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psnet.ahrq.gov/issue/miscount-incidents-novel-approach-exploring-risk-factors-unintentionally-retained-surgical
June 11, 2014 - Study
Miscount incidents: a novel approach to exploring risk factors for unintentionally retained surgical items.
Citation Text:
Judson TJ, Howell MD, Guglielmi C, et al. Miscount incidents: a novel approach to exploring risk factors for unintentionally retained surgical items. Jt Comm…
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digital.ahrq.gov/sites/default/files/docs/survey/document-workflow-assessment-guide-hospital.pdf
January 26, 2009 - Document Workflow Assessment Guide - Hospital
Document Workflow Assessment Guide: Hospital
HealthInsight, Salt Lake City UT
This is an interview guide designed to be conducted with staff in an inpatient setting. The
tool includes questions to assess user's needs of health information exchange.
Permission has been…
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psnet.ahrq.gov/issue/etiology-diagnostic-errors-controlled-trial-system-1-versus-system-2-reasoning
July 02, 2014 - Study
The etiology of diagnostic errors: a controlled trial of System 1 versus System 2 reasoning.
Citation Text:
Norman GR, Sherbino J, Dore KL, et al. The etiology of diagnostic errors: a controlled trial of system 1 versus system 2 reasoning. Acad Med. 2014;89(2):277-84. doi:10.1097…
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psnet.ahrq.gov/issue/patient-safety-and-ethical-implications-healthcare-sick-leave-policies-pandemic-era
September 16, 2020 - Commentary
Patient safety and ethical implications of healthcare sick leave policies in the pandemic era.
Citation Text:
Preston-Suni K, Celedon MA, Cordasco KM. Patient safety and ethical implications of healthcare sick leave policies in the pandemic era. Jt Comm J Qual Patient Saf. 202…
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psnet.ahrq.gov/issue/piece-my-mind-hard-times-and-hard-stops
December 11, 2024 - Commentary
A piece of my mind. Hard times and hard stops.
Citation Text:
Lifflander AL. Hard Times and Hard Stops. JAMA. 2019;321(9):837-838. doi:10.1001/jama.2019.1208.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMe…
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psnet.ahrq.gov/issue/human-factors-analysis-classification-system-hfacs-applied-health-care
November 16, 2022 - Study
The Human Factors Analysis Classification System (HFACS) applied to health care.
Citation Text:
Diller T, Helmrich G, Dunning S, et al. The Human Factors Analysis Classification System (HFACS) applied to health care. Am J Med Qual. 2014;29(3):181-190. doi:10.1177/1062860613491623. …
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psnet.ahrq.gov/issue/root-cause-analysis-swatting-mosquitoes-versus-draining-swamp
January 31, 2024 - Commentary
Root-cause analysis: swatting at mosquitoes versus draining the swamp.
Citation Text:
Trbovich PL, Shojania KG. Root-cause analysis: swatting at mosquitoes versus draining the swamp. BMJ Qual Saf. 2017;26(5):350-353. doi:10.1136/bmjqs-2016-006229.
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psnet.ahrq.gov/issue/case-outcomes-communication-and-resolution-program-new-york-hospitals
February 05, 2014 - Study
Case outcomes in a communication-and-resolution program in New York hospitals.
Citation Text:
Mello MM, Greenberg Y, Senecal SK, et al. Case Outcomes in a Communication-and-Resolution Program in New York Hospitals. Health Serv Res. 2016;51 Suppl 3:2583-2599. doi:10.1111/1475-6773.1…
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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…
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psnet.ahrq.gov/issue/exploring-emergency-physician-hospitalist-handoff-interactions-development-handoff
December 19, 2011 - Study
Exploring emergency physician–hospitalist handoff interactions: development of the Handoff Communication Assessment.
Citation Text:
Apker J, Mallak LA, Applegate B, et al. Exploring emergency physician-hospitalist handoff interactions: development of the Handoff Communication Ass…
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psnet.ahrq.gov/issue/heparin-containing-medical-devices-and-combination-products-recommendations-labeling-and
November 23, 2015 - Regulation
Heparin-containing medical devices and combination products: recommendations for labeling and safety testing. Draft guidance for industry and Food and Drug Administration staff.
Citation Text:
Heparin-containing medical devices and combination products: recommendations for lab…
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psnet.ahrq.gov/issue/request-comments-proposed-measures-and-2020-targets-national-action-plan-adverse-drug-event
October 21, 2016 - Press Release/Announcement
Request for comments on the proposed measures and 2020 targets for the National Action Plan for Adverse Drug Event Prevention: inpatient and outpatient measures for reduction of adverse drug events from anticoagulants, diabetes agents, and opioid analgesics.
Cita…
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psnet.ahrq.gov/issue/safer-care-improving-caregiver-comprehension-discharge-instructions
October 26, 2022 - Study
SAFER Care: improving caregiver comprehension of discharge instructions.
Citation Text:
Uong A, Philips K, Hametz P, et al. SAFER care: improving caregiver comprehension of discharge instructions. Pediatrics. 2021;147(4):e20200031. doi:10.1542/peds.2020-0031.
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psnet.ahrq.gov/issue/defining-incidence-cardiorespiratory-instability-patients-step-down-units-using-electronic
September 04, 2013 - Study
Defining the incidence of cardiorespiratory instability in patients in step-down units using an electronic integrated monitoring system.
Citation Text:
Hravnak M, Edwards L, Clontz A, et al. Defining the incidence of cardiorespiratory instability in patients in step-down units us…
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psnet.ahrq.gov/issue/classification-failures-perception-conversational-agents-cas-and-their-implications-patient
July 06, 2022 - Study
Classification of failures in the perception of conversational agents (CAs) and their implications on patient safety.
Citation Text:
Aftab H, Shah SHH, Habli I. Classification of failures in the perception of conversational agents (CAs) and their implications on patient safety. Stu…
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psnet.ahrq.gov/issue/situ-simulation-method-experiential-learning-promote-safety-and-team-behavior
September 03, 2011 - Commentary
In situ simulation: a method of experiential learning to promote safety and team behavior.
Citation Text:
Miller KK, Riley W, Davis SE, et al. In situ simulation: a method of experiential learning to promote safety and team behavior. J Perinat Neonatal Nurs. 2008;22(2):105-1…
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psnet.ahrq.gov/issue/quality-improvement-initiative-reduce-safety-events-among-adolescents-hospitalized-after
July 22, 2020 - Study
A quality improvement initiative to reduce safety events among adolescents hospitalized after a suicide attempt.
Citation Text:
Noelck M, Velazquez-Campbell M, Austin JP. A Quality Improvement Initiative to Reduce Safety Events Among Adolescents Hospitalized After a Suicide Attempt…
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psnet.ahrq.gov/issue/speak-addressing-paradox-plaguing-patient-centered-care
October 17, 2018 - Commentary
Speak up! Addressing the paradox plaguing patient-centered care.
Citation Text:
Mazor KM, Smith KM, Fisher K, et al. Speak Up! Addressing the Paradox Plaguing Patient-Centered Care. Ann Intern Med. 2016;164(9):618-9. doi:10.7326/M15-2416.
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psnet.ahrq.gov/issue/disclosing-adverse-events-patients-international-norms-and-trends
July 29, 2020 - Study
Disclosing adverse events to patients: international norms and trends.
Citation Text:
Wu AW, McCay L, Levinson W, et al. Disclosing Adverse Events to Patients: International Norms and Trends. J Patient Saf. 2017;13(1):43-49. doi:10.1097/PTS.0000000000000107.
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psnet.ahrq.gov/issue/friends-and-family-test-qualitative-study-concerns-influence-willingness-english-national
May 01, 2015 - Study
The friends and family test: a qualitative study of concerns that influence the willingness of English National Health Service staff to recommend their organisation.
Citation Text:
Dixon-Woods M, Minion JT, McKee L, et al. The friends and family test: a qualitative study of concern…