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  1. "That was a close call": endorsing a broad definition of near misses in health care. | PSNet

    psnet.ahrq.gov/issue/was-close-call-endorsing-broad-definition-near-misses-health-care
    August 31, 2016 - Commentary "That was a close call": endorsing a broad definition of near misses in health care. Citation Text: Marks CM, Kasda E, Paine LA, et al. "That was a close call": endorsing a broad definition of near misses in health care. Jt Comm J Qual Patient Saf. 2013;39(10):475-479. Cop…

  2. A comparative analysis of incident reporting lag times in academic medical centres in Japan and the USA. | PSNet

    psnet.ahrq.gov/issue/comparative-analysis-incident-reporting-lag-times-academic-medical-centres-japan-and-usa
    March 23, 2011 - Study A comparative analysis of incident reporting lag times in academic medical centres in Japan and the USA. Citation Text: Regenbogen SE, Hirose M, Imanaka Y, et al. A comparative analysis of incident reporting lag times in academic medical centres in Japan and the USA. Qual Saf Hea…

  3. Preventing blood transfusion failures: FMEA, an effective assessment method. | PSNet

    psnet.ahrq.gov/issue/preventing-blood-transfusion-failures-fmea-effective-assessment-method
    August 25, 2021 - Study Preventing blood transfusion failures: FMEA, an effective assessment method. Citation Text: Najafpour Z, Hasoumi M, Behzadi F, et al. Preventing blood transfusion failures: FMEA, an effective assessment method. BMC Health Serv Res. 2017;17(1):453. doi:10.1186/s12913-017-2380-3. C…

  4. Making infection prevention and control everyone's business? Hospital staff views on patient involvement. | PSNet

    psnet.ahrq.gov/issue/making-infection-prevention-and-control-everyones-business-hospital-staff-views-patient
    April 29, 2015 - Study Making infection prevention and control everyone's business? Hospital staff views on patient involvement. Citation Text: Sutton E, Brewster L, Tarrant C. Making infection prevention and control everyone's business? Hospital staff views on patient involvement. Health Expect. 2019;22…

  5. Supporting second victims of patient safety events: shouldn't these communications be covered by legal privilege? | PSNet

    psnet.ahrq.gov/issue/supporting-second-victims-patient-safety-events-shouldnt-these-communications-be-covered
    November 06, 2019 - Commentary Supporting second victims of patient safety events: shouldn't these communications be covered by legal privilege? Citation Text: de Wit ME, Marks CM, Natterman JP, et al. Supporting second victims of patient safety events: shouldn't these communications be covered by legal pri…

  6. Team-training in healthcare: a narrative synthesis of the literature. | PSNet

    psnet.ahrq.gov/issue/team-training-healthcare-narrative-synthesis-literature
    July 02, 2014 - Review Team-training in healthcare: a narrative synthesis of the literature. Citation Text: Weaver SJ, Dy SM, Rosen MA. Team-training in healthcare: a narrative synthesis of the literature. BMJ Qual Saf. 2014;23(5):359-72. doi:10.1136/bmjqs-2013-001848. Copy Citation Format: …

  7. Please reconcile, not wait a while. | PSNet

    psnet.ahrq.gov/issue/please-reconcile-not-wait-while
    April 19, 2023 - Commentary Please reconcile, not wait a while. Citation Text: Trivedi A, Sharma S, Ajitsaria R, et al. Please reconcile, not wait a while. Arch Dis Child Educ Pract Ed. 2019;105(2):122-126. doi:10.1136/archdischild-2018-316356. Copy Citation Format: DOI Google Scholar BibTe…

  8. Investigation of urology intraoperative events leading to root cause analysis at national VA medical centers. | PSNet

    psnet.ahrq.gov/issue/investigation-urology-intraoperative-events-leading-root-cause-analysis-national-va-medical
    June 02, 2021 - Study Investigation of urology intraoperative events leading to root cause analysis at national VA medical centers. Citation Text: Investigation of urology intraoperative events leading to root cause analysis at national VA medical centers. Peard LM, Teplitsky S, Annabathula A, et al. Ca…

  9. Using a logic model to design and evaluate quality and patient safety improvement programs. | PSNet

    psnet.ahrq.gov/issue/using-logic-model-design-and-evaluate-quality-and-patient-safety-improvement-programs
    November 10, 2010 - Commentary Using a logic model to design and evaluate quality and patient safety improvement programs. Citation Text: Goeschel CA, Weiss WM, Pronovost P. Using a logic model to design and evaluate quality and patient safety improvement programs. Int J Qual Health Care. 2012;24(4):330-7. …

  10. To err is system: a comparison of methodologies for the investigation of adverse outcomes in healthcare. | PSNet

    psnet.ahrq.gov/issue/err-system-comparison-methodologies-investigation-adverse-outcomes-healthcare
    January 26, 2022 - Commentary To err is system: a comparison of methodologies for the investigation of adverse outcomes in healthcare. Citation Text: Isherwood P, Waterson P. To err is system: a comparison of methodologies for the investigation of adverse outcomes in healthcare. J Patient Saf Risk Manag. 2…

  11. Patient safety and workplace bullying: an integrative review. | PSNet

    psnet.ahrq.gov/issue/patient-safety-and-workplace-bullying-integrative-review
    March 11, 2020 - Review Patient safety and workplace bullying: an integrative review. Citation Text: Houck NM, Colbert AM. Patient Safety and Workplace Bullying: An Integrative Review. J Nurs Care Qual. 2017;32(2):164-171. doi:10.1097/NCQ.0000000000000209. Copy Citation Format: DOI Google S…

  12. Does a checklist reduce the number of errors made in nurse-assembled discharge prescriptions? | PSNet

    psnet.ahrq.gov/issue/does-checklist-reduce-number-errors-made-nurse-assembled-discharge-prescriptions
    March 24, 2019 - Study Does a checklist reduce the number of errors made in nurse-assembled discharge prescriptions? Citation Text: Byrne C, Sierra H, Tolhurst R. Does a checklist reduce the number of errors made in nurse-assembled discharge prescriptions? Br J Nurs. 2017;26(8):464-467. doi:10.12968/bjon…

  13. Associations between perceived crisis mode work climate and poor information exchange within hospitals. | PSNet

    psnet.ahrq.gov/issue/associations-between-perceived-crisis-mode-work-climate-and-poor-information-exchange-within
    October 19, 2022 - Study Associations between perceived crisis mode work climate and poor information exchange within hospitals. Citation Text: Patterson ME, Bogart MS, Starr KR. Associations between perceived crisis mode work climate and poor information exchange within hospitals. J Hosp Med. 2015;10(3):1…

  14. Challenges of implementing a communication-and-resolution program where multiple organizations must cooperate. | PSNet

    psnet.ahrq.gov/issue/challenges-implementing-communication-and-resolution-program-where-multiple-organizations
    May 11, 2016 - Study Challenges of implementing a communication-and-resolution program where multiple organizations must cooperate. Citation Text: Mello MM, Armstrong S, Greenberg Y, et al. Challenges of Implementing a Communication-and-Resolution Program Where Multiple Organizations Must Cooperate. He…

  15. The association between patient safety indicators and medical malpractice risk: evidence from Florida and Texas. | PSNet

    psnet.ahrq.gov/issue/association-between-patient-safety-indicators-and-medical-malpractice-risk-evidence-florida
    September 28, 2022 - Study The association between patient safety indicators and medical malpractice risk: evidence from Florida and Texas. Citation Text: Black BS, Wagner AR, Zabinski Z. The Association between Patient Safety Indicators and Medical Malpractice Risk: Evidence from Florida and Texas. Am J Hea…

  16. Trends in medical and nonmedical use of prescription opioids among US adolescents: 1976–2015. | PSNet

    psnet.ahrq.gov/issue/trends-medical-and-nonmedical-use-prescription-opioids-among-us-adolescents-1976-2015
    January 23, 2019 - Study Trends in medical and nonmedical use of prescription opioids among US adolescents: 1976–2015. Citation Text: McCabe SE, West BT, Veliz P, et al. Trends in Medical and Nonmedical Use of Prescription Opioids Among US Adolescents: 1976-2015. Pediatrics. 2017;139(4):e20162387. doi:10.1…

  17. Conducting an efficient proactive risk assessment prior to CPOE implementation in an intensive care unit. | PSNet

    psnet.ahrq.gov/issue/conducting-efficient-proactive-risk-assessment-prior-cpoe-implementation-intensive-care-unit
    December 31, 2014 - Study Conducting an efficient proactive risk assessment prior to CPOE implementation in an intensive care unit. Citation Text: Hundt AS, Adams JA, Schmid A, et al. Conducting an efficient proactive risk assessment prior to CPOE implementation in an intensive care unit. Int J Med Inform…

  18. Defining speaking up in the healthcare system: a systematic review. | PSNet

    psnet.ahrq.gov/issue/defining-speaking-healthcare-system-systematic-review
    September 27, 2023 - Review Defining speaking up in the healthcare system: a systematic review. Citation Text: Kane J, Munn L, Kane SF, et al. Defining speaking up in the healthcare system: a systematic review. J Gen Intern Med. 2023;38(15):3406-3413. doi:10.1007/s11606-023-08322-0. Copy Citation Forma…

  19. Standardization and visualization of the surgical time-out. | PSNet

    psnet.ahrq.gov/issue/standardization-and-visualization-surgical-time-out
    November 06, 2024 - Study Standardization and visualization of the surgical time-out. Citation Text: Levy BE, Wilt WS, Lantz S, et al. Standardization and visualization of the surgical time-out. J Patient Saf. 2023;19(7):453-459. doi:10.1097/pts.0000000000001156. Copy Citation Format: DOI Goog…

  20. Coping with errors in the operating room: intraoperative strategies, postoperative strategies, and sex differences. | PSNet

    psnet.ahrq.gov/issue/coping-errors-operating-room-intraoperative-strategies-postoperative-strategies-and-sex
    September 09, 2020 - Study Coping with errors in the operating room: intraoperative strategies, postoperative strategies, and sex differences. Citation Text: D'Angelo JD, Lund S, Busch RA, et al. Coping with errors in the operating room: intraoperative strategies, postoperative strategies, and sex difference…
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