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Learning from experience: a qualitative study of surgeons' perspectives on reporting and dealing with serious adverse events. | PSNet

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June 12, 2024 - Study Learning from experience: a qualitative study of surgeons' perspectives on reporting and dealing with serious adverse events. Citation Text: Øyri SF, Søreide K, Søreide E, et al. Learning from experience: a qualitative study of surgeons’ perspectives on reporting and dealing with s…

Morbidity and mortality caused by noncompliance with California hospital licensure: immediate jeopardies in California hospitals, 2007-2017. | PSNet

psnet.ahrq.gov/issue/morbidity-and-mortality-caused-noncompliance-california-hospital-licensure-immediate

May 19, 2021 - Study Morbidity and mortality caused by noncompliance with California hospital licensure: immediate jeopardies in California hospitals, 2007-2017. Citation Text: Zheng MY, Lui H, Patino G, et al. Morbidity and mortality caused by noncompliance with California hospital licensure: immediat…

Increasing patient safety event reporting in an emergency medicine residency. | PSNet

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August 04, 2021 - Commentary Increasing patient safety event reporting in an emergency medicine residency. Citation Text: Steen S, Jaeger C, Price L, et al. Increasing Patient Safety Event Reporting in an Emergency Medicine Residency. BMJ Qual Improv Rep. 2017;6(1). doi:10.1136/bmjquality.u223876.w5716. …

Good people who try their best can have problems: recognition of human factors and how to minimise error. | PSNet

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October 29, 2017 - Review Good people who try their best can have problems: recognition of human factors and how to minimise error. Citation Text: Brennan PA, Mitchell DA, Holmes S, et al. Good people who try their best can have problems: recognition of human factors and how to minimise error. Br J Oral Ma…

A retrospective analysis demonstrates that a failure to document key comorbid diseases in the anesthesia preoperative evaluation associates with increased length of stay and mortality. | PSNet

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May 26, 2021 - Study A retrospective analysis demonstrates that a failure to document key comorbid diseases in the anesthesia preoperative evaluation associates with increased length of stay and mortality. Citation Text: Hofer IS, Cheng D, Grogan T. A retrospective analysis demonstrates that a failure …

How well is quality improvement described in the perioperative care literature? A systematic review. | PSNet

psnet.ahrq.gov/issue/how-well-quality-improvement-described-perioperative-care-literature-systematic-review

January 19, 2022 - Review How well is quality improvement described in the perioperative care literature? A systematic review. Citation Text: Jones EL, Lees N, Martin G, et al. How Well Is Quality Improvement Described in the Perioperative Care Literature? A Systematic Review. Jt Comm J Qual Patient Saf. 2…

Long-term effects of teamwork training on communication and teamwork climate in ambulatory reproductive health care. | PSNet

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May 01, 2019 - Study Long-term effects of teamwork training on communication and teamwork climate in ambulatory reproductive health care. Citation Text: Dodge LE, Nippita S, Hacker MR, et al. Long‐term effects of teamwork training on communication and teamwork climate in ambulatory reproductive health …

System factors affecting intraoperative risk and resilience: applying a novel integrated approach to study surgical performance and patient safety. | PSNet

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August 25, 2021 - Study Emerging Classic System factors affecting intraoperative risk and resilience: applying a novel integrated approach to study surgical performance and patient safety. Citation Text: Kolodzey L, Trbovich PL, Kashfi A, et al. System Factors Affecting Intraope…

Evaluating an evidence-based bundle for preventing surgical site infection. | PSNet

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August 21, 2019 - Study Evaluating an evidence-based bundle for preventing surgical site infection. Citation Text: Anthony T, Murray BW, Sum-Ping JT, et al. Evaluating an evidence-based bundle for preventing surgical site infection: a randomized trial. Arch Surg. 2011;146(3):263-9. doi:10.1001/archsurg.20…

Association of hospital markup with preventable adverse events following pancreatic surgery in the United States. | PSNet

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March 14, 2022 - Study Association of hospital markup with preventable adverse events following pancreatic surgery in the United States. Citation Text: Alterio RE, Abreu AA, Meier J, et al. Association of hospital markup with preventable adverse events following pancreatic surgery in the United States. C…

Iatrogenic events in admitted neonates: a prospective cohort study. | PSNet

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December 18, 2014 - Study Iatrogenic events in admitted neonates: a prospective cohort study. Citation Text: Ligi I, Arnaud F, Jouve E, et al. Iatrogenic events in admitted neonates: a prospective cohort study. Lancet. 2008;371(9610):404-10. doi:10.1016/S0140-6736(08)60204-4. Copy Citation Format: …

Transparency, public reporting, and a culture of change to quality and safety in cardiac surgery. | PSNet

psnet.ahrq.gov/issue/transparency-public-reporting-and-culture-change-quality-and-safety-cardiac-surgery

February 17, 2021 - Commentary Transparency, public reporting, and a culture of change to quality and safety in cardiac surgery. Citation Text: Ibrahim M, Szeto WY, Gutsche J, et al. Transparency, public reporting, and a culture of change to quality and safety in cardiac surgery. Ann Thorac Surg. 2022;114(3…

CheckPOINT: a simple tool to measure Surgical Safety Checklist implementation fidelity. | PSNet

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December 06, 2023 - Study CheckPOINT: a simple tool to measure Surgical Safety Checklist implementation fidelity. Citation Text: Moyal-Smith R, Etheridge JC, Turley N, et al. CheckPOINT: a simple tool to measure Surgical Safety Checklist implementation fidelity. BMJ Qual Saf. 2024;33(4):223-231. doi:10.1136…

Surgeon-specific mortality data disguise wider failings in delivery of safe surgical services. | PSNet

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March 09, 2022 - Study Surgeon-specific mortality data disguise wider failings in delivery of safe surgical services. Citation Text: Westaby S, De Silva R, Petrou M, et al. Surgeon-specific mortality data disguise wider failings in delivery of safe surgical services. Eur J Cardiothorac Surg. 2015;47(2):3…

Sustained improvement in quality of patient handoffs after orthopaedic surgery I-PASS intervention. | PSNet

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June 15, 2022 - Study Sustained improvement in quality of patient handoffs after orthopaedic surgery I-PASS intervention. Citation Text: Stenquist DS, Yeung CM, Szapary HJ, et al. Sustained improvement in quality of patient handoffs after orthopaedic surgery I-PASS intervention. J Am Acad Orthop Surg Gl…

Using video to assess and improve patient safety during simulated and actual neonatal resuscitation. | PSNet

psnet.ahrq.gov/issue/using-video-assess-and-improve-patient-safety-during-simulated-and-actual-neonatal

July 29, 2020 - Study Using video to assess and improve patient safety during simulated and actual neonatal resuscitation. Citation Text: Leone TA. Using video to assess and improve patient safety during simulated and actual neonatal resuscitation. Semin Perinatol. 2019;43(8):151179. doi:10.1053/j.semp…

Patient safety and quality improvement adaptation during the COVID-19 pandemic. | PSNet

psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-adaptation-during-covid-19-pandemic

February 12, 2020 - Commentary Patient safety and quality improvement adaptation during the COVID-19 pandemic. Citation Text: Sterling RS, Berry SA, Herzke C, et al. Patient safety and quality improvement adaptation during the COVID-19 pandemic. Am J Med Qual. 2021;36(1):57-59. doi:10.1097/01.jmq.0000733448…

Barriers to and facilitators of bedside nursing handover: a systematic review and meta-synthesis. | PSNet

psnet.ahrq.gov/issue/barriers-and-facilitators-bedside-nursing-handover-systematic-review-and-meta-synthesis

August 25, 2021 - Review Barriers to and facilitators of bedside nursing handover: a systematic review and meta-synthesis. Citation Text: Clari M, Conti A, Chiarini D, et al. Barriers to and facilitators of bedside nursing handover: a systematic review and meta-synthesis. J Nurs Care Qual. 2021;36(4):e51-…

Preventing surgical site infections: are safety climate level and its strength associated with self-reported commitment to, subjective norms toward, and knowledge about preventive measures? | PSNet

psnet.ahrq.gov/issue/preventing-surgical-site-infections-are-safety-climate-level-and-its-strength-associated-self

July 19, 2023 - Study Preventing surgical site infections: are safety climate level and its strength associated with self-reported commitment to, subjective norms toward, and knowledge about preventive measures? Citation Text: Pfeiffer Y, Atkinson A, Maag J, et al. Preventing surgical site infections: a…

Statewide collaborative to reduce surgical site infections: results of the Hawaii Surgical Unit-Based Safety Program. | PSNet

psnet.ahrq.gov/issue/statewide-collaborative-reduce-surgical-site-infections-results-hawaii-surgical-unit-based

March 21, 2012 - Study Statewide collaborative to reduce surgical site infections: results of the Hawaii Surgical Unit-Based Safety Program. Citation Text: Lin DM, Carson KA, Lubomski LH, et al. Statewide Collaborative to Reduce Surgical Site Infections: Results of the Hawaii Surgical Unit-Based Safety P…

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