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  1. The second victim of unanticipated adverse events. | PSNet

    psnet.ahrq.gov/issue/second-victim-unanticipated-adverse-events
    February 12, 2020 - Commentary The second victim of unanticipated adverse events. Citation Text: Chen S, Skidmore S, Ferrigno BN, et al. The second victim of unanticipated adverse events. J Thorac Cardiovasc Surg. 2023;166(3):890-894. doi:10.1016/j.jtcvs.2022.09.010. Copy Citation Format: DOI …

  2. A review of healthcare failure mode and effects analysis (HFMEA) in radiotherapy. | PSNet

    psnet.ahrq.gov/issue/review-healthcare-failure-mode-and-effects-analysis-hfmea-radiotherapy
    June 13, 2011 - Review A review of healthcare failure mode and effects analysis (HFMEA) in radiotherapy. Citation Text: Giardina M, Cantone MC, Tomarchio E, et al. A Review of Healthcare Failure Mode and Effects Analysis (HFMEA) in Radiotherapy. Health Phys. 2016;111(4):317-26. doi:10.1097/HP.0000000000…

  3. ED handoffs: observed practices and communication errors. | PSNet

    psnet.ahrq.gov/issue/ed-handoffs-observed-practices-and-communication-errors
    October 19, 2022 - Study ED handoffs: observed practices and communication errors. Citation Text: Maughan BC, Lei L, Cydulka RK. ED handoffs: observed practices and communication errors. Am J Emerg Med. 2011;29(5):502-11. doi:10.1016/j.ajem.2009.12.004. Copy Citation Format: DOI Google Scho…

  4. Effective triage can ameliorate the deleterious effects of delayed transfer of trauma patients from the emergency department to the ICU. | PSNet

    psnet.ahrq.gov/issue/effective-triage-can-ameliorate-deleterious-effects-delayed-transfer-trauma-patients
    August 04, 2021 - Study Effective triage can ameliorate the deleterious effects of delayed transfer of trauma patients from the emergency department to the ICU. Citation Text: Richardson D, Franklin G, Santos A, et al. Effective triage can ameliorate the deleterious effects of delayed transfer of trauma…

  5. A survey of outpatient internal medicine clinician perceptions of diagnostic error. | PSNet

    psnet.ahrq.gov/issue/survey-outpatient-internal-medicine-clinician-perceptions-diagnostic-error
    February 12, 2020 - Study A survey of outpatient internal medicine clinician perceptions of diagnostic error. Citation Text: Matulis JC, Kok SN, Dankbar EC, et al. A survey of outpatient Internal Medicine clinician perceptions of diagnostic error. Diagnosis. 2020;7(2):107-114. doi:10.1515/dx-2019-0070. Co…

  6. Trends in the prevalence of intraoperative adverse events at two academic hospitals after implementation of a mandatory reporting system. | PSNet

    psnet.ahrq.gov/issue/trends-prevalence-intraoperative-adverse-events-two-academic-hospitals-after-implementation
    August 09, 2017 - Study Trends in the prevalence of intraoperative adverse events at two academic hospitals after implementation of a mandatory reporting system. Citation Text: Wanderer JP, Gratch DM, St Jacques P, et al. Trends in the Prevalence of Intraoperative Adverse Events at Two Academic Hospitals …

  7. Work hours, work stress, and collaboration among ward staff in relation to risk of hospital-associated infection among patients. | PSNet

    psnet.ahrq.gov/issue/work-hours-work-stress-and-collaboration-among-ward-staff-relation-risk-hospital-associated
    December 14, 2022 - Study Work hours, work stress, and collaboration among ward staff in relation to risk of hospital-associated infection among patients. Citation Text: Virtanen M, Kurvinen T, Terho K, et al. Work hours, work stress, and collaboration among ward staff in relation to risk of hospital-asso…

  8. Passing the baton: a grounded practical theory of handoff communication between multidisciplinary providers in two Department of Veterans Affairs outpatient settings. | PSNet

    psnet.ahrq.gov/issue/passing-baton-grounded-practical-theory-handoff-communication-between-multidisciplinary
    November 16, 2022 - Study Passing the baton: a grounded practical theory of handoff communication between multidisciplinary providers in two Department of Veterans Affairs outpatient settings. Citation Text: Koenig CJ, Maguen S, Daley A, et al. Passing the baton: a grounded practical theory of handoff commu…

  9. Addressing adultification of black pediatric patients in the emergency department: a framework to decrease disparities. | PSNet

    psnet.ahrq.gov/issue/addressing-adultification-black-pediatric-patients-emergency-department-framework-decrease
    October 27, 2021 - Commentary Addressing adultification of black pediatric patients in the emergency department: a framework to decrease disparities. Citation Text: Koch A, Kozhumam A. Addressing adultification of black pediatric patients in the emergency department: a framework to decrease disparities. He…

  10. Handoff tool improves transitions from the operating room to the neonatal intensive care unit. | PSNet

    psnet.ahrq.gov/issue/handoff-tool-improves-transitions-operating-room-neonatal-intensive-care-unit
    November 16, 2022 - Study Handoff tool improves transitions from the operating room to the neonatal intensive care unit. Citation Text: Gallois JB, Zagory JA, Barkemeyer B, et al. Handoff tool improves transitions from the operating room to the neonatal intensive care unit. Pediatr Qual Saf. 2023;8(5):e695.…

  11. Developing agreement on never events in primary care dentistry: an international eDelphi study. | PSNet

    psnet.ahrq.gov/issue/developing-agreement-never-events-primary-care-dentistry-international-edelphi-study
    October 05, 2016 - Study Developing agreement on never events in primary care dentistry: an international eDelphi study. Citation Text: Ensaldo-Carrasco E, Carson-Stevens A, Cresswell K, et al. Developing agreement on never events in primary care dentistry: an international eDelphi study. Br Dent J. 2018;2…

  12. Early adopters of computerized physician order entry in hospitals that care for children: a picture of US health care shortly after the Institute of Medicine reports on quality. | PSNet

    psnet.ahrq.gov/issue/early-adopters-computerized-physician-order-entry-hospitals-care-children-picture-us-health
    December 20, 2023 - Study Early adopters of computerized physician order entry in hospitals that care for children: a picture of US health care shortly after the Institute of Medicine reports on quality. Citation Text: Teufel RJ, Kazley AS, Basco WT. Early adopters of computerized physician order entry in…

  13. Cognitive bias during clinical decision-making and its influence on patient outcomes in the emergency department: a scoping review. | PSNet

    psnet.ahrq.gov/issue/cognitive-bias-during-clinical-decision-making-and-its-influence-patient-outcomes-emergency
    September 21, 2022 - Review Cognitive bias during clinical decision-making and its influence on patient outcomes in the emergency department: a scoping review. Citation Text: Jala S, Fry M, Elliott R. Cognitive bias during clinical decision‐making and its influence on patient outcomes in the emergency depart…

  14. The impact of sleep deprivation on product quality and procedure effectiveness in a laparoscopic physical simulator: a randomized controlled trial.   | PSNet

    psnet.ahrq.gov/issue/impact-sleep-deprivation-product-quality-and-procedure-effectiveness-laparoscopic-physical
    June 03, 2020 - Study The impact of sleep deprivation on product quality and procedure effectiveness in a laparoscopic physical simulator: a randomized controlled trial.   Citation Text: Uchal M, Tjugum J, Martinsen E, et al. The impact of sleep deprivation on product quality and procedure effectivene…

  15. Patient misidentifications caused by errors in standard barcode technology. | PSNet

    psnet.ahrq.gov/issue/patient-misidentifications-caused-errors-standard-barcode-technology
    June 13, 2012 - Study Patient misidentifications caused by errors in standard barcode technology. Citation Text: Snyder ML, Carter A, Jenkins K, et al. Patient misidentifications caused by errors in standard bar code technology. Clin Chem. 2010;56(10):1554-60. doi:10.1373/clinchem.2010.150094. Copy …

  16. Improvement in the detection of adverse drug events by the use of electronic health and prescription records: an evaluation of two trigger tools. | PSNet

    psnet.ahrq.gov/issue/improvement-detection-adverse-drug-events-use-electronic-health-and-prescription-records
    September 23, 2020 - Study Improvement in the detection of adverse drug events by the use of electronic health and prescription records: an evaluation of two trigger tools. Citation Text: Nwulu U, Nirantharakumar K, Odesanya R, et al. Improvement in the detection of adverse drug events by the use of electr…

  17. Comparison of internal medicine and general surgery residents' assessments of risk of postsurgical complications in surgically complex patients. | PSNet

    psnet.ahrq.gov/issue/comparison-internal-medicine-and-general-surgery-residents-assessments-risk-postsurgical
    September 27, 2017 - Study Comparison of internal medicine and general surgery residents' assessments of risk of postsurgical complications in surgically complex patients. Citation Text: Healy JM, Davis KA, Pei KY. Comparison of Internal Medicine and General Surgery Residents' Assessments of Risk of Postsurg…

  18. An assessment of basic patient safety skills in residents entering the first year of clinical training. | PSNet

    psnet.ahrq.gov/issue/assessment-basic-patient-safety-skills-residents-entering-first-year-clinical-training
    February 21, 2018 - Study An assessment of basic patient safety skills in residents entering the first year of clinical training. Citation Text: Comunale ME, Sandoval M, Broussard LT. An Assessment of Basic Patient Safety Skills in Residents Entering the First Year of Clinical Training. J Patient Saf. 2018;…

  19. Novel telephone-based interactive voice response system for incident reporting. | PSNet

    psnet.ahrq.gov/issue/novel-telephone-based-interactive-voice-response-system-incident-reporting
    September 08, 2021 - Study Novel telephone-based interactive voice response system for incident reporting. Citation Text: McNiven B, Brown AD. Novel telephone-based interactive voice response system for incident reporting. Jt Comm J Qual Patient Saf. 2021;47(12):809-813. doi:10.1016/j.jcjq.2021.09.010. Cop…

  20. Speaking the same language? International variations in the safety information accompanying top-selling prescription drugs. | PSNet

    psnet.ahrq.gov/issue/speaking-same-language-international-variations-safety-information-accompanying-top-selling
    September 25, 2008 - Study Speaking the same language? International variations in the safety information accompanying top-selling prescription drugs. Citation Text: Kesselheim AS, Franklin JM, Avorn J, et al. Speaking the same language? International variations in the safety information accompanying top-se…
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