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psnet.ahrq.gov/issue/human-error-not-communication-and-systems-underlies-surgical-complications
November 18, 2020 - Study
Human error, not communication and systems, underlies surgical complications.
Citation Text:
Fabri PJ, Zayas-Castro JL. Human error, not communication and systems, underlies surgical complications. Surgery. 2008;144(4):557-63; discussion 563-5. doi:10.1016/j.surg.2008.06.011.
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psnet.ahrq.gov/issue/medical-error-using-storytelling-and-reflection-impact-error-response-factors-family-medicine
June 05, 2019 - Study
Medical error: using storytelling and reflection to impact error response factors in family medicine residents.
Citation Text:
Adkins S, Alta’any R, Brar K, et al. Medical error: using storytelling and reflection to impact error response factors in family medicine residents. J Med …
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psnet.ahrq.gov/issue/active-surveillance-vaccine-safety-system-detect-early-signs-adverse-events
March 29, 2010 - Study
Active surveillance of vaccine safety: a system to detect early signs of adverse events.
Citation Text:
Davis RL, Kolczak M, Lewis E, et al. Active surveillance of vaccine safety: a system to detect early signs of adverse events. Epidemiology. 2005;16(3):336-41.
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psnet.ahrq.gov/issue/observational-analysis-surgical-team-compliance-perioperative-safety-practices-after-crew
May 04, 2012 - Study
An observational analysis of surgical team compliance with perioperative safety practices after crew resource management training.
Citation Text:
France DJ, Leming-Lee S, Jackson T, et al. An observational analysis of surgical team compliance with perioperative safety practices a…
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psnet.ahrq.gov/issue/crossing-communication-chasm-challenges-and-opportunities-transitions-care-hospital-primary
October 23, 2024 - Study
Crossing the communication chasm: challenges and opportunities in transitions of care from the hospital to the primary care clinic.
Citation Text:
Rattray NA, Sico JJ, Cox LAM, et al. Crossing the Communication Chasm: Challenges and Opportunities in Transitions of Care from the Hos…
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psnet.ahrq.gov/issue/evaluating-impact-radio-frequency-identification-retained-surgical-instruments-tracking
August 03, 2022 - Review
Evaluating the impact of radio frequency identification retained surgical instruments tracking on patient safety: literature review.
Citation Text:
Schnock KO, Biggs B, Fladger A, et al. Evaluating the impact of radio frequency identification retained surgical instruments tracking…
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psnet.ahrq.gov/issue/influence-stress-responses-surgical-performance-and-outcomes-literature-review-and
December 21, 2014 - Review
Emerging Classic
The influence of stress responses on surgical performance and outcomes: literature review and the development of the surgical stress effects (SSE) framework.
Citation Text:
Chrouser KL, Xu J, Hallbeck S, et al. The influence of stress res…
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psnet.ahrq.gov/issue/incidence-adverse-events-among-home-care-patients
December 04, 2015 - Study
The incidence of adverse events among home care patients.
Citation Text:
Sears NA, Baker R, Barnsley J, et al. The incidence of adverse events among home care patients. Int J Qual Health Care. 2013;25(1):16-28. doi:10.1093/intqhc/mzs075.
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psnet.ahrq.gov/issue/discrepancies-between-home-medications-listed-hospital-admission-and-reported-medical
November 03, 2021 - Study
Discrepancies between home medications listed at hospital admission and reported medical conditions.
Citation Text:
Slain D, Kincaid SE, Dunsworth TS. Discrepancies between home medications listed at hospital admission and reported medical conditions. Am J Geriatr Pharmacother.…
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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/diagnostic-accuracy-artificial-intelligence-based-automated-diabetic-retinopathy-screening
September 28, 2022 - Review
Diagnostic accuracy of artificial intelligence-based automated diabetic retinopathy screening in real-world settings: a systematic review and meta-analysis.
Citation Text:
Joseph S, Selvaraj J, Mani I, et al. Diagnostic accuracy of artificial intelligence-based automated diabetic …
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psnet.ahrq.gov/issue/innovative-approach-reconstruct-bedside-handoff-using-simple-rules-complexity-science-promote
November 16, 2022 - Commentary
Innovative approach to reconstruct bedside handoff: using simple rules of complexity science to promote partnership with patients.
Citation Text:
Anthony MK, Kloos J, Beam P, et al. Innovative Approach to Reconstruct Bedside Handoff: Using Simple Rules of Complexity Science to…
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psnet.ahrq.gov/issue/impact-computerized-physician-order-entry-medication-prescription-errors-intensive-care-unit
May 15, 2013 - Study
Impact of computerized physician order entry on medication prescription errors in the intensive care unit: a controlled cross-sectional trial.
Citation Text:
Colpaert K, Claus B, Somers A, et al. Impact of computerized physician order entry on medication prescription errors in th…
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www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module2/tools.html
March 01, 2017 - Examples of Technical and Adaptive Solutions for Change
AHRQ Safety Program for Long-Term Care: HAIs/CAUTI
Purpose: To provide senior leaders with a deeper explanation of technical and adaptive solutions for change
Who should use this tool? Senior leaders (long-term care facility administrator…
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psnet.ahrq.gov/issue/exploring-error-team-based-acute-care-scenarios-observational-study-united-kingdom
November 02, 2011 - Study
Exploring error in team-based acute care scenarios: an observational study from the United Kingdom.
Citation Text:
Tallentire VR, Smith SE, Skinner J, et al. Exploring error in team-based acute care scenarios: an observational study from the United kingdom. Acad Med. 2012;87(6):79…
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psnet.ahrq.gov/issue/no-safety-no-quality-synthesis-research-hospital-and-patient-safety-1996-2007
January 04, 2010 - Review
No safety, no quality: synthesis of research on hospital and patient safety (1996-2007).
Citation Text:
Tzeng H-M, Yin C-Y. No safety, no quality: synthesis of research on hospital and patient safety (1996-2007). J Nurs Care Qual. 2007;22(4):299-306.
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psnet.ahrq.gov/issue/establishing-multi-institutional-quality-and-patient-safety-consortium-collaboration-across
June 24, 2009 - Commentary
Establishing a multi-institutional quality and patient safety consortium: collaboration across affiliates in a community-based medical school.
Citation Text:
Hillman E, Paul J, Neustadt M, et al. Establishing a multi-institutional quality and patient safety consortium: collab…
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psnet.ahrq.gov/issue/what-driving-hospitals-patient-safety-efforts
February 10, 2015 - Commentary
What is driving hospitals' patient-safety efforts?
Citation Text:
Devers KJ, Pham HH, Liu G. What is driving hospitals' patient-safety efforts? Health Aff (Millwood). 2004;23(2):103-15.
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psnet.ahrq.gov/issue/building-framework-trust-critical-event-analysis-deaths-surgical-care
June 23, 2009 - Study
Building a framework for trust: critical event analysis of deaths in surgical care.
Citation Text:
Thompson A, Stonebridge PA. Building a framework for trust: critical event analysis of deaths in surgical care. BMJ. 2005;330(7500):1139-42.
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psnet.ahrq.gov/issue/addressing-systemic-racism-nursing-homes-time-action
November 18, 2020 - Commentary
Emerging Classic
Addressing systemic racism in nursing homes: a time for action.
Citation Text:
Sloane PD, Yearby R, Konetzka RT, et al. Addressing systemic racism in nursing homes: a time for action. J Am Med Dir Assoc. 2021;22(4):886-892. doi:10.101…