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Strength of improvement recommendations from injurious fall investigations: a retrospective multi-incident analysis. | PSNet

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August 17, 2022 - Study Strength of improvement recommendations from injurious fall investigations: a retrospective multi-incident analysis. Citation Text: Paulik O, Hallen J, Lapkin S, et al. Strength of improvement recommendations from injurious fall investigations: a retrospective multi-incident analys…

Code debriefing from the Department of Veterans Affairs (VA) Medical Team Training Program improves the cardiopulmonary resuscitation code process. | PSNet

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August 18, 2010 - Study Code debriefing from the Department of Veterans Affairs (VA) Medical Team Training Program improves the cardiopulmonary resuscitation code process. Citation Text: Percarpio KB, Harris FS, Hatfield BA, et al. Code debriefing from the Department of Veterans Affairs (VA) Medical Tea…

Use of unit-based interventions to improve the quality of care for hospitalized medical patients: a national survey. | PSNet

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November 01, 2023 - Study Use of unit-based interventions to improve the quality of care for hospitalized medical patients: a national survey. Citation Text: O'Leary KJ, Johnson J, Manojlovich M, et al. Use of Unit-Based Interventions to Improve the Quality of Care for Hospitalized Medical Patients: A Natio…

Are surgeons and anesthesiologists lying to each other or gaming the system? A national random sample survey about "truth-telling practices" in the perioperative setting in the United States. | PSNet

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June 29, 2022 - Study Are surgeons and anesthesiologists lying to each other or gaming the system? A national random sample survey about "truth-telling practices" in the perioperative setting in the United States. Citation Text: Nurok M, Lee Y-Y, Ma Y, et al. Are surgeons and anesthesiologists lying to …

Performance of vascular exposure and fasciotomy among surgical residents before and after training compared with experts. | PSNet

psnet.ahrq.gov/issue/performance-vascular-exposure-and-fasciotomy-among-surgical-residents-and-after-training

November 20, 2019 - Study Performance of vascular exposure and fasciotomy among surgical residents before and after training compared with experts. Citation Text: Mackenzie CF, Garofalo E, Puche A, et al. Performance of Vascular Exposure and Fasciotomy Among Surgical Residents Before and After Training Comp…

Psychological safety and error reporting within Veterans Health Administration hospitals. | PSNet

psnet.ahrq.gov/issue/psychological-safety-and-error-reporting-within-veterans-health-administration-hospitals

November 24, 2021 - Study Psychological safety and error reporting within Veterans Health Administration hospitals. Citation Text: Derickson R, Fishman J, Osatuke K, et al. Psychological safety and error reporting within Veterans Health Administration hospitals. J Patient Saf. 2015;11(1):60-66. doi:10.1097/…

"Water cooler" learning: knowledge sharing at the clinical "backstage" and its contribution to patient safety. | PSNet

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January 29, 2014 - Study "Water cooler" learning: knowledge sharing at the clinical "backstage" and its contribution to patient safety. Citation Text: Waring J, Bishop S. "Water cooler" learning: knowledge sharing at the clinical "backstage" and its contribution to patient safety. J Health Organ Manag. 2…

Return on investment for a computerized physician order entry system. | PSNet

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January 19, 2014 - Study Classic Return on investment for a computerized physician order entry system. Citation Text: Kaushal R, Jha AK, Franz C, et al. Return on investment for a computerized physician order entry system. J Am Med Inform Assoc. 2006;13(3):261-6. Copy Citation…

Impact of contact isolation for multidrug-resistant organisms on the occurrence of medical errors and adverse events. | PSNet

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July 08, 2008 - Study Impact of contact isolation for multidrug-resistant organisms on the occurrence of medical errors and adverse events. Citation Text: Zahar JR, Garrouste-Orgeas M, Vesin A, et al. Impact of contact isolation for multidrug-resistant organisms on the occurrence of medical errors and…

Organizational culture, team climate and diabetes care in small office-based practices. | PSNet

psnet.ahrq.gov/issue/organizational-culture-team-climate-and-diabetes-care-small-office-based-practices

April 01, 2010 - Study Organizational culture, team climate and diabetes care in small office-based practices. Citation Text: Bosch M, Dijkstra R, Wensing M, et al. Organizational culture, team climate and diabetes care in small office-based practices. BMC Health Serv Res. 2008;8:180. doi:10.1186/1472-…

Reported clinical incidents of children with intellectual disability: a qualitative analysis. | PSNet

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March 16, 2022 - Study Reported clinical incidents of children with intellectual disability: a qualitative analysis. Citation Text: Ong N, Mimmo L, Barnett D, et al. Reported clinical incidents of children with intellectual disability: a qualitative analysis. Dev Med Child Neurol. 2022;64(11):1359-1365. …

Implementation of the surgical safety checklist in South Carolina hospitals is associated with improvement in perceived perioperative safety. | PSNet

psnet.ahrq.gov/issue/implementation-surgical-safety-checklist-south-carolina-hospitals-associated-improvement

June 02, 2015 - Study Implementation of the surgical safety checklist in South Carolina hospitals is associated with improvement in perceived perioperative safety. Citation Text: Molina G, Jiang W, Edmondson L, et al. Implementation of the Surgical Safety Checklist in South Carolina Hospitals Is Associa…

Systematic root cause analysis of adverse drug events in a tertiary referral hospital. | PSNet

psnet.ahrq.gov/issue/systematic-root-cause-analysis-adverse-drug-events-tertiary-referral-hospital

November 16, 2022 - Study Classic Systematic root cause analysis of adverse drug events in a tertiary referral hospital. Citation Text: Rex JH, Turnbull JE, Allen SJ, et al. Systematic Root Cause Analysis of Adverse Drug Events in a Tertiary Referral Hospital. Jt Comm J Qual Improv…

Differing perceptions of safety culture across job roles in the ambulatory setting: analysis of the AHRQ Medical Office Survey on Patient Safety Culture. | PSNet

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March 15, 2017 - Study Differing perceptions of safety culture across job roles in the ambulatory setting: analysis of the AHRQ Medical Office Survey on Patient Safety Culture. Citation Text: Hickner J, Smith SA, Yount N, et al. Differing perceptions of safety culture across job roles in the ambulatory s…

Evaluating inpatient mortality: a new electronic review process that gathers information from front-line providers. | PSNet

psnet.ahrq.gov/issue/evaluating-inpatient-mortality-new-electronic-review-process-gathers-information-front-line

February 18, 2011 - Study Evaluating inpatient mortality: a new electronic review process that gathers information from front-line providers. Citation Text: Provenzano A, Rohan S, Trevejo E, et al. Evaluating inpatient mortality: a new electronic review process that gathers information from front-line provi…

Disorganized care: the findings of an iterative, in-depth analysis of surgical morbidity and mortality. | PSNet

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October 19, 2022 - Study Disorganized care: the findings of an iterative, in-depth analysis of surgical morbidity and mortality. Citation Text: Anderson CI, Nelson CS, Graham CF, et al. Disorganized care: the findings of an iterative, in-depth analysis of surgical morbidity and mortality. J Surg Res. 201…

'I think we should just listen and get out': a qualitative exploration of views and experiences of Patient Safety Walkrounds. | PSNet

psnet.ahrq.gov/issue/i-think-we-should-just-listen-and-get-out-qualitative-exploration-views-and-experiences

June 22, 2022 - Study 'I think we should just listen and get out': a qualitative exploration of views and experiences of Patient Safety Walkrounds. Citation Text: Rotteau L, Shojania KG, Webster F. ‘I think we should just listen and get out’: a qualitative exploration of views and experiences of Patient…

Trigger alerts associated with laboratory abnormalities on identifying potentially preventable adverse drug events in the intensive care unit and general ward. | PSNet

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August 30, 2017 - Study Trigger alerts associated with laboratory abnormalities on identifying potentially preventable adverse drug events in the intensive care unit and general ward. Citation Text: Buckley MS, Rasmussen JR, Bikin DS, et al. Trigger alerts associated with laboratory abnormalities on ident…

Adverse event and complication tracking in anaesthesiology: dependence on self-reporting despite implementation of electronic health records. | PSNet

psnet.ahrq.gov/issue/adverse-event-and-complication-tracking-anaesthesiology-dependence-self-reporting-despite

March 17, 2021 - Commentary Adverse event and complication tracking in anaesthesiology: dependence on self-reporting despite implementation of electronic health records. Citation Text: Tewfik G, Naftalovich R, Kaushal N, et al. Adverse event and complication tracking in anaesthesiology: dependence on sel…

Delayed recognition of deterioration of patients in general wards is mostly caused by human related monitoring failures: a root cause analysis of unplanned ICU admissions. | PSNet

psnet.ahrq.gov/issue/delayed-recognition-deterioration-patients-general-wards-mostly-caused-human-related

December 21, 2017 - Study Delayed recognition of deterioration of patients in general wards is mostly caused by human related monitoring failures: a root cause analysis of unplanned ICU admissions. Citation Text: van Galen LS, Struik PW, Driesen BEJM, et al. Delayed Recognition of Deterioration of Patients …

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