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psnet.ahrq.gov/issue/fall-risk-and-prevention-agreement-engaging-patients-and-families-partnership-patient-safety
November 13, 2024 - Commentary
Fall risk and prevention agreement: engaging patients and families with a partnership for patient safety.
Citation Text:
Vonnes C, Wolf D. Fall risk and prevention agreement: engaging patients and families with a partnership for patient safety. BMJ Open Qual. 2017;6(2):e000038…
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psnet.ahrq.gov/node/33590/psn-pdf
September 15, 2024 - intervention by hospital
leadership for clinicians who display recurrent unprofessional behavior or are the subject
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psnet.ahrq.gov/node/33571/psn-pdf
March 15, 2025 - Event reports are subject
to selection bias due to their voluntary nature.
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psnet.ahrq.gov/issue/competent-surgeon-individual-accountability-era-systems-failure
May 30, 2014 - Commentary
The competent surgeon: individual accountability in the era of "systems" failure.
Citation Text:
Whittemore A. The competent surgeon: individual accountability in the era of "systems" failure. Ann Surg. 2009;250(3):357-62. doi:10.1097/SLA.0b013e3181b28c93.
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…
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psnet.ahrq.gov/node/852698/psn-pdf
August 30, 2023 - The results of the review and suggested
system improvement opportunities are then presented to subject … The results of the review and any recommended system improvements are then presented to
subject matter
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psnet.ahrq.gov/issue/key-potentially-inappropriate-drugs-pediatrics-kids-list
September 23, 2020 - Study
Emerging Classic
Key potentially inappropriate drugs in pediatrics: the KIDs list.
Citation Text:
Meyers RS, Thackray J, Matson KL, et al. Key potentially inappropriate drugs in pediatrics: the KIDs list. J Pediatr Pharmacol Ther. 2020;25(3). doi:10.5863/1…
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psnet.ahrq.gov/issue/evaluating-effect-distractions-operating-room-clinical-decision-making-and-patient-safety
November 16, 2022 - Study
Evaluating the effect of distractions in the operating room on clinical decision-making and patient safety.
Citation Text:
Murji A, Luketic L, Sobel ML, et al. Evaluating the effect of distractions in the operating room on clinical decision-making and patient safety. Surg Endosc. 2…
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psnet.ahrq.gov/issue/measure-twice-cut-once
June 14, 2023 - Commentary
Measure twice, cut once.
Citation Text:
Atkinson WK. Measure twice, cut once. AORN J. 2013;98(1):77-80. doi:10.1016/j.aorn.2013.05.004.
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Format:
DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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psnet.ahrq.gov/issue/partnering-pediatric-patients-and-families-high-reliability-identify-and-reduce-preventable
December 02, 2020 - Commentary
Partnering with pediatric patients and families in high reliability to identify and reduce preventable safety events.
Citation Text:
Partnering with pediatric patients and families in high reliability to identify and reduce preventable safety events. Kirby J, Cannon C, Darrah …
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psnet.ahrq.gov/issue/systematic-review-effectiveness-compliance-and-critical-factors-implementation-safety
December 04, 2024 - Review
A systematic review of the effectiveness, compliance, and critical factors for implementation of safety checklists in surgery.
Citation Text:
Borchard A, Schwappach DLB, Barbir A, et al. A systematic review of the effectiveness, compliance, and critical factors for implementatio…
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psnet.ahrq.gov/issue/night-and-day-shedding-light-hours-care
September 28, 2010 - Commentary
Like night and day — shedding light on off-hours care.
Citation Text:
Shulkin DJ. Like night and day--shedding light on off-hours care. N Engl J Med. 2008;358(20):2091-3. doi:10.1056/NEJMp0707144.
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Format:
DOI Google Scholar PubMed BibTeX EndNote X…
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psnet.ahrq.gov/issue/implementing-aorn-recommended-practices-prevention-retained-surgical-items
January 05, 2017 - Commentary
Implementing AORN recommended practices for prevention of retained surgical items.
Citation Text:
Goldberg JL, Feldman DL. Implementing AORN recommended practices for prevention of retained surgical items. AORN J. 2012;95(2):205-16; quiz 217-9. doi:10.1016/j.aorn.2011.11.010…
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psnet.ahrq.gov/issue/overdiagnosis-coronary-artery-disease-detected-coronary-computed-tomography-angiography
March 03, 2011 - Commentary
Overdiagnosis of coronary artery disease detected by coronary computed tomography angiography: a teachable moment.
Citation Text:
Schmidt T, Maag R, Foy AJ. Overdiagnosis of Coronary Artery Disease Detected by Coronary Computed Tomography Angiography: A Teachable Moment. JAMA …
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psnet.ahrq.gov/issue/crisis-resource-management-evaluating-outcomes-multidisciplinary-team
December 23, 2011 - Study
Crisis resource management: evaluating outcomes of a multidisciplinary team.
Citation Text:
Jankouskas T, Bush MC, Murray B, et al. Crisis resource management: evaluating outcomes of a multidisciplinary team. Simul Healthc. 2007;2(2):96-101. doi:10.1097/SIH.0b013e31805d8b0d.
Co…
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psnet.ahrq.gov/node/49608/psn-pdf
August 01, 2010 - triage accuracy, it is not the complete
answer, since many judgments remain subjective and thereby subject
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psnet.ahrq.gov/node/49513/psn-pdf
July 01, 2006 - endorsed guidelines for safe
transport of this patient population, nor any peer-reviewed article on the subject … transport tends to "fall between the cracks" of divisions, departments, and
providers, it has been the subject
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psnet.ahrq.gov/issue/reviewing-deaths-british-and-us-hospitals-study-two-scales-assessing-preventability
April 03, 2019 - Study
Reviewing deaths in British and US hospitals: a study of two scales for assessing preventability.
Citation Text:
Manaseki-Holland S, Lilford RJ, Bishop JRB, et al. Reviewing deaths in British and US hospitals: a study of two scales for assessing preventability. BMJ Qual Saf. 2017;2…
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psnet.ahrq.gov/issue/low-perfusion-and-missed-diagnosis-hypoxemia-pulse-oximetry-darkly-pigmented-skin-prospective
March 14, 2022 - Study
Low perfusion and missed diagnosis of hypoxemia by pulse oximetry in darkly pigmented skin: a prospective study.
Citation Text:
Gudelunas MK, Lipnick M, Hendrickson C, et al. Low perfusion and missed diagnosis of hypoxemia by pulse oximetry in darkly pigmented skin: a prospective s…
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psnet.ahrq.gov/issue/associations-between-hospitalist-shift-busyness-diagnostic-confidence-and-resource
September 16, 2020 - Study
Associations between hospitalist shift busyness, diagnostic confidence, and resource utilization: a pilot study.
Citation Text:
Gupta AB, Greene MT, Fowler KE, et al. Associations between hospitalist shift busyness, diagnostic confidence, and resource utilization: a pilot study. J …
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psnet.ahrq.gov/issue/impact-independent-chemotherapy-prescribing-advanced-practice-providers-patient-safety-and
November 16, 2022 - Study
The impact of independent chemotherapy prescribing by advanced practice providers on patient safety and clinician satisfaction.
Citation Text:
LeStrange N, Walton AM, Watson JL, et al. The impact of independent chemotherapy prescribing by advanced practice providers on patient safe…