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psnet.ahrq.gov/issue/patient-participation-surgical-site-marking-can-be-additional-tool-help-avoid-wrong-site
March 14, 2022 - Study
Patient participation in surgical site marking: can this be an additional tool to help avoid wrong-site surgery?
Citation Text:
Bergal LM, Schwarzkopf R, Walsh M, et al. Patient participation in surgical site marking: can this be an additional tool to help avoid wrong-site surger…
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psnet.ahrq.gov/issue/double-checking-second-look
August 28, 2017 - Study
Double checking: a second look.
Citation Text:
Hewitt T, Chreim S, Forster AJ. Double checking: a second look. J Eval Clin Pract. 2016;22(2):267-74. doi:10.1111/jep.12468.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagg…
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psnet.ahrq.gov/issue/how-effective-teamwork-really-relationship-between-teamwork-and-performance-healthcare-teams
February 14, 2017 - Review
Classic
How effective is teamwork really? The relationship between teamwork and performance in healthcare teams: a systematic review and meta-analysis.
Citation Text:
Schmutz JB, Meier LL, Manser T. How effective is teamwork really? The relationship betwe…
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psnet.ahrq.gov/issue/how-active-resisters-and-organizational-constipators-affect-health-care-acquired-infection
September 15, 2010 - Study
How active resisters and organizational constipators affect health care–acquired infection prevention efforts.
Citation Text:
Saint S, Kowalski CP, Banaszak-Holl J, et al. How active resisters and organizational constipators affect health care-acquired infection prevention effort…
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psnet.ahrq.gov/issue/developing-conceptual-framework-patient-safety-culture-emergency-department-review-literature
March 02, 2011 - Review
Developing a conceptual framework for patient safety culture in emergency department: a review of the literature.
Citation Text:
Alshyyab MA, FitzGerald G, Dingle K, et al. Developing a conceptual framework for patient safety culture in emergency department: A review of the litera…
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psnet.ahrq.gov/issue/alarm-burden-and-nursing-care-environment-213-hospital-cross-sectional-study
October 25, 2023 - Study
Alarm burden and the nursing care environment: a 213-hospital cross-sectional study.
Citation Text:
Ruppel H, Dougherty M, Bonafide CP, et al. Alarm burden and the nursing care environment: a 213-hospital cross-sectional study. BMJ Open Qual. 2023;12(4):e002342. doi:10.1136/bmjoq-2…
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psnet.ahrq.gov/issue/patient-participation-current-knowledge-and-applicability-patient-safety
February 01, 2011 - Commentary
Classic
Patient participation: current knowledge and applicability to patient safety.
Citation Text:
Longtin Y, Sax H, Leape L, et al. Patient participation: current knowledge and applicability to patient safety. Mayo Clin Proc. 2010;85(1):53-62. doi:…
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psnet.ahrq.gov/issue/effect-multispecialty-faculty-handoff-initiative-safety-culture-and-handoff-quality
March 10, 2019 - Study
Effect of a multispecialty faculty handoff initiative on safety culture and handoff quality.
Citation Text:
Fitzgerald KM, Banerjee TR, Starmer AJ, et al. Effect of a multispecialty faculty handoff initiative on safety culture and handoff quality. Pediatr Qual Saf. 2022;7(2):e539. …
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psnet.ahrq.gov/issue/attending-physician-remote-access-electronic-health-record-and-implications-resident
September 22, 2010 - Study
Attending physician remote access of the electronic health record and implications for resident supervision: a mixed methods study.
Citation Text:
Martin SK, Tulla K, Meltzer DO, et al. Attending Physician Remote Access of the Electronic Health Record and Implications for Resident …
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psnet.ahrq.gov/issue/does-lean-management-improve-patient-safety-culture-extensive-evaluation-safety-culture
December 05, 2018 - Study
Does lean management improve patient safety culture? An extensive evaluation of safety culture in a radiotherapy institute.
Citation Text:
Simons P, Houben R, Vlayen A, et al. Does lean management improve patient safety culture? An extensive evaluation of safety culture in a radiot…
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psnet.ahrq.gov/issue/wisdom-and-justice-not-paying-preventable-complications
January 22, 2014 - Commentary
Classic
The wisdom and justice of not paying for "preventable complications."
Citation Text:
Pronovost P, Goeschel CA, Wachter R. The wisdom and justice of not paying for "preventable complications". JAMA. 2008;299(18):2197-9. doi:10.1001/jama.299.1…
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psnet.ahrq.gov/issue/interventions-reducing-wrong-site-surgery-and-invasive-procedures
September 07, 2011 - Review
Interventions for reducing wrong-site surgery and invasive procedures.
Citation Text:
Algie CM, Mahar RK, Wasiak J, et al. Interventions for reducing wrong-site surgery and invasive clinical procedures. Cochrane Database Syst Rev. 2015;3)(3):CD009404. doi:10.1002/14651858.CD009404…
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psnet.ahrq.gov/issue/perspectives-anesthesia-and-perioperative-patient-safety-past-present-and-future
June 19, 2019 - Commentary
Perspectives on anesthesia and perioperative patient safety: past, present, and future.
Citation Text:
Kanjia MK, Kurth CD, Hyman D, et al. Perspectives on anesthesia and perioperative patient safety: past, present, and future. Anesthesiology. 2024;141(5):835-848. doi:10.1097/…
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psnet.ahrq.gov/web-mm/discharged-blindly
October 26, 2022 - Discharged Blindly
Citation Text:
Iezzoni LI. Discharged Blindly. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/web-mm/amended-lab-results-communication-slip
September 26, 2012 - Amended Lab Results: Communication Slip
Citation Text:
Mohta V. Amended Lab Results: Communication Slip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/node/49574/psn-pdf
November 01, 2008 - A Mid-Summer Fog
November 1, 2008
Braddock CH. A Mid-Summer Fog. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/mid-summer-fog
The Case
A 33-year-old woman with type I diabetes mellitus was admitted for symptoms of left flank pain, dysuria,
and emesis, concerning for pyelonephritis. The patient was taking …
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psnet.ahrq.gov/node/49389/psn-pdf
February 01, 2003 - Procedural Mishap: Learning Curve?
February 1, 2003
Gibbs VC, Leape L. Procedural Mishap: Learning Curve? PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve
The Case
A 28-year-old multiparous obese female presented for laparoscopic tubal ligation. The patient had
undesired fert…
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psnet.ahrq.gov/node/33689/psn-pdf
October 01, 2009 - The Media: An Essential, If Sometimes Arbitrary,
Promoter of Patient Safety
October 1, 2009
Wachter R. The Media: An Essential, If Sometimes Arbitrary, Promoter of Patient Safety. PSNet [internet].
2009.
https://psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety
Perspective
…
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psnet.ahrq.gov/node/33621/psn-pdf
November 01, 2005 - Rapid Response Teams: Lessons from the Early
Experience
November 1, 2005
Krimsky WS. Rapid Response Teams: Lessons from the Early Experience. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/rapid-response-teams-lessons-early-experience
Perspective
Health care organizations throughout the world have ide…
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psnet.ahrq.gov/node/60168/psn-pdf
March 25, 2020 - Right Electrocardiogram, Wrong Patient
March 25, 2020
Chen C, Venugopal S. Right Electrocardiogram, Wrong Patient. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/right-electrocardiogram-wrong-patient
The Cases
Multiple electrocardiograms (EKGs) were incorrectly documented at a large urban tertiary care hosp…