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psnet.ahrq.gov/issue/adverse-events-and-near-miss-reporting-nhs
August 30, 2023 - Study
Adverse events and near miss reporting in the NHS.
Citation Text:
Shaw R. Adverse events and near miss reporting in the NHS. Quality and Safety in Health Care. 2005;14(4). doi:10.1136/qshc.2004.010553.
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psnet.ahrq.gov/issue/zero-preventable-deaths-after-traumatic-injury-achievable-goal
March 24, 2021 - Commentary
Zero preventable deaths after traumatic injury: an achievable goal.
Citation Text:
Spinella PC. Zero preventable deaths after traumatic injury. J Trauma Acute Care Surg. 2017;82:S2-S8. doi:10.1097/ta.0000000000001425.
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psnet.ahrq.gov/issue/complying-acgme-resident-duty-hours-restrictions-restructuring-80-hour-workweek-enhance
August 04, 2021 - Study
Complying with ACGME resident duty hours restrictions: restructuring the 80-hour workweek to enhance education and patient safety at Texas A&M/Scott & White Memorial Hospital.
Citation Text:
Ogden PE, Sibbitt S, Howell M, et al. Complying with ACGME resident duty hours restrictio…
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psnet.ahrq.gov/issue/adopting-system-models-multiple-incident-analysis-utility-and-usability
May 19, 2021 - Study
Adopting system models for multiple incident analysis: utility and usability.
Citation Text:
Wheway JL, Jun GT. Adopting systems models for multiple incident analysis: utility and usability. Int J Qual Health Care. 2021;33(4):mzab135. doi:10.1093/intqhc/mzab135.
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psnet.ahrq.gov/issue/consequences-running-more-operating-theatres-anaesthetists-staff-them-stochastic-simulation
October 19, 2022 - Study
Consequences of running more operating theatres than anaesthetists to staff them: a stochastic simulation study.
Citation Text:
Paoletti X, Marty J. Consequences of running more operating theatres than anaesthetists to staff them: a stochastic simulation study. Br J Anaesth. 2007…
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psnet.ahrq.gov/issue/health-literacy-medication-errors-and-health-outcomes-there-relationship
January 02, 2008 - Review
Health literacy, medication errors, and health outcomes: is there a relationship?
Citation Text:
Warner A, Menachemi N, Brooks RG. Health Literacy, Medication Errors, and Health Outcomes: Is There a Relationship? Hosp Pharm. 2010;41(6):542-551. doi:10.1310/hpj4106-538.
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psnet.ahrq.gov/issue/examining-effects-obstetrics-interprofessional-programme-reductions-reportable-events-and
August 04, 2021 - Study
Examining the effects of an obstetrics interprofessional programme on reductions to reportable events and their related costs.
Citation Text:
Geary M, Ruiter PJA, Yasseen AS. Examining the effects of an obstetrics interprofessional programme on reductions to reportable events and t…
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psnet.ahrq.gov/issue/determinants-adverse-events-hospitals-potential-role-patient-safety-culture
October 22, 2008 - Study
Determinants of adverse events in hospitals—the potential role of patient safety culture.
Citation Text:
Kline TJB, Willness C, Ghali WA. Determinants of adverse events in hospitals--the potential role of patient safety culture. J Healthc Qual. 2008;30(1):11-7.
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psnet.ahrq.gov/issue/omitted-and-unjustified-medications-discharge-summary
May 18, 2022 - Study
Omitted and unjustified medications in the discharge summary.
Citation Text:
Perren A, Previsdomini M, Cerutti B, et al. Omitted and unjustified medications in the discharge summary. Qual Saf Health Care. 2009;18(3):205-8. doi:10.1136/qshc.2007.024588.
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psnet.ahrq.gov/issue/human-factors-engineering-tool-medical-device-evaluation-hospital-procurement-decision-making
June 28, 2017 - Study
Human factors engineering: a tool for medical device evaluation in hospital procurement decision-making.
Citation Text:
Ginsburg G. Human factors engineering: a tool for medical device evaluation in hospital procurement decision-making. J Biomed Inform. 2005;38(3):213-9.
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psnet.ahrq.gov/issue/shifting-and-sharing-academic-physicians-strategies-navigating-underperformance-and-failure
August 21, 2019 - Study
Shifting and sharing: academic physicians' strategies for navigating underperformance and failure.
Citation Text:
LaDonna KA, Ginsburg S, Watling C. Shifting and Sharing: Academic Physicians' Strategies for Navigating Underperformance and Failure. Acad Med. 2018;93(11):1713-1718. d…
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psnet.ahrq.gov/issue/maximizing-student-potential-lessons-pharmacy-programs-patient-safety-movement
October 23, 2024 - Commentary
Maximizing student potential: lessons for pharmacy programs from the patient safety movement.
Citation Text:
Abebe E, Bao A, Kokkinias P, et al. Maximizing student potential: lessons for pharmacy programs from the patient safety movement. Explor Res Clin Soc Pharm. 2023;9:1002…
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psnet.ahrq.gov/issue/reconcilable-differences-correcting-medication-errors-hospital-admission-and-discharge
February 13, 2019 - Study
Reconcilable differences: correcting medication errors at hospital admission and discharge.
Citation Text:
Vira T, Colquhoun M, Etchells E. Reconcilable differences: correcting medication errors at hospital admission and discharge. Qual Saf Health Care. 2006;15(2):122-6.
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psnet.ahrq.gov/issue/weaving-quality-improvement-and-patient-safety-skills-all-levels-medical-training-annotated
August 09, 2023 - Review
Weaving quality improvement and patient safety skills into all levels of medical training: an annotated bibliography.
Citation Text:
Mochan E, Nash DB. Weaving quality improvement and patient safety skills into all levels of medical training: an annotated bibliography. Am J Med Qu…
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psnet.ahrq.gov/issue/methods-increase-reliability-quality-improvement-projects
October 20, 2021 - Commentary
Methods to increase reliability in quality improvement projects.
Citation Text:
Lenk MA, LaMantia S, Oehler J, et al. Methods to increase reliability in quality improvement projects. Hosp Pediatr. 2024;14(8):e372-e377. doi:10.1542/hpeds.2023-007340.
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psnet.ahrq.gov/issue/risk-factors-patient-safety-minimally-invasive-surgery-versus-conventional-surgery
August 10, 2016 - Study
Risk factors in patient safety: minimally invasive surgery versus conventional surgery.
Citation Text:
Rodrigues SP, Wever AM, Dankelman J, et al. Risk factors in patient safety: minimally invasive surgery versus conventional surgery. Surg Endosc. 2012;26(2):350-6. doi:10.1007/s0…
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psnet.ahrq.gov/issue/improving-patient-safety-older-people-acute-admissions-implementation-frailsafe-checklist-12
February 20, 2016 - Study
Improving patient safety for older people in acute admissions: implementation of the Frailsafe checklist in 12 hospitals across the UK.
Citation Text:
Papoutsi C, Poots A, Clements J, et al. Improving patient safety for older people in acute admissions: implementation of the Frails…
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psnet.ahrq.gov/issue/safety-standards-implementing-fall-prevention-interventions-and-sustaining-lower-fall-rates
July 12, 2018 - Commentary
Safety standards: implementing fall prevention interventions and sustaining lower fall rates by promoting the culture of safety on an inpatient rehabilitation unit.
Citation Text:
Leone RM, Adams RJ. Safety Standards: Implementing Fall Prevention Interventions and Sustaining L…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.68_slideshow.ppt
July 01, 2004 - Misuse
Eighteen hours after infusion, the patient developed severe bleeding and hemodynamic instability requiring
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.122_slideshow.ppt
April 01, 2006 - Over the next 10 minutes, the child’s cardiovascular status deteriorated, requiring epinephrine.