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psnet.ahrq.gov/sites/default/files/2023-09/a_missed_bowel_perforation_-_the_importance_of_diagnostic_reasoning.pdf
January 01, 2023 - • Applying root-cause-analysis (RCA) methodology, we can appreciate the
complexity of the case and
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psnet.ahrq.gov/perspective/conversation-lucian-leape-md
June 12, 2019 - others that showed how remarkably successful the checklists were, were biased—either because of the methodology
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psnet.ahrq.gov/node/867653/psn-pdf
February 26, 2025 - Sarah Mossburg: How have organizations implemented and used the RCA2 methodology since its
introduction
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psnet.ahrq.gov/perspective/conversation-freya-spielberg-md-mph
September 28, 2022 - Community-Oriented Primary Care at George Washington University and evolved a curriculum that teaches a methodology … understand barriers to implementing different parts of the model, so that is really part of the COQI methodology
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psnet.ahrq.gov/node/35855/psn-pdf
October 25, 2013 - HealthGrades Quality Study: Third Annual Patient Safety
in American Hospitals Study.
October 25, 2013
Denver, CO: HealthGrades; 2006.
https://psnet.ahrq.gov/issue/healthgrades-quality-study-third-annual-patient-safety-american-hospitals-
study
This third annual report on the safety of hospitalized Medicare patien…
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psnet.ahrq.gov/node/40634/psn-pdf
September 20, 2011 - "July Effect": impact of the academic year-end
changeover on patient outcomes. A systematic review.
September 20, 2011
Young JQ, Ranji SR, Wachter R, et al. "July effect": impact of the academic year-end changeover on
patient outcomes: a systematic review. Ann Intern Med. 2011;155(5):309-15. doi:10.7326/0003-4819-1…
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psnet.ahrq.gov/node/37437/psn-pdf
June 03, 2010 - Effects of rapid response systems on clinical outcomes:
systematic review and meta-analysis.
June 3, 2010
Ranji SR, Auerbach AD, Hurd CJ, et al. Effects of rapid response systems on clinical outcomes: systematic
review and meta-analysis. J Hosp Med. 2007;2(6):422-432.
https://psnet.ahrq.gov/issue/effects-rapid-res…
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psnet.ahrq.gov/node/38691/psn-pdf
June 10, 2009 - Effects of shift length on quality of patient care and health
provider outcomes: systematic review.
June 10, 2009
Estabrooks CA, Cummings GG, Olivo SA, et al. Effects of shift length on quality of patient care and health
provider outcomes: systematic review. Qual Saf Health Care. 2009;18(3):181-188.
doi:10.1136/qs…
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psnet.ahrq.gov/node/41355/psn-pdf
April 05, 2013 - Comparative economic analyses of patient safety
improvement strategies in acute care: a systematic
review.
April 5, 2013
Etchells E, Koo M, Daneman N, et al. Comparative economic analyses of patient safety improvement
strategies in acute care: a systematic review. BMJ Qual Saf. 2012;21(6):448-56. doi:10.1136/bmjqs…
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psnet.ahrq.gov/node/36807/psn-pdf
October 25, 2013 - HealthGrades Quality Study: Fourth Annual Patient Safety
in American Hospitals Study.
October 25, 2013
Denver, CO; Health Grades Inc; 2007.
https://psnet.ahrq.gov/issue/healthgrades-quality-study-fourth-annual-patient-safety-american-hospitals-
study
This fourth annual report on the safety of hospitalized Medicar…
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psnet.ahrq.gov/node/43851/psn-pdf
March 13, 2015 - Systematic review of the effectiveness of strategies to
encourage patients to remind healthcare professionals
about their hand hygiene.
March 13, 2015
Davis R, Parand A, Pinto A, et al. Systematic review of the effectiveness of strategies to encourage
patients to remind healthcare professionals about their hand hy…
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psnet.ahrq.gov/node/37363/psn-pdf
February 03, 2011 - Effect of a rapid response team on hospital-wide mortality
and code rates outside the ICU in a children’s hospital.
February 3, 2011
Sharek PJ, Parast L, Leong K, et al. Effect of a rapid response team on hospital-wide mortality and code
rates outside the ICU in a Children's Hospital. JAMA. 2007;298(19):2267-74.
h…
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psnet.ahrq.gov/node/38120/psn-pdf
June 16, 2011 - Organizational culture, team climate and diabetes care in
small office-based practices.
June 16, 2011
Bosch M, Dijkstra R, Wensing M, et al. Organizational culture, team climate and diabetes care in small
office-based practices. BMC Health Serv Res. 2008;8:180. doi:10.1186/1472-6963-8-180.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/44079/psn-pdf
May 28, 2015 - Differences in the rates of patient safety events by payer:
implications for providers and policymakers.
May 28, 2015
Spencer CS, Roberts ET, Gaskin DJ. Differences in the rates of patient safety events by payer: implications
for providers and policymakers. Med Care. 2015;53(6):524-9. doi:10.1097/MLR.00000000000003…
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psnet.ahrq.gov/node/40893/psn-pdf
November 02, 2011 - Systematic review of safety checklists for use by medical
care teams in acute hospital settings—limited evidence of
effectiveness.
November 2, 2011
Ko HCH, Turner TJ, Finnigan MA. Systematic review of safety checklists for use by medical care teams in
acute hospital settings--limited evidence of effectiveness. BMC…
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psnet.ahrq.gov/node/45116/psn-pdf
February 15, 2017 - Postoperative adverse events inconsistently improved by
the World Health Organization surgical safety checklist: a
systematic literature review of 25 studies.
February 15, 2017
de Jager E, McKenna C, Bartlett L, et al. Postoperative adverse events inconsistently improved by the
World Health Organization surgical s…
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psnet.ahrq.gov/node/39788/psn-pdf
April 21, 2011 - Effects of reducing or eliminating resident work shifts
over 16 hours: a systematic review.
April 21, 2011
Levine AC, Adusumilli J, Landrigan CP. Effects of reducing or eliminating resident work shifts over 16
hours: a systematic review. Sleep. 2010;33(8):1043-53. doi:10.1093/sleep/33.8.1043.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/43687/psn-pdf
November 12, 2014 - Changes in medical errors after implementation of a
handoff program.
November 12, 2014
Starmer AJ, Spector ND, Srivastava R, et al. Changes in medical errors after implementation of a handoff
program. New Engl J Med. 2014;371(19):1803-1812. doi:10.1056/NEJMsa1405556.
https://psnet.ahrq.gov/issue/changes-medical-er…
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psnet.ahrq.gov/node/45113/psn-pdf
May 11, 2016 - Medical error—the third leading cause of death in the US.
May 11, 2016
Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016;353:i2139.
doi:10.1136/bmj.i2139.
https://psnet.ahrq.gov/issue/medical-error-third-leading-cause-death-us
How many patients die each year due to preventabl…
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psnet.ahrq.gov/node/43042/psn-pdf
December 18, 2014 - Introduction of surgical safety checklists in Ontario,
Canada.
December 18, 2014
Urbach DR, Govindarajan A, Saskin R, et al. Introduction of Surgical Safety Checklists in Ontario, Canada.
New Engl J Med. 2014;370(11):1029-1038. doi:10.1056/nejmsa1308261.
https://psnet.ahrq.gov/issue/introduction-surgical-safety-ch…