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Sentinel events, serious reportable events, and root cause analysis. | PSNet

psnet.ahrq.gov/issue/sentinel-events-serious-reportable-events-and-root-cause-analysis

February 26, 2014 - Commentary Sentinel events, serious reportable events, and root cause analysis. Citation Text: Chen TC, Schein OD, Miller JW. Sentinel events, serious reportable events, and root cause analysis. JAMA Ophthalmol. 2015;133(6):631-632. doi:10.1001/jamaophthalmol.2015.0672. Copy Citation …

Now is the time to routinely ask patients about safety. | PSNet

psnet.ahrq.gov/issue/now-time-routinely-ask-patients-about-safety

March 08, 2023 - Commentary Now is the time to routinely ask patients about safety. Citation Text: Gandhi TK. Now Is the Time to Routinely Ask Patients About Safety. Jt Comm J Qual Patient Saf. 2023;49(4):235-236. doi:10.1016/j.jcjq.2023.01.009. Copy Citation Format: DOI Google Scholar BibT…

Medical students benefit from learning about patient safety in an interprofessional team. | PSNet

psnet.ahrq.gov/issue/medical-students-benefit-learning-about-patient-safety-interprofessional-team

November 03, 2015 - Image/Poster Medical students benefit from learning about patient safety in an interprofessional team. Citation Text: Anderson E, Thorpe L, Heney D, et al. Medical students benefit from learning about patient safety in an interprofessional team. Med Educ. 2009;43(6):542-52. doi:10.1111…

When a vital sign leads a country astray—the opioid epidemic. | PSNet

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May 27, 2020 - Commentary When a vital sign leads a country astray—the opioid epidemic. Citation Text: Chidgey BA, McGinigle KL, McNaull PP. When a Vital Sign Leads a Country Astray—The Opioid Epidemic. JAMA Surg. 2019;154(11):987-988. doi:10.1001/jamasurg.2019.2104. Copy Citation Format: …

Peer support: healthcare professionals supporting each other after adverse medical events. | PSNet

psnet.ahrq.gov/issue/peer-support-healthcare-professionals-supporting-each-other-after-adverse-medical-events

July 24, 2024 - Study Peer support: healthcare professionals supporting each other after adverse medical events. Citation Text: van Pelt F. Peer support: healthcare professionals supporting each other after adverse medical events. Qual Saf Health Care. 2008;17(4):249-52. doi:10.1136/qshc.2007.025536. …

Frequency of risk factors that potentially increase harm from medications in older adults receiving primary care. | PSNet

psnet.ahrq.gov/issue/frequency-risk-factors-potentially-increase-harm-medications-older-adults-receiving-primary

May 18, 2022 - Study Frequency of risk factors that potentially increase harm from medications in older adults receiving primary care. Citation Text: Frequency of risk factors that potentially increase harm from medications in older adults receiving primary care. McCarthy L, Dolovich L, Haq M, et a…

Video registration of trauma team performance in the emergency department: the results of a 2-year analysis in a Level 1 trauma center. | PSNet

psnet.ahrq.gov/issue/video-registration-trauma-team-performance-emergency-department-results-2-year-analysis-level

November 16, 2022 - Study Video registration of trauma team performance in the emergency department: the results of a 2-year analysis in a Level 1 trauma center. Citation Text: Lubbert PHW, Kaasschieter EG, Hoorntje LE, et al. Video registration of trauma team performance in the emergency department: the …

Strategies to enhance adoption of ventilator-associated pneumonia prevention interventions: a systematic literature review. | PSNet

psnet.ahrq.gov/issue/strategies-enhance-adoption-ventilator-associated-pneumonia-prevention-interventions

July 10, 2017 - Review Strategies to enhance adoption of ventilator-associated pneumonia prevention interventions: a systematic literature review. Citation Text: Goutier JM, Holzmueller CG, Edwards KC, et al. Strategies to enhance adoption of ventilator-associated pneumonia prevention interventions: a s…

The wicked problem of patient misidentification: how could the technological revolution help address patient safety? | PSNet

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July 10, 2024 - Commentary The wicked problem of patient misidentification: how could the technological revolution help address patient safety? Citation Text: Ferguson C, Hickman L, Macbean C, et al. The wicked problem of patient misidentification: How could the technological revolution help address pat…

A complementary approach to promoting professionalism: identifying, measuring, and addressing unprofessional behaviors. | PSNet

psnet.ahrq.gov/issue/complementary-approach-promoting-professionalism-identifying-measuring-and-addressing

June 27, 2018 - Study Classic A complementary approach to promoting professionalism: identifying, measuring, and addressing unprofessional behaviors. Citation Text: Hickson GB, Pichert JW, Webb LE, et al. A complementary approach to promoting professionalism: identifying, mea…

Reframing the morbidity and mortality conference: the impact of a just culture. | PSNet

psnet.ahrq.gov/issue/reframing-morbidity-and-mortality-conference-impact-just-culture

November 15, 2018 - Review Reframing the morbidity and mortality conference: the impact of a just culture. Citation Text: Brook K, Agarwala AV, Tewfik GL. Reframing the morbidity and mortality conference: the impact of a just culture. J Patient Saf. 2024;40(4):280-287. doi:10.1097/pts.0000000000001224. Co…

Normal Accidents: Living with High-Risk Technologies. | PSNet

psnet.ahrq.gov/issue/normal-accidents-living-high-risk-technologies

March 06, 2005 - Book/Report Classic Normal Accidents: Living with High-Risk Technologies. Citation Text: Normal Accidents: Living with High-Risk Technologies. Perrow C. Princeton NJ: Princeton University Press; 1999. Copy Citation Save Save to you…

Disparities in racial, ethnic, and payer groups for pediatric safety events in US hospitals. | PSNet

psnet.ahrq.gov/issue/disparities-racial-ethnic-and-payer-groups-pediatric-safety-events-us-hospitals

February 21, 2024 - Study Disparities in racial, ethnic, and payer groups for pediatric safety events in US hospitals. Citation Text: Parikh K, Hall M, Tieder JS, et al. Disparities in racial, ethnic, and payer groups for pediatric safety events in US hospitals. Pediatrics. 2024;153(3):e2023063714. doi:10.1…

On error management: lessons from aviation. | PSNet

psnet.ahrq.gov/issue/error-management-lessons-aviation

September 13, 2011 - Commentary Classic On error management: lessons from aviation. Citation Text: Helmreich RL. On error management: lessons from aviation. BMJ . 2000;320(7237):781-785. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML En…

The proportion of clinically relevant alarms decreases as patient clinical severity decreases in intensive care units: a pilot study. | PSNet

psnet.ahrq.gov/issue/proportion-clinically-relevant-alarms-decreases-patient-clinical-severity-decreases-intensive

November 21, 2021 - Study The proportion of clinically relevant alarms decreases as patient clinical severity decreases in intensive care units: a pilot study. Citation Text: Inokuchi R, Sato H, Nanjo Y, et al. The proportion of clinically relevant alarms decreases as patient clinical severity decreases in…

Burnout in the nursing home health care aide: a systematic review. | PSNet

psnet.ahrq.gov/issue/burnout-nursing-home-health-care-aide-systematic-review

May 18, 2022 - Review Burnout in the nursing home health care aide: a systematic review. Citation Text: Cooper SL, Carleton HL, Chamberlain SA, et al. Burnout in the nursing home health care aide: A systematic review. Burn Res. 2016;3(3):76-87. doi:10.1016/j.burn.2016.06.003. Copy Citation Format…

A multiple-drawer medication layout problem in automated dispensing cabinets. | PSNet

psnet.ahrq.gov/issue/multiple-drawer-medication-layout-problem-automated-dispensing-cabinets

December 21, 2017 - Study A multiple-drawer medication layout problem in automated dispensing cabinets. Citation Text: Pazour JA, Meller RD. A multiple-drawer medication layout problem in automated dispensing cabinets. Health Care Manag Sci. 2012;15(4). doi:10.1007/s10729-012-9197-8. Copy Citation Fo…

Teaching medical students about medical errors and patient safety: evaluation of a required curriculum. | PSNet

psnet.ahrq.gov/issue/teaching-medical-students-about-medical-errors-and-patient-safety-evaluation-required

June 08, 2022 - Study Teaching medical students about medical errors and patient safety: evaluation of a required curriculum. Citation Text: Halbach JL, Sullivan LL. Teaching medical students about medical errors and patient safety: evaluation of a required curriculum. Acad Med. 2005;80(6):600-6. Co…

Bridging the gap: leveraging business intelligence tools in support of patient safety and financial effectiveness. | PSNet

psnet.ahrq.gov/issue/bridging-gap-leveraging-business-intelligence-tools-support-patient-safety-and-financial

February 15, 2011 - Commentary Bridging the gap: leveraging business intelligence tools in support of patient safety and financial effectiveness. Citation Text: Ferranti JM, Langman MK, Tanaka D, et al. Bridging the gap: leveraging business intelligence tools in support of patient safety and financial effe…

Institutional disclosure: promise and problems. | PSNet

psnet.ahrq.gov/issue/institutional-disclosure-promise-and-problems

August 12, 2015 - Study Institutional disclosure: promise and problems. Citation Text: Wolk SW, Sine DM, Paull DE. Institutional disclosure: promise and problems. J Healthc Risk Manag. 2014;33(3):24-32. doi:10.1002/jhrm.21132. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3…

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