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"That was a close call": endorsing a broad definition of near misses in health care. | PSNet

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August 31, 2016 - Commentary "That was a close call": endorsing a broad definition of near misses in health care. Citation Text: Marks CM, Kasda E, Paine LA, et al. "That was a close call": endorsing a broad definition of near misses in health care. Jt Comm J Qual Patient Saf. 2013;39(10):475-479. Cop…

Creating a just culture in the perioperative setting. | PSNet

psnet.ahrq.gov/issue/creating-just-culture-perioperative-setting

July 13, 2009 - Commentary Creating a just culture in the perioperative setting. Citation Text: Hooven K, Altmiller G. Creating a just culture in the perioperative setting. AORN J. 2024;119(2):152-160. doi:10.1002/aorn.14074. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML E…

Preventing blood transfusion failures: FMEA, an effective assessment method. | PSNet

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August 25, 2021 - Study Preventing blood transfusion failures: FMEA, an effective assessment method. Citation Text: Najafpour Z, Hasoumi M, Behzadi F, et al. Preventing blood transfusion failures: FMEA, an effective assessment method. BMC Health Serv Res. 2017;17(1):453. doi:10.1186/s12913-017-2380-3. C…

Preventable anesthesia mishaps: a study of human factors. | PSNet

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June 23, 2015 - Study Classic Preventable anesthesia mishaps: a study of human factors. Citation Text: Cooper JB, Newbower RS, Long CD, et al. Preventable anesthesia mishaps: a study of human factors. Anesthesiology. 1978;49(6):399-406. Copy Citation Format: Goo…

Health services under pressure: a scoping review and development of a taxonomy of adaptive strategies. | PSNet

psnet.ahrq.gov/issue/health-services-under-pressure-scoping-review-and-development-taxonomy-adaptive-strategies

January 22, 2020 - Commentary Health services under pressure: a scoping review and development of a taxonomy of adaptive strategies. Citation Text: Page B, Irving D, Amalberti R, et al. Health services under pressure: a scoping review and development of a taxonomy of adaptive strategies. BMJ Qual Saf. 2023…

Critical Issues in Food Allergy: A National Academies Consensus Report. | PSNet

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November 16, 2022 - Commentary Critical Issues in Food Allergy: A National Academies Consensus Report. Citation Text: Sicherer SH, Allen K, Lack G, et al. Critical Issues in Food Allergy: A National Academies Consensus Report. Pediatrics. 2017;140(2). doi:10.1542/peds.2017-0194. Copy Citation Format: …

Clinical review: the hospital of the future—building intelligent environments to facilitate safe and effective acute care delivery. | PSNet

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March 16, 2022 - Review Clinical review: the hospital of the future—building intelligent environments to facilitate safe and effective acute care delivery. Citation Text: Pickering BW, Litell JM, Herasevich V, et al. Clinical review: the hospital of the future - building intelligent environments to faci…

Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects analysis, and structured communications skills. | PSNet

psnet.ahrq.gov/issue/key-performance-outcomes-patient-safety-curricula-root-cause-analysis-failure-mode-and

July 23, 2010 - Commentary Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects analysis, and structured communications skills. Citation Text: Fassett WE. Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects …

"Everybody makes mistakes": children's views on medical errors and disclosure. | PSNet

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March 20, 2019 - Study "Everybody makes mistakes": children's views on medical errors and disclosure. Citation Text: Koller D, Binder MJ, Alexander S, et al. "Everybody Makes Mistakes": Children's Views on Medical Errors and Disclosure. J Ped Nurs. 2019;49:1-9. doi:10.1016/j.pedn.2019.07.014. Copy Cita…

Team-training in healthcare: a narrative synthesis of the literature. | PSNet

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July 02, 2014 - Review Team-training in healthcare: a narrative synthesis of the literature. Citation Text: Weaver SJ, Dy SM, Rosen MA. Team-training in healthcare: a narrative synthesis of the literature. BMJ Qual Saf. 2014;23(5):359-72. doi:10.1136/bmjqs-2013-001848. Copy Citation Format: …

What context features might be important determinants of the effectiveness of patient safety practice interventions? | PSNet

psnet.ahrq.gov/issue/what-context-features-might-be-important-determinants-effectiveness-patient-safety-practice

September 20, 2011 - Study What context features might be important determinants of the effectiveness of patient safety practice interventions? Citation Text: Taylor SL, Dy SM, Foy R, et al. What context features might be important determinants of the effectiveness of patient safety practice interventions?…

'Broken hospital windows': debating the theory of spreading disorder and its application to healthcare organizations. | PSNet

psnet.ahrq.gov/issue/broken-hospital-windows-debating-theory-spreading-disorder-and-its-application-healthcare

October 26, 2022 - Commentary 'Broken hospital windows': debating the theory of spreading disorder and its application to healthcare organizations. Citation Text: Churruca K, Ellis LA, Braithwaite J. 'Broken hospital windows': debating the theory of spreading disorder and its application to healthcare orga…

Chief resident for quality improvement and patient safety: a description. | PSNet

psnet.ahrq.gov/issue/chief-resident-quality-improvement-and-patient-safety-description

July 02, 2014 - Commentary Chief resident for quality improvement and patient safety: a description. Citation Text: Cox LAM, Fanucchi LC, Sinex NC, et al. Chief resident for quality improvement and patient safety: a description. Am J Med. 2014;127(6):565-8. doi:10.1016/j.amjmed.2014.02.034. Copy Citat…

Thirty-day outcomes support implementation of a surgical safety checklist. | PSNet

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April 10, 2024 - Study Thirty-day outcomes support implementation of a surgical safety checklist. Citation Text: Bliss LA, Ross-Richardson CB, Sanzari LJ, et al. Thirty-day outcomes support implementation of a surgical safety checklist. J Am Coll Surg. 2012;215(6):766-76. doi:10.1016/j.jamcollsurg.2012…

Error reporting and disclosure systems: views from hospital leaders. | PSNet

psnet.ahrq.gov/issue/error-reporting-and-disclosure-systems-views-hospital-leaders

June 16, 2010 - Study Classic Error reporting and disclosure systems: views from hospital leaders. Citation Text: Weissman JS, Annas CL, Epstein AM, et al. Error reporting and disclosure systems: views from hospital leaders. JAMA. 2005;293(11):1359-66. Copy Citation For…

Learning from near misses: from quick fixes to closing off the Swiss-cheese holes. | PSNet

psnet.ahrq.gov/issue/learning-near-misses-quick-fixes-closing-swiss-cheese-holes

April 11, 2012 - Study Learning from near misses: from quick fixes to closing off the Swiss-cheese holes. Citation Text: Jeffs L, Berta W, Lingard LA, et al. Learning from near misses: from quick fixes to closing off the Swiss-cheese holes. BMJ Qual Saf. 2012;21(4):287-94. doi:10.1136/bmjqs-2011-000256…

Ambulatory medication reconciliation: using a collaborative approach to process improvement at an academic medical center. | PSNet

psnet.ahrq.gov/issue/ambulatory-medication-reconciliation-using-collaborative-approach-process-improvement

December 04, 2019 - Study Ambulatory medication reconciliation: using a collaborative approach to process improvement at an academic medical center. Citation Text: Keogh C, Kachalia A, Fiumara K, et al. Ambulatory Medication Reconciliation: Using a Collaborative Approach to Process Improvement at an Academi…

Interprofessional care in intensive care settings and the factors that impact it: results from a scoping review of ethnographic studies. | PSNet

psnet.ahrq.gov/issue/interprofessional-care-intensive-care-settings-and-factors-impact-it-results-scoping-review

August 15, 2018 - Review Interprofessional care in intensive care settings and the factors that impact it: results from a scoping review of ethnographic studies. Citation Text: Paradis E, Leslie M, Gropper MA, et al. Interprofessional care in intensive care settings and the factors that impact it: resul…

Team mental models and their potential to improve teamwork and safety: a review and implications for future research in healthcare. | PSNet

psnet.ahrq.gov/issue/team-mental-models-and-their-potential-improve-teamwork-and-safety-review-and-implications

June 09, 2021 - Review Team mental models and their potential to improve teamwork and safety: a review and implications for future research in healthcare. Citation Text: Burtscher MJ, Manser T. Team mental models and their potential to improve teamwork and safety: A review and implications for future …

Exploring the association between organizational safety climate, failure to rescue, and mortality in inpatient surgical units. | PSNet

psnet.ahrq.gov/issue/exploring-association-between-organizational-safety-climate-failure-rescue-and-mortality

January 26, 2022 - Study Exploring the association between organizational safety climate, failure to rescue, and mortality in inpatient surgical units. Citation Text: Bacon CT, McCoy TP, Henshaw DS. Exploring the Association Between Organizational Safety Climate, Failure to Rescue, and Mortality in Inpatie…

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