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  1. Five years after 'To Err is Human': what have we learned? | PSNet

    psnet.ahrq.gov/issue/five-years-after-err-human-what-have-we-learned
    March 18, 2019 - Commentary Classic Five years after 'To Err is Human': what have we learned? Citation Text: Leape L, Berwick DM. Five years after To Err Is Human: what have we learned? JAMA. 2005;293(19):2384-90. Copy Citation Format: Google Scholar PubMed BibTe…

  2. Development of trigger tools for surveillance of adverse events in ambulatory surgery. | PSNet

    psnet.ahrq.gov/issue/development-trigger-tools-surveillance-adverse-events-ambulatory-surgery
    October 01, 2014 - Study Development of trigger tools for surveillance of adverse events in ambulatory surgery. Citation Text: Kaafarani HMA, Rosen AK, Nebeker JR, et al. Development of trigger tools for surveillance of adverse events in ambulatory surgery. Qual Saf Health Care. 2010;19(5):425-9. doi:10.…

  3. Learning collaboratives: insights and a new taxonomy from AHRQ's two decades of experience. | PSNet

    psnet.ahrq.gov/issue/learning-collaboratives-insights-and-new-taxonomy-ahrqs-two-decades-experience
    April 27, 2019 - Commentary Emerging Classic Learning collaboratives: insights and a new taxonomy from AHRQ's two decades of experience. Citation Text: Nix M, McNamara P, Genevro J, et al. Learning Collaboratives: Insights And A New Taxonomy From AHRQ's Two Decades Of Experience…

  4. Clinical validation of the AHRQ postoperative venous thromboembolism patient safety indicator. | PSNet

    psnet.ahrq.gov/issue/clinical-validation-ahrq-postoperative-venous-thromboembolism-patient-safety-indicator
    September 25, 2011 - Study Clinical validation of the AHRQ postoperative venous thromboembolism patient safety indicator. Citation Text: Henderson KE, Recktenwald AJ, Reichley RM, et al. Clinical validation of the AHRQ postoperative venous thromboembolism patient safety indicator. Jt Comm J Qual Patient Saf.…

  5. Compliance to technical guidelines for radiotherapy treatment in relation to patient safety. | PSNet

    psnet.ahrq.gov/issue/compliance-technical-guidelines-radiotherapy-treatment-relation-patient-safety
    December 10, 2014 - Study Compliance to technical guidelines for radiotherapy treatment in relation to patient safety. Citation Text: Simons PAM, Houben RMA, Backes HH, et al. Compliance to technical guidelines for radiotherapy treatment in relation to patient safety. Int J Qual Health Care. 2010;22(3):18…

  6. Medication errors in an intensive care unit. | PSNet

    psnet.ahrq.gov/issue/medication-errors-intensive-care-unit
    October 12, 2022 - Study Medication errors in an intensive care unit. Citation Text: Bohomol E, Ramos LH, D'Innocenzo M. Medication errors in an intensive care unit. J Adv Nurs. 2009;65(6):1259-67. doi:10.1111/j.1365-2648.2009.04979.x. Copy Citation Format: DOI Google Scholar PubMed BibTeX …

  7. Successful implementation of standardized multidisciplinary bedside rounds, including daily goals, in a pediatric ICU. | PSNet

    psnet.ahrq.gov/issue/successful-implementation-standardized-multidisciplinary-bedside-rounds-including-daily-goals
    September 03, 2011 - Study Successful implementation of standardized multidisciplinary bedside rounds, including daily goals, in a pediatric ICU. Citation Text: Seigel J, Whalen L, Burgess E, et al. Successful implementation of standardized multidisciplinary bedside rounds, including daily goals, in a pediat…

  8. Healthcare Inspection—Emergency Department Patient Deaths: Memphis VAMC, Memphis, Tennessee. | PSNet

    psnet.ahrq.gov/issue/healthcare-inspection-emergency-department-patient-deaths-memphis-vamc-memphis-tennessee
    November 29, 2023 - Book/Report Healthcare Inspection—Emergency Department Patient Deaths: Memphis VAMC, Memphis, Tennessee. Citation Text: Healthcare Inspection—Emergency Department Patient Deaths: Memphis VAMC, Memphis, Tennessee. Washington, DC: Department of Veterans Affairs, Office of Inspector…

  9. Building collaborative teams in neonatal intensive care. | PSNet

    psnet.ahrq.gov/issue/building-collaborative-teams-neonatal-intensive-care
    August 14, 2019 - Study Building collaborative teams in neonatal intensive care. Citation Text: Brodsky D, Gupta M, Quinn M, et al. Building collaborative teams in neonatal intensive care. BMJ Qual Saf. 2013;22(5):374-82. doi:10.1136/bmjqs-2012-000909. Copy Citation Format: DOI Google Scho…

  10. Educational strategy to reduce medication errors in a neonatal intensive care unit. | PSNet

    psnet.ahrq.gov/issue/educational-strategy-reduce-medication-errors-neonatal-intensive-care-unit
    November 03, 2008 - Study Educational strategy to reduce medication errors in a neonatal intensive care unit. Citation Text: Campino A, Lopez-Herrera MC, Lopez-de-Heredia I, et al. Educational strategy to reduce medication errors in a neonatal intensive care unit. Acta Paediatr. 2009;98(5):782-5. doi:10.1…

  11. Improving code team performance and survival outcomes: implementation of pediatric resuscitation team training. | PSNet

    psnet.ahrq.gov/issue/improving-code-team-performance-and-survival-outcomes-implementation-pediatric-resuscitation
    February 03, 2011 - Study Improving code team performance and survival outcomes: implementation of pediatric resuscitation team training. Citation Text: Knight LJ, Gabhart JM, Earnest KS, et al. Improving code team performance and survival outcomes: implementation of pediatric resuscitation team training. C…

  12. Development and pilot evaluation of a preoperative briefing protocol for cardiovascular surgery. | PSNet

    psnet.ahrq.gov/issue/development-and-pilot-evaluation-preoperative-briefing-protocol-cardiovascular-surgery
    September 27, 2016 - Study Development and pilot evaluation of a preoperative briefing protocol for cardiovascular surgery. Citation Text: Henrickson SE, Wadhera RK, Elbardissi AW, et al. Development and pilot evaluation of a preoperative briefing protocol for cardiovascular surgery. J Am Coll Surg. 2009;20…

  13. Workplace team resilience: a systematic review and conceptual development. | PSNet

    psnet.ahrq.gov/issue/workplace-team-resilience-systematic-review-and-conceptual-development
    January 03, 2017 - Review Classic Workplace team resilience: a systematic review and conceptual development. Citation Text: Hartwig A, Clarke S, Johnson S, et al. Workplace team resilience: s systematic review and conceptual development. Org Psychol Rev. 2020;10(3-4):169-200. doi:…

  14. Patient safety informatics: meeting the challenges of emerging digital health. | PSNet

    psnet.ahrq.gov/issue/patient-safety-informatics-meeting-challenges-emerging-digital-health
    June 08, 2022 - Commentary Patient safety informatics: meeting the challenges of emerging digital health. Citation Text: McInerney C, Benn J, Dowding D, et al. Patient safety informatics: meeting the challenges of emerging digital health. Stud Health Technol Inform. 2022;290:364-368. doi:10.3233/shti220…

  15. Development and evaluation of an observational tool for assessing surgical flow disruptions and their impact on surgical performance. | PSNet

    psnet.ahrq.gov/issue/development-and-evaluation-observational-tool-assessing-surgical-flow-disruptions-and-their
    June 17, 2009 - Study Development and evaluation of an observational tool for assessing surgical flow disruptions and their impact on surgical performance. Citation Text: Parker SEH, Laviana AA, Wadhera RK, et al. Development and evaluation of an observational tool for assessing surgical flow disruption…

  16. Mindful workarounds in bar code medication administration. | PSNet

    psnet.ahrq.gov/issue/mindful-workarounds-bar-code-medication-administration
    July 20, 2022 - Commentary Mindful workarounds in bar code medication administration. Citation Text: Lichtner V, Dowding D. Mindful workarounds in bar code medication administration. Stud Health Technol Inform. 2022;294:740-744. doi:10.3233/shti220575. Copy Citation Format: DOI Google Scho…

  17. Comparison of a prototype for indications-based prescribing with 2 commercial prescribing systems. | PSNet

    psnet.ahrq.gov/issue/comparison-prototype-indications-based-prescribing-2-commercial-prescribing-systems
    June 05, 2018 - Study Comparison of a prototype for indications-based prescribing with 2 commercial prescribing systems. Citation Text: Garabedian PM, Wright A, Newbury I, et al. Comparison of a Prototype for Indications-Based Prescribing With 2 Commercial Prescribing Systems. JAMA Netw Open. 2019;2(3):…

  18. Outcomes after out-of-hospital endotracheal intubation errors. | PSNet

    psnet.ahrq.gov/issue/outcomes-after-out-hospital-endotracheal-intubation-errors
    July 20, 2010 - Study Outcomes after out-of-hospital endotracheal intubation errors. Citation Text: Wang HE, Cook LJ, Chang C-CH, et al. Outcomes after out-of-hospital endotracheal intubation errors. Resuscitation. 2009;80(1):50-5. doi:10.1016/j.resuscitation.2008.08.016. Copy Citation Format…

  19. Improving responses to safety incidents: we need to talk about justice. | PSNet

    psnet.ahrq.gov/issue/improving-responses-safety-incidents-we-need-talk-about-justice
    February 02, 2022 - Commentary Improving responses to safety incidents: we need to talk about justice. Citation Text: Cribb A, O'Hara JK, Waring J. Improving responses to safety incidents: we need to talk about justice. BMJ Qual Saf. 2022;31(4):327-330. doi:10.1136/bmjqs-2021-014333. Copy Citation For…

  20. Assessing distractors and teamwork during surgery: developing an event-based method for direct observation. | PSNet

    psnet.ahrq.gov/issue/assessing-distractors-and-teamwork-during-surgery-developing-event-based-method-direct
    February 19, 2020 - Study Assessing distractors and teamwork during surgery: developing an event-based method for direct observation. Citation Text: Seelandt JC, Tschan F, Keller S, et al. Assessing distractors and teamwork during surgery: developing an event-based method for direct observation. BMJ Qual Sa…
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