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psnet.ahrq.gov/issue/applying-fault-tree-analysis-prevention-wrong-site-surgery
September 09, 2015 - Review
Applying fault tree analysis to the prevention of wrong-site surgery.
Citation Text:
Abecassis ZA, McElroy LM, Patel RM, et al. Applying fault tree analysis to the prevention of wrong-site surgery. J Surg Res. 2015;193(1):88-94. doi:10.1016/j.jss.2014.08.062.
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psnet.ahrq.gov/issue/time-motion-study-pediatric-emergency-department-and-after-computer-physician-order-entry
October 19, 2022 - Study
Time motion study in a pediatric emergency department before and after computer physician order entry.
Citation Text:
Yen K, Shane EL, Pawar SS, et al. Time motion study in a pediatric emergency department before and after computer physician order entry. Ann Emerg Med. 2009;53(4)…
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psnet.ahrq.gov/issue/evolution-procedural-competency-internal-medicine-training
December 15, 2021 - Commentary
The evolution of procedural competency in internal medicine training.
Citation Text:
Sacks CA, Alba GA, Miloslavsky EM. The Evolution of Procedural Competency in Internal Medicine Training. JAMA Intern Med. 2017;177(12):1713-1714. doi:10.1001/jamainternmed.2017.5014.
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psnet.ahrq.gov/issue/letter-health-care-providers-safe-use-surgical-staplers-and-staples
October 20, 2021 - Press Release/Announcement
Letter to Health Care Providers: Safe Use of Surgical Staplers and Staples.
Citation Text:
Letter to Health Care Providers: Safe Use of Surgical Staplers and Staples. US Food and Drug Administration. October 7, 2021.
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psnet.ahrq.gov/issue/equipment-related-incidents-operating-room-analysis-occurrence-underlying-causes-and
February 14, 2024 - Study
Equipment-related incidents in the operating room: an analysis of occurrence, underlying causes and consequences for the clinical process.
Citation Text:
Wubben I, van Manen JG, van den Akker BJ, et al. Equipment-related incidents in the operating room: an analysis of occurrence,…
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psnet.ahrq.gov/issue/root-cause-analysis-transfusion-error-identifying-causes-implement-changes
August 15, 2018 - Commentary
Root cause analysis of transfusion error: identifying causes to implement changes.
Citation Text:
Elhence P, Veena S, Sharma RK, et al. Root cause analysis of transfusion error: identifying causes to implement changes. Transfusion (Paris). 2010;50(12 Pt 2):2772-2777. doi:10.…
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psnet.ahrq.gov/issue/systematic-review-application-plan-do-study-act-method-improve-quality-healthcare
May 01, 2019 - Review
Systematic review of the application of the plan-do-study-act method to improve quality in healthcare.
Citation Text:
Taylor MJ, McNicholas C, Nicolay C, et al. Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Qual Saf. 2…
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psnet.ahrq.gov/issue/minimising-treatment-associated-risks-systemic-cancer-therapy
December 22, 2021 - Review
Minimising treatment-associated risks in systemic cancer therapy.
Citation Text:
Jaehde U, Liekweg A, Simons S, et al. Minimising treatment-associated risks in systemic cancer therapy. Pharm World Sci. 2008;30(2):161-8.
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psnet.ahrq.gov/issue/changes-physician-practice-patterns-after-implementation-communication-and-resolution-program
September 01, 2018 - Study
Changes in physician practice patterns after implementation of a communication-and-resolution program.
Citation Text:
Helmchen LA, Lambert BL, McDonald TB. Changes in Physician Practice Patterns after Implementation of a Communication-and-Resolution Program. Health Serv Res. 2016;5…
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psnet.ahrq.gov/issue/continuous-monitoring-adverse-events-influence-quality-care-and-incidence-errors-general
March 09, 2022 - Study
Continuous monitoring of adverse events: influence on the quality of care and the incidence of errors in general surgery.
Citation Text:
Rebasa P, Mora L, Luna A, et al. Continuous monitoring of adverse events: influence on the quality of care and the incidence of errors in gener…
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psnet.ahrq.gov/issue/use-standard-design-medication-room-promote-medication-safety-organizational-implications
July 27, 2022 - Study
The use of a standard design medication room to promote medication safety: organizational implications.
Citation Text:
Rozenbaum H, Gordon L, Brezis M, et al. The use of a standard design medication room to promote medication safety: organizational implications. Int J Qual Health C…
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psnet.ahrq.gov/issue/harm-hope-and-purposeful-action-what-could-we-do-after-francis
August 01, 2016 - Commentary
From harm to hope and purposeful action: what could we do after Francis?
Citation Text:
Woodhead T, Lachman P, Mountford J, et al. From harm to hope and purposeful action: what could we do after Francis? BMJ Qual Saf. 2014;23(8):619-23. doi:10.1136/bmjqs-2013-002581.
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psnet.ahrq.gov/issue/end-beginning-patient-safety-five-years-after-err-human
March 02, 2011 - Commentary
Classic
The end of the beginning: patient safety five years after 'To Err Is Human.'
Citation Text:
Wachter RM. The End Of The Beginning: Patient Safety Five Years After ‘To Err Is Human’. Health Aff. 2004;23(Suppl1). doi:10.1377/hlthaff.w4.534.
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digital.ahrq.gov/sites/default/files/docs/page/2006Cauley_051311comp.pdf
June 16, 2021 - The Next Generation of RHIOs: Health Information Exchange Through Common Shared Record
The Next Generation of RHIOs:
Health Information Exchange
Through Common Shared Record
Presented by
Kate Cauley, PhD, Director Center for Healthy Communities
Boonshoft School of Medicine
Wright State University, Dayton, Ohio…
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psnet.ahrq.gov/issue/role-safety-culture-influencing-provider-perceptions-patient-safety
November 09, 2016 - Study
The role of safety culture in influencing provider perceptions of patient safety.
Citation Text:
Bishop A, Boyle TA. The Role of Safety Culture in Influencing Provider Perceptions of Patient Safety. J Patient Saf. 2016;12(4):204-209.
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psnet.ahrq.gov/issue/optimizing-situation-awareness-reduce-emergency-transfers-hospitalized-children
January 19, 2022 - Study
Optimizing situation awareness to reduce emergency transfers in hospitalized children.
Citation Text:
Sosa T, Sitterding M, Dewan M, et al. Optimizing situation awareness to reduce emergency transfers in hospitalized children. Pediatrics. 2021;148(4):e2020034603. doi:10.1542/peds.2…
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psnet.ahrq.gov/issue/interventions-increase-clinical-incident-reporting-health-care
September 02, 2009 - Review
Interventions to increase clinical incident reporting in health care.
Citation Text:
Parmelli E, Flodgren G, Fraser SG, et al. Interventions to increase clinical incident reporting in health care. Cochrane Database Syst Rev. 2012;8(8):CD005609. doi:10.1002/14651858.cd005609.pub2…
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psnet.ahrq.gov/issue/disparities-diagnostic-timeliness-and-outcomes-pediatric-appendicitis
September 13, 2023 - Study
Disparities in diagnostic timeliness and outcomes of pediatric appendicitis.
Citation Text:
Michelson KA, Bachur RG, Rangel SJ, et al. Disparities in diagnostic timeliness and outcomes of pediatric appendicitis. JAMA Netw Open. 2024;7(1):e2353667. doi:10.1001/jamanetworkopen.2023.5…
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psnet.ahrq.gov/issue/comparison-adverse-events-during-procedural-sedation-between-specially-trained-pediatric
August 21, 2008 - Study
Comparison of adverse events during procedural sedation between specially trained pediatric residents and pediatric emergency physicians in Israel.
Citation Text:
Shavit I, Steiner IP, Idelman S, et al. Comparison of adverse events during procedural sedation between specially tra…
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psnet.ahrq.gov/issue/pediatric-crisis-resource-management-training-improves-emergency-medicine-trainees-perceived
March 25, 2020 - Study
Pediatric crisis resource management training improves emergency medicine trainees' perceived ability to manage emergencies and ability to identify teamwork errors.
Citation Text:
Bank I, Snell L, Bhanji F. Pediatric crisis resource management training improves emergency medicine t…