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Broadening the concept of patient safety culture through value-based healthcare. | PSNet

psnet.ahrq.gov/issue/broadening-concept-patient-safety-culture-through-value-based-healthcare

September 29, 2021 - Commentary Broadening the concept of patient safety culture through value-based healthcare. Citation Text: Dombrádi V, Bíró K, Jonitz G, et al. Broadening the concept of patient safety culture through value-based healthcare. J Health Organ Manag. 2021;35(5):541-549. doi:10.1108/jhom-07-2…

A decade of health information technology usability challenges and the path forward. | PSNet

psnet.ahrq.gov/issue/decade-health-information-technology-usability-challenges-and-path-forward

January 16, 2019 - Commentary Emerging Classic A decade of health information technology usability challenges and the path forward. Citation Text: Ratwani RM, Reider J, Singh H. A Decade of Health Information Technology Usability Challenges and the Path Forward. JAMA. 2019;321(8):…

A practical framework for patient care teams to prospectively identify and mitigate clinical hazards. | PSNet

psnet.ahrq.gov/issue/practical-framework-patient-care-teams-prospectively-identify-and-mitigate-clinical-hazards

March 01, 2011 - Commentary A practical framework for patient care teams to prospectively identify and mitigate clinical hazards. Citation Text: Herzer KR, Rodriguez-Paz JM, Doyle PA, et al. A practical framework for patient care teams to prospectively identify and mitigate clinical hazards. Jt Comm J Qu…

Teaching nursing students the ethical and legal consequences of medical errors: insights from the RaDonda Vaught case using the jigsaw technique. | PSNet

psnet.ahrq.gov/issue/teaching-nursing-students-ethical-and-legal-consequences-medical-errors-insights-radonda

July 05, 2017 - Study Teaching nursing students the ethical and legal consequences of medical errors: insights from the RaDonda Vaught case using the jigsaw technique. Citation Text: Geiselman EL, Opsahl A, Townsend C. Teaching nursing students the ethical and legal consequences of medical errors: insig…

Fumbled handoffs: one dropped ball after another. | PSNet

psnet.ahrq.gov/issue/fumbled-handoffs-one-dropped-ball-after-another

April 10, 2024 - Commentary Fumbled handoffs: one dropped ball after another. Citation Text: Gandhi TK. Fumbled handoffs: one dropped ball after another. Ann Intern Med. 2005;142(5):352-358. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pub…

High-alert medications in the pediatric intensive care unit. | PSNet

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December 16, 2015 - Study High-alert medications in the pediatric intensive care unit. Citation Text: Franke HA, Woods D, Holl JL. High-alert medications in the pediatric intensive care unit. Pediatr Crit Care Med. 2009;10(1):85-90. doi:10.1097/PCC.0b013e3181936ff8. Copy Citation Format: DOI…

An analysis of major errors and equipment failures in anesthesia management: considerations for prevention and detection. | PSNet

psnet.ahrq.gov/issue/analysis-major-errors-and-equipment-failures-anesthesia-management-considerations-prevention

May 27, 2011 - Study Classic An analysis of major errors and equipment failures in anesthesia management: considerations for prevention and detection. Citation Text: Cooper JB, Newbower RS, Kitz RJ. An analysis of major errors and equipment failures in anesthesia management: c…

Organisational reporting and learning systems: innovating inside and outside of the box. | PSNet

psnet.ahrq.gov/issue/organisational-reporting-and-learning-systems-innovating-inside-and-outside-box

July 22, 2020 - Commentary Organisational reporting and learning systems: innovating inside and outside of the box. Citation Text: Sujan M, Furniss D. Organisational reporting and learning systems: Innovating inside and outside of the box. Clin Risk. 2015;21(1):7-12. doi:10.1177/1356262215574203. Copy…

Understanding the link between burnout and sub-optimal care: why should healthcare education be interested in employee silence? | PSNet

psnet.ahrq.gov/issue/understanding-link-between-burnout-and-sub-optimal-care-why-should-healthcare-education-be

August 03, 2022 - Review Understanding the link between burnout and sub-optimal care: why should healthcare education be interested in employee silence? Citation Text: Montgomery A, Lainidi O. Understanding the link between burnout and sub-optimal care: why should healthcare education be interested in emp…

The flaw of medicine: addressing racial and gender disparities in critical care. | PSNet

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June 16, 2010 - Commentary The flaw of medicine: addressing racial and gender disparities in critical care. Citation Text: Hilton EJ, Goff KL, Sreedharan R, et al. The flaw of medicine: addressing racial and gender disparities in critical care. Anesthesiol Clin. 2020;38(2):357-368. doi:10.1016/j.anclin.…

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…

Using Failure Mode and Effects Analysis for safe administration of chemotherapy to hospitalized children with cancer. | PSNet

psnet.ahrq.gov/issue/using-failure-mode-and-effects-analysis-safe-administration-chemotherapy-hospitalized

August 08, 2018 - Study Using Failure Mode and Effects Analysis for safe administration of chemotherapy to hospitalized children with cancer. Citation Text: Robinson DL, Heigham M, Clark J. Using Failure Mode and Effects Analysis for safe administration of chemotherapy to hospitalized children with cancer…

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

psnet.ahrq.gov/issue/when-vital-sign-leads-country-astray-opioid-epidemic

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

psnet.ahrq.gov/issue/wicked-problem-patient-misidentification-how-could-technological-revolution-help-address

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…

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