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psnet.ahrq.gov/issue/safety-overlapping-surgery-high-volume-referral-center
January 11, 2017 - Study
Classic
Safety of overlapping surgery at a high-volume referral center.
Citation Text:
Hyder JA, Hanson KT, Storlie CB, et al. Safety of Overlapping Surgery at a High-volume Referral Center. Ann Surg. 2017;265(4):639-644. doi:10.1097/SLA.0000000000002084. …
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psnet.ahrq.gov/issue/disparities-adverse-event-reporting-hospitalized-children
July 27, 2022 - Study
Disparities in adverse event reporting for hospitalized children.
Citation Text:
Halvorson EE, Thurtle DP, Easter A, et al. Disparities in adverse event reporting for hospitalized children. J Patient Saf. 2022;18(6):e928-e933. doi:10.1097/pts.0000000000001049.
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psnet.ahrq.gov/issue/multiple-failures-test-results-follow-patient-diagnosed-prostate-cancer-hampton-va-medical
July 26, 2023 - Book/Report
Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate Cancer at the Hampton VA Medical Center in Virginia.
Citation Text:
Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate Cancer at the Hampton VA Medical Center in V…
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psnet.ahrq.gov/issue/crossover-patient-satisfaction-surveys-adverse-events-and-patient-complaints-continuous
July 27, 2022 - Study
Crossover of the patient satisfaction surveys, adverse events and patient complaints for continuous improvement in radiotherapy department.
Citation Text:
Cucchiaro SÉ, Princen F, Goreux JË, et al. Crossover of the patient satisfaction surveys, adverse events and patient complaints…
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psnet.ahrq.gov/issue/deficiencies-community-care-network-credentialing-process-former-va-surgeon-and-veterans
November 29, 2023 - Book/Report
Deficiencies in the Community Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures.
Citation Text:
Deficiencies in the Community Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administra…
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psnet.ahrq.gov/issue/perioperative-covid-19-defense-evidence-based-approach-optimization-infection-control-and
November 30, 2012 - Commentary
Classic
Perioperative COVID-19 defense: an evidence-based approach for optimization of infection control and operating room management.
Citation Text:
Dexter F, Parra MC, Brown JR, et al. Perioperative COVID-19 defense: an evidence-based approach for …
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psnet.ahrq.gov/issue/inadequate-outpatient-mental-health-triage-and-care-patient-chico-community-based-outpatient
November 29, 2023 - Book/Report
Inadequate Outpatient Mental Health Triage and Care of a Patient at the Chico Community-Based Outpatient Clinic in California.
Citation Text:
Inadequate Outpatient Mental Health Triage and Care of a Patient at the Chico Community-Based Outpatient Clinic in California. Washing…
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psnet.ahrq.gov/issue/deficiencies-quality-management-processes-and-delays-communication-test-results-and-follow
March 01, 2023 - Book/Report
Deficiencies in Quality Management Processes and Delays in the Communication of Test Results and Follow-Up Care at the Phoenix VA Health Care System in Arizona.
Citation Text:
Deficiencies in Quality Management Processes and Delays in the Communication of Test Results and Fol…
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psnet.ahrq.gov/issue/patient-suicide-locked-mental-health-unit-west-palm-beach-va-medical-center-florida
January 24, 2024 - Book/Report
Patient Suicide on a Locked Mental Health Unit at the West Palm Beach VA Medical Center, Florida.
Citation Text:
Patient Suicide on a Locked Mental Health Unit at the West Palm Beach VA Medical Center, Florida. Washington, DC: Department of Veterans Affairs, Office of Inspect…
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psnet.ahrq.gov/issue/risks-complications-attending-physicians-after-performing-nighttime-procedures
February 14, 2018 - Study
Classic
Risks of complications by attending physicians after performing nighttime procedures.
Citation Text:
Rothschild JM. Risks of Complications by Attending Physicians After Performing Nighttime Procedures. JAMA. 2009;302(14):1565-1572. doi:10.1001/ja…
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psnet.ahrq.gov/issue/evaluation-quality-safety-and-value-veterans-health-administration-facilities-fy-2020
September 10, 2014 - Book/Report
Evaluation of Quality, Safety, and Value in Veterans Health Administration Facilities, FY 2020.
Citation Text:
Evaluation of Quality, Safety, and Value in Veterans Health Administration Facilities, FY 2020. Washington, DC: Veterans Affairs Office of Inspector General; August …
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psnet.ahrq.gov/issue/effect-us-drug-enforcement-administrations-rescheduling-hydrocodone-combination-analgesic
August 04, 2021 - Study
Effect of US Drug Enforcement Administration's rescheduling of hydrocodone combination analgesic products on opioid analgesic prescribing.
Citation Text:
Jones CM, Lurie PG, Throckmorton DC. Effect of US Drug Enforcement Administration's Rescheduling of Hydrocodone Combination Anal…
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psnet.ahrq.gov/issue/patient-safety-incidents-endoscopy-human-factors-analysis-non-procedural-significant-harm
January 29, 2020 - Study
Patient safety incidents in endoscopy: a human factors analysis of non-procedural significant harm incidents from the National Reporting and Learning System (NRLS).
Citation Text:
Ravindran S, Matharoo M, Rutter MD, et al. Patient safety incidents in endoscopy: a human factors anal…
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psnet.ahrq.gov/issue/do-house-officers-learn-their-mistakes
April 19, 2011 - Study
Classic
Do house officers learn from their mistakes?
Citation Text:
Wu AW, Folkman S, McPhee SJ, et al. Do house officers learn from their mistakes? JAMA. 1991;265(16):2089-94.
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psnet.ahrq.gov/issue/enculturation-unsafe-attitudes-and-behaviors-student-perceptions-safety-culture
October 31, 2012 - Study
Enculturation of unsafe attitudes and behaviors: student perceptions of safety culture.
Citation Text:
Bowman C, Neeman N, Sehgal NL. Enculturation of unsafe attitudes and behaviors: student perceptions of safety culture. Acad Med. 2013;88(6):802-10. doi:10.1097/ACM.0b013e31828fd4f…
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psnet.ahrq.gov/issue/lawrence-d-dorr-surgical-techniques-technologies-award-running-two-rooms-does-not-compromise
July 29, 2020 - Study
The Lawrence D. Dorr Surgical Techniques & Technologies Award: "Running two rooms" does not compromise outcomes or patient safety in joint arthroplasty.
Citation Text:
Hamilton WG, Ho H, Parks NL, et al. The Lawrence D. Dorr Surgical Techniques & Technologies Award: "Running Two Ro…
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psnet.ahrq.gov/issue/association-overlapping-surgery-patient-outcomes-large-series-neurosurgical-cases
November 16, 2022 - Study
Association of overlapping surgery with patient outcomes in a large series of neurosurgical cases.
Citation Text:
Howard BM, Holland CM, Mehta C, et al. Association of Overlapping Surgery With Patient Outcomes in a Large Series of Neurosurgical Cases. JAMA Surg. 2018;153(4):313-321…
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psnet.ahrq.gov/issue/ed-handoffs-observed-practices-and-communication-errors
October 19, 2022 - Study
ED handoffs: observed practices and communication errors.
Citation Text:
Maughan BC, Lei L, Cydulka RK. ED handoffs: observed practices and communication errors. Am J Emerg Med. 2011;29(5):502-11. doi:10.1016/j.ajem.2009.12.004.
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psnet.ahrq.gov/issue/specimen-labeling-errors-q-probes-analysis-147-clinical-laboratories
February 15, 2010 - Study
Specimen labeling errors: a Q-probes analysis of 147 clinical laboratories.
Citation Text:
Wagar EA, Stankovic AK, Raab SS, et al. Specimen labeling errors: a Q-probes analysis of 147 clinical laboratories. Arch Pathol Lab Med. 2008;132(10):1617-22. doi:10.1043/1543-2165(2008)…
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psnet.ahrq.gov/node/851389/psn-pdf
July 31, 2023 - communicate uncertainty, provide patient information on
the red-flag symptoms, and plan for future appointments … Working groups must be convened to establish a meeting schedule, design agendas, and conduct the
work … In January 2018, sending letters to patients yielded 12 scheduled appointments
and seven completed colonoscopies … .1 As efforts were ramped up and a phone call
to the patient was added, in August of 2018 scheduled appointments … By March 2019, using both outreach letters and calls
resulted in 113 scheduled appointments and 84 completed