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psnet.ahrq.gov/issue/assessment-healthcare-professionals-knowledge-managing-emergency-complications-patients
March 14, 2018 - Slideset
Assessment of healthcare professionals' knowledge of managing emergency complications in patients with a tracheostomy.
Citation Text:
Casserly P, Lang E, Fenton JE, et al. Assessment of healthcare professionals' knowledge of managing emergency complications in patients with a …
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psnet.ahrq.gov/issue/decimal-numbers-and-safe-interpretation-clinical-pathology-results
July 16, 2014 - Study
Decimal numbers and safe interpretation of clinical pathology results.
Citation Text:
Sinnott M, Eley R, Steinle V, et al. Decimal numbers and safe interpretation of clinical pathology results. J Clin Pathol. 2014;67(2):179-81. doi:10.1136/jclinpath-2013-201865.
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psnet.ahrq.gov/issue/culture-cure-assessments-patient-safety-culture-oecd-countries
October 07, 2020 - Book/Report
Culture as a Cure: Assessments of Patient Safety Culture in OECD Countries.
Citation Text:
Culture as a Cure: Assessments of Patient Safety Culture in OECD Countries. de Bienassisi K, Kristensenii S, Burtscheri M, et al for the Organisation for Economic Co-operation and …
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psnet.ahrq.gov/perspective/conversation-sidney-dekker-ma-msc-phd
February 26, 2025 - That is, if there is a particular decision to be made about a surgeon, I would certainly have an operating … Having that perspective involved, that viewpoint for whom the world looks quite differently inside of an operating … things, who has perhaps a completely different overview of the social order of what happened in that operating
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psnet.ahrq.gov/node/49415/psn-pdf
September 01, 2003 - patient
safety research in San Diego, CA, communication failures contributed to 16% (20 of 98) of operating … , unpublished work),
communication or coordination issues played a role in about 11% of 118 actual operating … particular time.(13) For example, an anesthesiologist, who is an accomplished laryngoscopist in the
operating
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psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis
January 29, 2021 - especially in high-stake environments such as the critical care unit, the emergency department and the operating … )
WebM&M Cases
Unintentional Ketamine Overdose in the Operating … : Fluid administration errors in the operating room.
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psnet.ahrq.gov/web-mm/hurried-team-huddle-and-poor-communication-unsafe-practice-during-anesthesia-emergency
September 27, 2023 - This huddle includes at least one provider from obstetrics, anesthesia, nursing, and the operating room … Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating … Too Long
November 1, 2003
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Operating
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psnet.ahrq.gov/node/33776/psn-pdf
January 01, 2015 - engage
employees in improvement, instead of just expecting them to come to work and follow a standard operating … these are the cultural themes
that lead to improved safety and improved quality in a factory or in an operating … A chief operating officer that had
worked his way up from being a frontline nurse was embracing Lean
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psnet.ahrq.gov/node/36804/psn-pdf
August 26, 2011 - Patterns of communication breakdowns resulting in injury
to surgical patients.
August 26, 2011
Greenberg CC, Regenbogen SE, Studdert DM, et al. Patterns of communication breakdowns resulting in
injury to surgical patients. J Am Coll Surg. 2007;204(4):533-40.
https://psnet.ahrq.gov/issue/patterns-communication-brea…
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psnet.ahrq.gov/node/865875/psn-pdf
May 15, 2024 - Digital health interventions and patient safety in
abdominal surgery: a systematic review and meta-
analysis.
May 15, 2024
Grygorian A, Montano D, Shojaa M, et al. Digital health interventions and patient safety in abdominal
surgery: a systematic review and meta-analysis. JAMA Netw Open. 2024;7(4):e248555.
doi:10…
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psnet.ahrq.gov/node/843414/psn-pdf
February 01, 2023 - Leadership behavior associations with domains of safety
culture, engagement, and healthcare worker well-being.
February 1, 2023
Tawfik DS, Adair KC, Palassof S, et al. Leadership behavior associations with domains of safety culture,
engagement, and healthcare worker well-being. Jt Comm J Qual Patient Saf. 2023;49(3…
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psnet.ahrq.gov/node/844550/psn-pdf
September 01, 2012 - The effect of a Lean quality improvement implementation
program on surgical pathology specimen accessioning
and gross preparation error frequency.
September 1, 2012
Smith ML, Wilkerson T, Grzybicki DM, et al. The effect of a Lean quality improvement implementation
program on surgical pathology specimen accessionin…
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psnet.ahrq.gov/web-mm/case-patient-flow-management
February 23, 2019 - The Case for Patient Flow Management
Citation Text:
Litvak E, Bernheim SA. The Case for Patient Flow Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/issue/understanding-factors-influencing-safety-and-team-functionality-operative-vaginal-birth
September 01, 2016 - Study
Understanding factors influencing safety and team functionality at operative vaginal birth through multidisciplinary perspectives: a mixed methods study.
Citation Text:
Skinner SM, Kippen E, Rolnik DL, et al. Understanding factors influencing safety and team functionality at operat…
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psnet.ahrq.gov/node/60057/psn-pdf
March 18, 2020 - How does the WHO Surgical Safety Checklist fit with
existing perioperative risk management strategies? An
ethnographic study across surgical specialties.
March 18, 2020
Wæhle HV, Haugen AS, Wiig S, et al. How does the WHO Surgical Safety Checklist fit with existing
perioperative risk management strategies? An ethn…
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psnet.ahrq.gov/issue/assisting-beginners-root-cause-analysis-operations-analysis-and-recommendations-regarding
June 08, 2022 - Commentary
Assisting beginners in root cause analysis operations: analysis and recommendations regarding the spread of COVID-19 in nursing facilities for the elderly.
Citation Text:
Tsuchiya H. Assisting beginners in root cause analysis operations: analysis and recommendations regarding …
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psnet.ahrq.gov/issue/development-and-evaluation-patient-safety-interventions-perspectives-operational-safety
February 26, 2025 - Study
Development and evaluation of patient safety interventions: perspectives of operational safety leaders and patient safety organizations.
Citation Text:
Gomes KM, Handley J, Pruitt ZM, et al. Development and evaluation of patient safety interventions: perspectives of operational saf…
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psnet.ahrq.gov/issue/handoff-strategies-settings-high-consequences-failure-lessons-health-care-operations
March 14, 2018 - Study
Classic
Handoff strategies in settings with high consequences for failure: lessons for health care operations.
Citation Text:
Patterson ES. Handoff strategies in settings with high consequences for failure: lessons for health care operations. Int J Qual …
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psnet.ahrq.gov/issue/prescriptions-analysis-clinical-pharmacists-post-operative-period-4-year-prospective-study
August 04, 2021 - Study
Prescriptions analysis by clinical pharmacists in the post-operative period: a 4-year prospective study.
Citation Text:
Charpiat B, Goutelle S, Schoeffler M, et al. Prescriptions analysis by clinical pharmacists in the post-operative period: a 4-year prospective study. Acta Anaes…
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psnet.ahrq.gov/issue/operational-rounds-practical-administrative-process-improve-safety-and-clinical-services
May 12, 2010 - Commentary
Operational rounds: a practical administrative process to improve safety and clinical services in radiology.
Citation Text:
Donnelly LF, Dickerson JM, Lehkamp TW, et al. IRQN award paper: Operational rounds: a practical administrative process to improve safety and clinical s…