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psnet.ahrq.gov/issue/handoff-strategies-settings-high-consequences-failure-lessons-health-care-operations
March 14, 2018 - Study
Classic
Handoff strategies in settings with high consequences for failure: lessons for health care operations.
Citation Text:
Patterson ES. Handoff strategies in settings with high consequences for failure: lessons for health care operations. Int J Qual …
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psnet.ahrq.gov/issue/residents-feel-unprepared-and-unsupervised-leaders-cardiac-arrest-teams-teaching-hospitals
February 07, 2024 - Study
Residents feel unprepared and unsupervised as leaders of cardiac arrest teams in teaching hospitals: a survey of internal medicine residents.
Citation Text:
Hayes CW, Rhee A, Detsky ME, et al. Residents feel unprepared and unsupervised as leaders of cardiac arrest teams in teachi…
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psnet.ahrq.gov/issue/detecting-adverse-events-surgery-comparing-events-detected-veterans-health-administration
June 20, 2011 - Study
Detecting adverse events in surgery: comparing events detected by the Veterans Health Administration Surgical Quality Improvement Program and the Patient Safety Indicators.
Citation Text:
Mull HJ, Borzecki A, Loveland S, et al. Detecting adverse events in surgery: comparing events …
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psnet.ahrq.gov/issue/preventing-surgical-site-infections-are-safety-climate-level-and-its-strength-associated-self
July 19, 2023 - Study
Preventing surgical site infections: are safety climate level and its strength associated with self-reported commitment to, subjective norms toward, and knowledge about preventive measures?
Citation Text:
Pfeiffer Y, Atkinson A, Maag J, et al. Preventing surgical site infections: a…
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psnet.ahrq.gov/issue/creating-high-reliability-health-care-organizations
September 20, 2011 - Commentary
Creating high reliability in health care organizations.
Citation Text:
Pronovost P, Berenholtz SM, Goeschel CA, et al. Creating high reliability in health care organizations. Health Serv Res. 2006;41(4 Pt 2):1599-1617.
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Google Scholar PubMe…
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psnet.ahrq.gov/issue/safety-ii-behavior-pediatric-intensive-care-unit
January 12, 2022 - Study
Safety II behavior in a pediatric intensive care unit.
Citation Text:
Merandi J, Vannatta K, Davis T, et al. Safety II Behavior in a Pediatric Intensive Care Unit. Pediatrics. 2018;141(6):e20180018. doi:10.1542/peds.2018-0018.
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DOI Google Scholar …
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psnet.ahrq.gov/issue/simulation-hospital-pediatric-medical-emergencies-and-cardiopulmonary-arrests-highlighting
October 14, 2009 - Study
Simulation of in-hospital pediatric medical emergencies and cardiopulmonary arrests: highlighting the importance of the first 5 minutes.
Citation Text:
Hunt EA, Walker AR, Shaffner DH, et al. Simulation of in-hospital pediatric medical emergencies and cardiopulmonary arrests: hig…
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psnet.ahrq.gov/issue/understanding-diagnostic-safety-emergency-medicine-case-case-review-closed-ed-malpractice
May 11, 2019 - Study
Understanding diagnostic safety in emergency medicine: a case‐by‐case review of closed ED malpractice claims.
Citation Text:
Lemoine N, Dajer A, Konwinski J, et al. Understanding diagnostic safety in emergency medicine: A case-by-case review of closed ED malpractice claims. J Healt…
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psnet.ahrq.gov/issue/accuracy-medication-documentation-hospital-discharge-summaries-retrospective-analysis
March 23, 2012 - Study
Accuracy of medication documentation in hospital discharge summaries: a retrospective analysis of medication transcription errors in manual and electronic discharge summaries.
Citation Text:
Callen J, McIntosh J, Li J. Accuracy of medication documentation in hospital discharge su…
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psnet.ahrq.gov/issue/who-pays-medical-errors-analysis-adverse-event-costs-medical-liability-system-and-incentives
April 13, 2011 - Study
Classic
Who pays for medical errors? An analysis of adverse event costs, the medical liability system, and incentives for patient safety improvement.
Citation Text:
Mello MM, Studdert DM, Thomas EJ, et al. Who Pays for Medical Errors? An Analysis of Advers…
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psnet.ahrq.gov/issue/surgeons-and-systems-working-together-drive-safety-and-quality
February 02, 2022 - Commentary
Surgeons and systems working together to drive safety and quality.
Citation Text:
Hawkins RB, Nallamothu BK. Surgeons and systems working together to drive safety and quality. BMJ Qual Saf. 2023;32(4):181-184. doi:10.1136/bmjqs-2022-015045.
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psnet.ahrq.gov/issue/early-cost-and-safety-benefits-inpatient-electronic-health-record
August 04, 2021 - Study
Early cost and safety benefits of an inpatient electronic health record.
Citation Text:
Zlabek JA, Wickus JW, Mathiason MA. Early cost and safety benefits of an inpatient electronic health record. Journal of the American Medical Informatics Association. 2011;18(2). doi:10.1136/ja…
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psnet.ahrq.gov/web-mm/pregnant-danger
January 12, 2011 - e.g., CT scan) might have detected the aortic dissection before the discharge and subsequent tragic outcome … The mother and fetus in this case suffered a tragic outcome at a hospital that appeared to lack a structured … It is unclear whether the outcome would have been different elsewhere. … Aortic dissection in pregnancy: analysis of risk factors and outcome.
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psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-occult-hemothorax-following-complicated-central-line
April 01, 2008 - judgment and errors in technique occurred, and the attending surgeon was ultimately responsible for the outcome … Approach to Improving Patient Safety
Errors in both judgement and technique led to this adverse outcome … understandings about the allowable number and location of cannulation attempts, could also have improved the outcome … Following these best practices could have resulted in a much better outcome for the patient in this case
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psnet.ahrq.gov/node/49546/psn-pdf
October 17, 2007 - https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
Luckily, this case has a good outcome … student or practicing team level through critical incident root cause analysis and
http://www.acgme.org/outcome … Available at:
http://www.acgme.org/outcome/. Accessed September 27, 2007.
13. … cmd=retrieve&db=pubmed&dopt=abstract&list_uids=9032162
http://www.acgme.org/outcome/
http://www.ama-assn.org
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psnet.ahrq.gov/issue/barbers-civility
October 07, 2015 - June 16, 2011
The relationship of the emotional climate of work and threat to patient outcome
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psnet.ahrq.gov/issue/applying-toyota-production-system-using-patient-safety-alert-system-reduce-error
June 21, 2015 - June 23, 2015
Effect of outcome on physician judgments of appropriateness of care.
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psnet.ahrq.gov/issue/medical-and-surgical-comanagement-after-elective-hip-and-knee-arthroplasty-randomized
January 22, 2014 - 25, 2011
Evaluating implementation of a rapid response team: considering alternative outcome
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psnet.ahrq.gov/issue/latency-ecg-displays-hospital-telemetry-systems-science-advisory-american-heart-association
March 14, 2018 - A clinical case of electronic health record drug alert fatigue: consequences for patient outcome
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psnet.ahrq.gov/issue/safety-climate-and-medical-errors-62-us-emergency-departments
June 16, 2009 - March 10, 2011
EMS helicopter crashes: what influences fatal outcome?