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Near-misses are an opportunity to improve patient safety: adapting strategies of high reliability organizations to healthcare. | PSNet

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July 01, 2011 - Review Near-misses are an opportunity to improve patient safety: adapting strategies of high reliability organizations to healthcare. Citation Text: Van Spall H, Kassam A, Tollefson TT. Near-misses are an opportunity to improve patient safety: adapting strategies of high reliability orga…

Patient safety incidents associated with airway devices in critical care: a review of reports to the UK National Patient Safety Agency. | PSNet

psnet.ahrq.gov/issue/patient-safety-incidents-associated-airway-devices-critical-care-review-reports-uk-national

March 12, 2025 - Study Patient safety incidents associated with airway devices in critical care: a review of reports to the UK National Patient Safety Agency. Citation Text: Thomas AN, McGrath BA. Patient safety incidents associated with airway devices in critical care: a review of reports to the UK Na…

Failure events in transition of care for surgical patients. | PSNet

psnet.ahrq.gov/issue/failure-events-transition-care-surgical-patients

October 19, 2022 - Study Failure events in transition of care for surgical patients. Citation Text: Helling TS, Martin LC, Martin M, et al. Failure events in transition of care for surgical patients. J Am Coll Surg. 2014;218(4):723-31. doi:10.1016/j.jamcollsurg.2013.12.026. Copy Citation Format: …

Nursing home residents with dementia: association between place of death and patient safety culture. | PSNet

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November 04, 2020 - Study Nursing home residents with dementia: association between place of death and patient safety culture. Citation Text: Orth J, Li Y, Simning A, et al. Nursing Home Residents With Dementia: Association Between Place of Death and Patient Safety Culture. Gerontologist. 2021;61(8):1296-1…

A systematic review of team training in health care: ten questions. | PSNet

psnet.ahrq.gov/issue/systematic-review-team-training-health-care-ten-questions

September 11, 2016 - Review A systematic review of team training in health care: ten questions. Citation Text: Marlow SL, Hughes A, Sonesh SC, et al. A Systematic Review of Team Training in Health Care: Ten Questions. Jt Comm J Qual Patient Saf. 2017;43(4):197-204. doi:10.1016/j.jcjq.2016.12.004. Copy Cita…

Risk factors for retained surgical items: a meta-analysis and proposed risk stratification system. | PSNet

psnet.ahrq.gov/issue/risk-factors-retained-surgical-items-meta-analysis-and-proposed-risk-stratification-system

January 18, 2013 - Study Risk factors for retained surgical items: a meta-analysis and proposed risk stratification system. Citation Text: Moffatt-Bruce SD, Cook CH, Steinberg SM, et al. Risk factors for retained surgical items: a meta-analysis and proposed risk stratification system. J Surg Res. 2014;190(…

Misdiagnosis of heart failure: a systematic review of the literature. | PSNet

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October 06, 2021 - Review Misdiagnosis of heart failure: a systematic review of the literature. Citation Text: Wong CW, Tafuro J, Azam Z, et al. Misdiagnosis of heart failure: a systematic review of the literature. J Cardiac Failure. 2021;27(9):925-933. doi:10.1016/j.cardfail.2021.05.014. Copy Citation …

Implementing human factors in anaesthesia: guidance for clinicians, departments and hospitals: Guidelines from the Difficult Airway Society and the Association of Anaesthetists. | PSNet

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February 15, 2023 - Organizational Policy/Guidelines Implementing human factors in anaesthesia: guidance for clinicians, departments and hospitals: Guidelines from the Difficult Airway Society and the Association of Anaesthetists. Citation Text: Kelly FE, Frerk C, Bailey CR, et al. Implementing human factor…

Identifying and measuring administrative harms experienced by hospitalists and administrative leaders. | PSNet

psnet.ahrq.gov/issue/identifying-and-measuring-administrative-harms-experienced-hospitalists-and-administrative

April 12, 2023 - Study Identifying and measuring administrative harms experienced by hospitalists and administrative leaders. Citation Text: Burden M, Astik GJ, Auerbach AD, et al. Identifying and measuring administrative harms experienced by hospitalists and administrative leaders. JAMA Intern Med. 2024…

Family-centered multidisciplinary rounds enhance the team approach in pediatrics. | PSNet

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November 21, 2021 - Study Family-centered multidisciplinary rounds enhance the team approach in pediatrics. Citation Text: Rosen P, Stenger E, Bochkoris M, et al. Family-centered multidisciplinary rounds enhance the team approach in pediatrics. Pediatrics. 2009;123(4):e603-8. doi:10.1542/peds.2008-2238. C…

Prevalence and characteristics of interruptions and distractions during surgical counts. | PSNet

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March 09, 2016 - Study Prevalence and characteristics of interruptions and distractions during surgical counts. Citation Text: Bubric KA, Biesbroek SL, Laberge JC, et al. Prevalence and characteristics of interruptions and distractions during surgical counts. Jt Comm J Qual Patient Saf. 2021;47(9):556-56…

Computerized surveillance for adverse drug events in a pediatric hospital. | PSNet

psnet.ahrq.gov/issue/computerized-surveillance-adverse-drug-events-pediatric-hospital

January 03, 2017 - Study Computerized surveillance for adverse drug events in a pediatric hospital. Citation Text: Kilbridge PM, Noirot LA, Reichley RM, et al. Computerized surveillance for adverse drug events in a pediatric hospital. J Am Med Inform Assoc. 2009;16(5):607-12. doi:10.1197/jamia.M3167. C…

Measuring hospital-acquired complications associated with low-value care. | PSNet

psnet.ahrq.gov/issue/measuring-hospital-acquired-complications-associated-low-value-care

August 11, 2021 - Study Emerging Classic Measuring hospital-acquired complications associated with low-value care. Citation Text: Badgery-Parker T, Pearson S-A, Dunn S, et al. Measuring Hospital-Acquired Complications Associated With Low-Value Care. JAMA Intern Med. 2019;179(4):4…

Identifying facilitators and barriers for patient safety in a medicine label design system using patient simulation and interviews. | PSNet

psnet.ahrq.gov/issue/identifying-facilitators-and-barriers-patient-safety-medicine-label-design-system-using

July 23, 2018 - Study Identifying facilitators and barriers for patient safety in a medicine label design system using patient simulation and interviews. Citation Text: Dieckmann P, Clemmensen MH, Sørensen TK, et al. Identifying Facilitators and Barriers for Patient Safety in a Medicine Label Design Sys…

Development and early experience from an intervention to facilitate teamwork between general practices and allied health providers: the Team-link study. | PSNet

psnet.ahrq.gov/issue/development-and-early-experience-intervention-facilitate-teamwork-between-general-practices

June 29, 2011 - Study Development and early experience from an intervention to facilitate teamwork between general practices and allied health providers: the Team-link study. Citation Text: Harris MF, Chan BC, Daniel C, et al. Development and early experience from an intervention to facilitate teamwor…

The differences between human error, at-risk behavior, and reckless behavior are key to a just culture. | PSNet

psnet.ahrq.gov/issue/differences-between-human-error-risk-behavior-and-reckless-behavior-are-key-just-culture

September 23, 2020 - Newspaper/Magazine Article The differences between human error, at-risk behavior, and reckless behavior are key to a just culture. Citation Text: The differences between human error, at-risk behavior, and reckless behavior are key to a just culture. ISMP Medication Safety Alert! Acute Ca…

Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. | PSNet

psnet.ahrq.gov/issue/lost-translation-challenges-and-opportunities-physician-physician-communication-during

April 12, 2011 - Study Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. Citation Text: Solet DJ, Norvell M, Rutan GH, et al. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoff…

Does physician's training induce overconfidence that hampers disclosing errors? | PSNet

psnet.ahrq.gov/issue/does-physicians-training-induce-overconfidence-hampers-disclosing-errors

October 21, 2009 - Study Does physician's training induce overconfidence that hampers disclosing errors? Citation Text: Brezis M, Orkin-Bedolach Y, Fink D, et al. Does Physician's Training Induce Overconfidence That Hampers Disclosing Errors? J Patient Saf. 2019;15(4):296-298. doi:10.1097/PTS.0000000000000…

Room of horrors simulation in healthcare education: a systematic review. | PSNet

psnet.ahrq.gov/issue/room-horrors-simulation-healthcare-education-systematic-review

September 09, 2020 - Review Room of horrors simulation in healthcare education: a systematic review. Citation Text: Lee SE, Repsha C, Seo WJ, et al. Room of horrors simulation in healthcare education: a systematic review. Nurse Educ Today. 2023;126:105824. doi:10.1016/j.nedt.2023.105824. Copy Citation …

Impact of fatigue on anaesthesia providers: a scoping review. | PSNet

psnet.ahrq.gov/issue/impact-fatigue-anaesthesia-providers-scoping-review

November 21, 2021 - Review Impact of fatigue on anaesthesia providers: a scoping review. Citation Text: Scholliers A, Cornelis S, Tosi M, et al. Impact of fatigue on anaesthesia providers: a scoping review. Br J Anaesth. 2023;130(5):622-635. doi:10.1016/j.bja.2022.12.011. Copy Citation Format: …

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