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psnet.ahrq.gov/issue/how-communication-among-members-health-care-team-affects-maternal-morbidity-and-mortality
November 12, 2014 - Commentary
How communication among members of the health care team affects maternal morbidity and mortality.
Citation Text:
Brennan RA, Keohane CA. How Communication Among Members of the Health Care Team Affects Maternal Morbidity and Mortality. J Obstet Gynecol Neonatal Nurs. 2016;45(6)…
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psnet.ahrq.gov/issue/role-clinical-learning-environments-preparing-new-clinicians-engage-patient-safety
November 18, 2020 - Book/Report
The Role of Clinical Learning Environments in Preparing New Clinicians to Engage in Patient Safety.
Citation Text:
The Role of Clinical Learning Environments in Preparing New Clinicians to Engage in Patient Safety. Disch J, Kilo CM, Passiment M, Wagner R, Weiss KB; National C…
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psnet.ahrq.gov/issue/piece-my-mind-despite-my-best-intentions
September 13, 2016 - Commentary
A piece of my mind. Despite my best intentions.
Citation Text:
Kahn JS. Despite My Best Intentions. JAMA. 2017;318(17). doi:10.1001/jama.2017.6123.
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psnet.ahrq.gov/issue/wrong-site-surgery-near-misses-and-actual-occurrences
November 30, 2012 - Study
Wrong site surgery near misses and actual occurrences.
Citation Text:
Blanco M, Clarke JR, Martindell D. Wrong site surgery near misses and actual occurrences. AORN J. 2009;90(2):215-8, 221-2. doi:10.1016/j.aorn.2009.07.010.
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psnet.ahrq.gov/issue/learning-health-care-system-using-computer-aided-diagnosis
May 08, 2017 - Commentary
A learning health care system using computer-aided diagnosis.
Citation Text:
Cahan A, Cimino JJ. A Learning Health Care System Using Computer-Aided Diagnosis. J Med Internet Res. 2017;19(3):e54. doi:10.2196/jmir.6663.
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psnet.ahrq.gov/issue/closing-disclosure-gap-medical-errors-pediatrics
March 30, 2022 - Review
Closing the disclosure gap: medical errors in pediatrics.
Citation Text:
Lin M, Famiglietti H. Closing the Disclosure Gap: Medical Errors in Pediatrics. Pediatrics. 2019;143(4). doi:10.1542/peds.2019-0221.
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psnet.ahrq.gov/issue/prevention-fall-related-injuries-long-term-care-randomized-controlled-trial-staff-education
February 17, 2011 - Study
Prevention of fall-related injuries in long-term care: a randomized controlled trial of staff education.
Citation Text:
Ray WA, Taylor JA, Brown AK, et al. Prevention of fall-related injuries in long-term care: a randomized controlled trial of staff education. Arch Intern Med. 20…
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psnet.ahrq.gov/issue/why-dont-nurses-consistently-take-patient-respiratory-rates
October 10, 2012 - Study
Why don't nurses consistently take patient respiratory rates?
Citation Text:
Ansell H, Meyer A, Thompson S. Why don't nurses consistently take patient respiratory rates? Br J Nurs. 2014;23(8):414-8.
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psnet.ahrq.gov/issue/am-i-unsafe-here-chemotherapy-patients-perspectives-towards-engaging-their-safety
February 01, 2011 - Study
Am I (un)safe here? Chemotherapy patients' perspectives towards engaging in their safety.
Citation Text:
Schwappach DLB, Wernli M. Am I (un)safe here? Chemotherapy patients' perspectives towards engaging in their safety. BMJ Qual Saf. 2010;19(5). doi:10.1136/qshc.2009.033118.
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psnet.ahrq.gov/issue/how-use-article-about-quality-improvement
August 03, 2010 - Commentary
How to use an article about quality improvement.
Citation Text:
Fan E, Laupacis A, Pronovost P, et al. How to use an article about quality improvement. JAMA. 2010;304(20):2279-87. doi:10.1001/jama.2010.1692.
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psnet.ahrq.gov/issue/debriefing-medical-teams-12-evidence-based-best-practices-and-tips
February 15, 2011 - Commentary
Debriefing medical teams: 12 evidence-based best practices and tips.
Citation Text:
Salas E, Klein C, King HB, et al. Debriefing medical teams: 12 evidence-based best practices and tips. Jt Comm J Qual Patient Saf. 2008;34(9):518-527.
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psnet.ahrq.gov/issue/first-year-who-surgical-safety-checklist-7148-otorhinolaryngological-operations-use-and-user
October 30, 2019 - Study
First year with WHO Surgical Safety Checklist in 7148 otorhinolaryngological operations: use and user attitudes.
Citation Text:
Helmiö P, Takala A, Aaltonen L-M, et al. First year with WHO Surgical Safety Checklist in 7148 otorhinolaryngological operations: use and user attitudes…
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psnet.ahrq.gov/issue/observational-study-direct-oral-anticoagulant-awareness-indicating-inadequate-recognition
April 24, 2018 - Study
An observational study of direct oral anticoagulant awareness indicating inadequate recognition with potential for patient harm.
Citation Text:
Olaiya A, Lurie B, Watt B, et al. An observational study of direct oral anticoagulant awareness indicating inadequate recognition with pot…
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psnet.ahrq.gov/issue/patient-safety-obstetrics-and-obstetric-anesthesia
August 04, 2021 - Review
Patient safety in obstetrics and obstetric anesthesia.
Citation Text:
Kung A, Pratt SD. Patient safety in obstetrics and obstetric anesthesia. Int Anesthesiol Clin. 2014;52(2):86-110. doi:10.1097/AIA.0000000000000017.
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psnet.ahrq.gov/issue/navigating-towards-improved-surgical-safety-using-aviation-based-strategies
January 04, 2011 - Review
Navigating towards improved surgical safety using aviation-based strategies.
Citation Text:
Kao LS, Thomas EJ. Navigating towards improved surgical safety using aviation-based strategies. J Surg Res. 2008;145(2):327-35.
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psnet.ahrq.gov/issue/conducting-root-cause-analysis-nursing-students-best-practice-nursing-education
September 09, 2015 - Commentary
Conducting root cause analysis with nursing students: best practice in nursing education.
Citation Text:
Lambton J, Mahlmeister L. Conducting root cause analysis with nursing students: best practice in nursing education. J Nurs Educ. 2010;49(8):444-8. doi:10.3928/01484834-…
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psnet.ahrq.gov/issue/clinical-impact-associated-corrected-results-clinical-microbiology-testing
December 03, 2008 - Study
Clinical impact associated with corrected results in clinical microbiology testing.
Citation Text:
Yuan S, Astion ML, Schapiro J, et al. Clinical impact associated with corrected results in clinical microbiology testing. J Clin Microbiol. 2005;43(5):2188-93.
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psnet.ahrq.gov/issue/effects-critical-care-nurses-work-hours-vigilance-and-patients-safety
February 19, 2010 - Study
Effects of critical care nurses' work hours on vigilance and patients' safety.
Citation Text:
Scott LD, Rogers AE, Hwang W-T, et al. Effects of critical care nurses' work hours on vigilance and patients' safety. Am J Crit Care. 2006;15(1):30-7.
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psnet.ahrq.gov/issue/incorporating-indications-medication-ordering-time-enter-age-reason
June 05, 2018 - Commentary
Incorporating indications into medication ordering—time to enter the age of reason.
Citation Text:
Schiff G, Seoane-Vazquez E, Wright A. Incorporating Indications into Medication Ordering--Time to Enter the Age of Reason. N Engl J Med. 2016;375(4):306-9. doi:10.1056/NEJMp16039…
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psnet.ahrq.gov/web-mm/stable-airway-fatal-airway-occlusion-after-inadequate-post-tracheostomy-care
June 28, 2023 - SPOTLIGHT CASE
A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care
Citation Text:
Gould E, Craddock K, Le Tellier T, et al. A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research…