation. Jt Comm J Qual Patient Saf. 2010;36(5):209-16.
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psnet.ahrq.gov/issue/use-novel-modified-fishbone-diagram-analyze-diagnostic-errors
February 13, 2019 - Commentary
Use of a novel, modified fishbone diagram to analyze diagnostic errors.
Citation Text:
Reilly JB, Myers JS, Salvador D, et al. Use of a novel, modified fishbone diagram to analyze diagnostic errors. Diagnosis (Berl). 2014;1(2):167-171. doi:10.1515/dx-2013-0040.
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psnet.ahrq.gov/issue/covid-19-be-or-not-be-diagnostic-question
September 02, 2020 - Commentary
COVID-19: to be or not to be; that is the diagnostic question.
Citation Text:
Coleman JJ, Manavi K, Marson EJ, et al. COVID-19: to be or not to be; that is the diagnostic question. Postgrad Med J. 2020;96(1137):392-398. doi:10.1136/postgradmedj-2020-137979.
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psnet.ahrq.gov/issue/randomized-trial-nighttime-physician-staffing-intensive-care-unit
September 23, 2020 - Study
A randomized trial of nighttime physician staffing in an intensive care unit.
Citation Text:
Kerlin MP, Small DS, Cooney E, et al. A randomized trial of nighttime physician staffing in an intensive care unit. N Engl J Med. 2013;368(23):2201-9. doi:10.1056/NEJMoa1302854.
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psnet.ahrq.gov/issue/va-health-care-improvements-needed-processes-used-address-providers-actions-contribute
October 12, 2022 - Book/Report
VA Health Care: Improvements Needed in Processes Used to Address Providers' Actions That Contribute to Adverse Events.
Citation Text:
VA Health Care: Improvements Needed in Processes Used to Address Providers' Actions That Contribute to Adverse Events. Draper D. Washington,…
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psnet.ahrq.gov/issue/err-system-comparison-methodologies-investigation-adverse-outcomes-healthcare
January 26, 2022 - Commentary
To err is system: a comparison of methodologies for the investigation of adverse outcomes in healthcare.
Citation Text:
Isherwood P, Waterson P. To err is system: a comparison of methodologies for the investigation of adverse outcomes in healthcare. J Patient Saf Risk Manag. 2…
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psnet.ahrq.gov/issue/linking-joint-commission-inpatient-core-measures-and-national-patient-safety-goals-evidence
October 19, 2022 - Commentary
Linking Joint Commission inpatient core measures and National Patient Safety Goals with evidence.
Citation Text:
Masica AL, Richter KM, Convery P, et al. Linking joint commission inpatient core measures and national patient safety goals with evidence. Proc (Bayl Univ Med Cen…
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psnet.ahrq.gov/issue/adverse-events-hospitals-care-study-incidence-among-medicare-beneficiaries-two-selected
January 14, 2009 - Book/Report
Adverse Events in Hospitals: Care Study of Incidence Among Medicare Beneficiaries in Two Selected Counties.
Citation Text:
Adverse Events in Hospitals: Care Study of Incidence Among Medicare Beneficiaries in Two Selected Counties. Levinson DR. Washington, DC: US Departmen…
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psnet.ahrq.gov/issue/improving-communication-icu-using-daily-goals
December 19, 2018 - Study
Improving communication in the ICU using daily goals.
Citation Text:
Pronovost P, Berenholtz SM, Dorman T, et al. Improving communication in the ICU using daily goals. J Crit Care. 2003;18(2):71-5.
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psnet.ahrq.gov/issue/framework-patient-safety-defense-nuclear-industry-based-high-reliability-model
June 14, 2017 - Commentary
A framework for patient safety: a defense nuclear industry-based high-reliability model.
Citation Text:
Birnbach DJ, Rosen LF, Williams L, et al. A framework for patient safety: a defense nuclear industry--based high-reliability model. Jt Comm J Qual Patient Saf. 2013;39(5):…
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psnet.ahrq.gov/issue/adverse-events-hospitals-state-reporting-systems
January 14, 2009 - Book/Report
Adverse Events in Hospitals: State Reporting Systems.
Citation Text:
Adverse Events in Hospitals: State Reporting Systems. Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-07-00471. …
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psnet.ahrq.gov/issue/typology-electronic-health-record-workarounds-small-medium-size-primary-care-practices
November 30, 2016 - Study
A typology of electronic health record workarounds in small-to-medium size primary care practices.
Citation Text:
Friedman A, Crosson JC, Howard J, et al. A typology of electronic health record workarounds in small-to-medium size primary care practices. J Am Med Inform Assoc. 2014;…