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psnet.ahrq.gov/issue/didactic-and-simulation-nontechnical-skills-team-training-improve-perinatal-patient-outcomes
October 21, 2011 - Study
Didactic and simulation nontechnical skills team training to improve perinatal patient outcomes in a community hospital.
Citation Text:
Riley W, Davis SE, Miller KK, et al. Didactic and simulation nontechnical skills team training to improve perinatal patient outcomes in a commun…
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psnet.ahrq.gov/issue/what-we-can-do-about-maternal-mortality-and-how-do-it-quickly
September 01, 2016 - Commentary
Emerging Classic
What we can do about maternal mortality—and how to do it quickly.
Citation Text:
Mann S, Hollier LM, McKay K, et al. What We Can Do about Maternal Mortality - And How to Do It Quickly. New Engl J Med. 2018;379(18):1689-1691. doi:10.10…
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psnet.ahrq.gov/issue/integrated-approach-reduce-perinatal-adverse-events-standardized-processes-interdisciplinary
September 01, 2018 - Study
Integrated approach to reduce perinatal adverse events: standardized processes, interdisciplinary teamwork training, and performance feedback.
Citation Text:
Riley W, Begun JW, Meredith L, et al. Integrated Approach to Reduce Perinatal Adverse Events: Standardized Processes, Interd…
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psnet.ahrq.gov/issue/medication-regimen-complexity-and-hospital-readmission-adverse-drug-event
December 03, 2014 - Study
Medication regimen complexity and hospital readmission for an adverse drug event.
Citation Text:
Willson MN, Greer CL, Weeks DL. Medication regimen complexity and hospital readmission for an adverse drug event. Ann Pharmacother. 2014;48(1):26-32. doi:10.1177/1060028013510898.
C…
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psnet.ahrq.gov/issue/enhancing-patient-safety-during-pediatric-sedation-impact-simulation-based-training
January 17, 2012 - Study
Enhancing patient safety during pediatric sedation: the impact of simulation-based training of nonanesthesiologists.
Citation Text:
Shavit I, Keidan I, Hoffmann Y, et al. Enhancing patient safety during pediatric sedation: the impact of simulation-based training of nonanesthesiol…
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psnet.ahrq.gov/issue/mobile-situ-obstetric-emergency-simulation-and-teamwork-training-improve-maternal-fetal
July 09, 2008 - Study
Mobile in situ obstetric emergency simulation and teamwork training to improve maternal–fetal safety in hospitals.
Citation Text:
Guise J-M, Lowe NK, Deering S, et al. Mobile in situ obstetric emergency simulation and teamwork training to improve maternal-fetal safety in hospitals.…
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psnet.ahrq.gov/issue/using-situ-simulation-identify-and-resolve-latent-environmental-threats-patient-safety-case
April 17, 2011 - Commentary
Using in situ simulation to identify and resolve latent environmental threats to patient safety: case study involving a labor and delivery ward.
Citation Text:
Hamman WR, Beaudin-Seiler BM, Beaubien JM, et al. Using in situ simulation to identify and resolve latent environme…
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psnet.ahrq.gov/issue/impact-agency-healthcare-research-and-qualitys-safety-program-perinatal-care
April 04, 2018 - Study
Impact of the Agency for Healthcare Research and Quality's Safety Program for Perinatal Care.
Citation Text:
Kahwati LC, Sorensen A, Teixeira-Poit S, et al. Impact of the Agency for Healthcare Research and Quality's Safety Program for Perinatal Care. Jt Comm J Qual Patient Saf. 201…
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psnet.ahrq.gov/issue/simulation-exercises-patient-safety-strategy-systematic-review
March 13, 2013 - Review
Simulation exercises as a patient safety strategy: a systematic review.
Citation Text:
Schmidt E, Goldhaber-Fiebert SN, Ho LA, et al. Simulation exercises as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):426-32. doi:10.7326/0003-4819-158-5-2013…
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psnet.ahrq.gov/issue/examining-patient-safety-events-using-behaviour-change-wheel-cross-sectional-analysis
September 20, 2012 - Study
Examining patient safety events using the behaviour change wheel: a cross-sectional analysis.
Citation Text:
Somerville M, Cassidy C, MacPhee S, et al. Examining patient safety events using the behaviour change wheel: a cross-sectional analysis. Jt Comm J Qual Patient Saf. 2025;51(…
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psnet.ahrq.gov/issue/sustained-decrease-latent-safety-threats-through-regular-interprofessional-situ-simulation
June 15, 2016 - Study
Sustained decrease in latent safety threats through regular interprofessional in situ simulation training of neonatal emergencies.
Citation Text:
Mileder LP, Schwaberger B, Baik-Schneditz N, et al. Sustained decrease in latent safety threats through regular interprofessional in sit…
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psnet.ahrq.gov/node/865373/psn-pdf
March 27, 2024 - We
often think of drift in the sense of new types of patients entering into the system, but drift can
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psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery
March 25, 2020 - When transcutaneous pacing pads are used, OR staff need to verify that the pads sense the ECG so that
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psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
July 01, 2011 - that any existing (nonacute) medical conditions require no attention, potentially creating a false sense
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psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_hindsight_is_2020_slides_final_revised_05.03.2024.pdf
January 01, 2024 - The accuracy of the olfactory sense in detecting alcohol intoxication in trauma patients Emerg Med J.
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psnet.ahrq.gov/perspective/conversation-withsanjay-saint-md-mph
November 01, 2008 - So, there was a sense anecdotally that the physicians weren't aware that the catheter was present.
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psnet.ahrq.gov/perspective/health-plan-patient-safety-initiatives
July 10, 2024 - Sarah Mossburg: That makes sense, and then considering what are the potential adverse events associated
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psnet.ahrq.gov/perspective/conversation-withamy-helwig-about-health-plan-patient-safety-initiatives
July 10, 2024 - Sarah Mossburg: That makes sense, and then considering what are the potential adverse events associated
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psnet.ahrq.gov/web-mm/case-mistaken-capacity-why-thorough-psychosocial-history-can-improve-care
July 08, 2022 - Routine evaluations in both inpatient and outpatient settings are important to gather a sense of the
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psnet.ahrq.gov/perspective/patient-safety-frail-older-patients
November 26, 2019 - our falls prevention work with our safe mobility and safe patient handling work because it just makes sense