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psnet.ahrq.gov/node/74226/psn-pdf
February 01, 2019 - The VHA’s randomized program evaluation of STORM included four different
VHA operational and research
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psnet.ahrq.gov/primer/safety-i-safety-ii-and-new-views-safety
October 02, 2024 - Pre-Accident Investigations: Better Questions-An Applied Approach to Operational Learning : CRC Press
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psnet.ahrq.gov/web-mm/management-csf-leaks-after-elective-spine-surgery-routine-laminectomy-leads-fatal-discitis
March 09, 2022 - SPOTLIGHT CASE
Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis
Citation Text:
Castillo JA, Price R, Kim KD. Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis. PSNet [internet]. …
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psnet.ahrq.gov/issue/enhancing-teamwork-communication-and-patient-safety-responsiveness-paediatric-intensive-care
March 10, 2021 - Study
Enhancing teamwork communication and patient safety responsiveness in a paediatric intensive care unit using the daily safety huddle tool.
Citation Text:
Aldawood F, Kazzaz Y, AlShehri A, et al. Enhancing teamwork communication and patient safety responsiveness in a paediatric inte…
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psnet.ahrq.gov/issue/effect-standardized-handoff-curriculum-improved-clinician-preparedness-intensive-care-unit
October 19, 2022 - Study
Classic
Effect of standardized handoff curriculum on improved clinician preparedness in the intensive care unit: a stepped-wedge cluster randomized clinical trial.
Citation Text:
Parent B, LaGrone LN, Albirair MT, et al. Effect of Standardized Handoff Curr…
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psnet.ahrq.gov/issue/predictors-gaps-patient-safety-and-quality-us-hospitals
December 23, 2020 - Study
Predictors of gaps in patient safety and quality in U.S. hospitals.
Citation Text:
Unruh L, Hofler R. Predictors of Gaps in Patient Safety and Quality in U.S. Hospitals. Health Serv Res. 2016;51(6):2258-2281. doi:10.1111/1475-6773.12468.
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psnet.ahrq.gov/issue/association-between-complications-incidents-and-patient-experience-retrospective-linkage
February 20, 2019 - Study
The association between complications, incidents, and patient experience: retrospective linkage of routine patient experience surveys and safety data.
Citation Text:
de Vos MS, Hamming JF, Boosman H, et al. The Association Between Complications, Incidents, and Patient Experience: R…
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psnet.ahrq.gov/issue/are-teaching-hospitals-treated-fairly-hospital-acquired-condition-reduction-program
July 11, 2018 - Study
Are teaching hospitals treated fairly in the Hospital-Acquired Condition Reduction Program?
Citation Text:
Mohajer MA, Joiner KA, Nix DE. Are Teaching Hospitals Treated Fairly in the Hospital-Acquired Condition Reduction Program? Acad Med. 2018;93(12):1827-1832. doi:10.1097/ACM.000…
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psnet.ahrq.gov/issue/association-2011-acgme-resident-duty-hour-reform-general-surgery-patient-outcomes-and
September 09, 2015 - Study
Classic
Association of the 2011 ACGME resident duty hour reform with general surgery patient outcomes and with resident examination performance.
Citation Text:
Rajaram R, Chung JW, Jones AT, et al. Association of the 2011 ACGME resident duty hour reform wi…
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psnet.ahrq.gov/issue/association-2011-acgme-resident-duty-hour-reforms-mortality-and-readmissions-among
November 26, 2014 - Study
Classic
Association of the 2011 ACGME resident duty hour reforms with mortality and readmissions among hospitalized Medicare patients.
Citation Text:
Patel MS, Volpp KG, Small DS, et al. Association of the 2011 ACGME resident duty hour reforms with mortali…
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psnet.ahrq.gov/issue/communication-between-primary-and-secondary-care-deficits-and-danger
September 23, 2020 - Study
Communication between primary and secondary care: deficits and danger.
Citation Text:
Dinsdale E, Hannigan A, O’Connor R, et al. Communication between primary and secondary care: deficits and danger. Fam Pract. 2019;17(1):63-68. doi:10.1093/fampra/cmz037.
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psnet.ahrq.gov/issue/leaders-and-followers-individual-experiences-during-early-phase-simulation-based-team
January 18, 2011 - Study
Leaders' and followers' individual experiences during the early phase of simulation-based team training: an exploratory study.
Citation Text:
Meurling L, Hedman L, Felländer-Tsai L, et al. Leaders' and followers' individual experiences during the early phase of simulation-based t…
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psnet.ahrq.gov/issue/prospective-controlled-trial-electronic-hand-hygiene-reminder-system
April 07, 2021 - Study
A prospective controlled trial of an electronic hand hygiene reminder system.
Citation Text:
Ellison RT, Barysauskas CM, Rundensteiner EA, et al. A Prospective Controlled Trial of an Electronic Hand Hygiene Reminder System. Open Forum Infect Dis. 2015;2(4):ofv121. doi:10.1093/ofid/…
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psnet.ahrq.gov/issue/national-incidence-medication-error-surgical-patients-and-after-accreditation-council
September 23, 2020 - Study
National incidence of medication error in surgical patients before and after Accreditation Council for Graduate Medical Education duty-hour reform.
Citation Text:
Vadera S, Griffith SD, Rosenbaum BP, et al. National Incidence of Medication Error in Surgical Patients Before and Afte…
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psnet.ahrq.gov/issue/engaging-patients-medication-reconciliation-patient-portal-following-hospital-discharge
February 03, 2011 - Study
Engaging patients in medication reconciliation via a patient portal following hospital discharge.
Citation Text:
Heyworth L, Paquin AM, Clark J, et al. Engaging patients in medication reconciliation via a patient portal following hospital discharge. J Am Med Inform Assoc. 2014;21(e…
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psnet.ahrq.gov/issue/effect-hospital-multifaceted-clinical-pharmacist-intervention-risk-readmission-randomized
September 13, 2023 - Study
Classic
Effect of an in-hospital multifaceted clinical pharmacist intervention on the risk of readmission: a randomized clinical trial.
Citation Text:
Ravn-Nielsen LV, Duckert M-L, Lund ML, et al. Effect of an In-Hospital Multifaceted Clinical Pharmacist I…
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psnet.ahrq.gov/issue/situ-simulation-tool-longitudinally-identify-and-track-latent-safety-threats-structured
June 08, 2022 - Study
In situ simulation as a tool to longitudinally identify and track latent safety threats in a structured quality improvement initiative for SARS-CoV-2 airway management: a single-center study.
Citation Text:
Jafri FN, Yang CJ, Kumar A, et al. In situ simulation as a tool to longitud…
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psnet.ahrq.gov/issue/healthcare-failure-mode-and-effect-analysis-hfmea-effective-mechanism-preventing-infection
April 05, 2023 - Study
Healthcare failure mode and effect analysis (HFMEA) as an effective mechanism in preventing infection caused by accompanying caregivers during COVID-19-experience of a city medical center in Taiwan.
Citation Text:
Tiao C-H, Tsai L-C, Chen L-C, et al. Healthcare Failure Mode and Eff…
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psnet.ahrq.gov/issue/investigating-impact-pharmacist-intervention-inappropriate-prescribing-practices-hospital
November 30, 2022 - Study
Investigating the impact of a pharmacist intervention on inappropriate prescribing practices at hospital admission and discharge in older patients: a secondary outcome analysis from a randomized controlled trial.
Citation Text:
Garcia BH, Omma KK, Småbrekke L, et al. Investigating …
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psnet.ahrq.gov/issue/national-cluster-randomized-trial-duty-hour-flexibility-surgical-training
September 09, 2015 - Study
Classic
National cluster-randomized trial of duty-hour flexibility in surgical training.
Citation Text:
Bilimoria KY, Chung JW, Hedges L, et al. National Cluster-Randomized Trial of Duty-Hour Flexibility in Surgical Training. New Engl J Med. 2016;374(8):71…