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How incident reporting systems can stimulate social and participative learning: a mixed-methods study. | PSNet

psnet.ahrq.gov/issue/how-incident-reporting-systems-can-stimulate-social-and-participative-learning-mixed-methods

November 04, 2020 - Study How incident reporting systems can stimulate social and participative learning: a mixed-methods study. Citation Text: de Kam D, Kok J, Grit K, et al. How incident reporting systems can stimulate social and participative learning: a mixed-methods study. Health Policy (New York). 202…

NHS ‘Learning from Deaths’ reports: a qualitative and quantitative document analysis of the first year of a countrywide patient safety programme. | PSNet

psnet.ahrq.gov/issue/nhs-learning-deaths-reports-qualitative-and-quantitative-document-analysis-first-year

February 22, 2023 - Study NHS ‘Learning from Deaths’ reports: a qualitative and quantitative document analysis of the first year of a countrywide patient safety programme. Citation Text: Brummell Z, Vindrola-Padros C, Braun D, et al. NHS ‘Learning from Deaths’ reports: a qualitative and quantitative documen…

Work effort, readability and quality of pharmacy transcription of patient directions from electronic prescriptions: a retrospective observational cohort analysis. | PSNet

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June 29, 2022 - Study Work effort, readability and quality of pharmacy transcription of patient directions from electronic prescriptions: a retrospective observational cohort analysis. Citation Text: Zheng Y, Jiang Y, Dorsch MP, et al. Work effort, readability and quality of pharmacy transcription of pa…

Effect of cognitive aids on adherence to best practice in the treatment of deteriorating surgical patients: a randomized clinical trial in a simulation setting. | PSNet

psnet.ahrq.gov/issue/effect-cognitive-aids-adherence-best-practice-treatment-deteriorating-surgical-patients

September 30, 2020 - Study Effect of cognitive aids on adherence to best practice in the treatment of deteriorating surgical patients: a randomized clinical trial in a simulation setting. Citation Text: Koers L, van Haperen M, Meijer CGF, et al. Effect of Cognitive Aids on Adherence to Best Practice in the T…

Physician burnout, well-being, and work unit safety grades in relationship to reported medical errors. | PSNet

psnet.ahrq.gov/issue/physician-burnout-well-being-and-work-unit-safety-grades-relationship-reported-medical-errors

June 01, 2022 - Study Classic Physician burnout, well-being, and work unit safety grades in relationship to reported medical errors. Citation Text: Tawfik DS, Profit J, Morgenthaler TI, et al. Physician Burnout, Well-being, and Work Unit Safety Grades in Relationship to Reporte…

25-Year summary of US malpractice claims for diagnostic errors 1986–2010: an analysis from the National Practitioner Data Bank. | PSNet

psnet.ahrq.gov/issue/25-year-summary-us-malpractice-claims-diagnostic-errors-1986-2010-analysis-national

July 17, 2019 - Study 25-Year summary of US malpractice claims for diagnostic errors 1986–2010: an analysis from the National Practitioner Data Bank. Citation Text: Tehrani ASS, Lee HW, Mathews SC, et al. 25-Year summary of US malpractice claims for diagnostic errors 1986-2010: an analysis from the N…

Nurse's Achilles Heel: using big data to determine workload factors that impact near misses. | PSNet

psnet.ahrq.gov/issue/nurses-achilles-heel-using-big-data-determine-workload-factors-impact-near-misses

July 28, 2021 - Study Nurse's Achilles Heel: using big data to determine workload factors that impact near misses. Citation Text: Campbell AA, Harlan T, Campbell M, et al. Nurse's Achilles Heel: using big data to determine workload factors that impact near misses. J Nurs Scholarsh. 2021;53(3):333-342. d…

Early death after discharge from emergency departments: analysis of national US insurance claims data. | PSNet

psnet.ahrq.gov/issue/early-death-after-discharge-emergency-departments-analysis-national-us-insurance-claims-data

June 25, 2018 - Study Classic Early death after discharge from emergency departments: analysis of national US insurance claims data. Citation Text: Obermeyer Z, Cohn B, Wilson M, et al. Early death after discharge from emergency departments: analysis of national US insurance cl…

Underlying reasons associated with hospital readmission following surgery in the United States. | PSNet

psnet.ahrq.gov/issue/underlying-reasons-associated-hospital-readmission-following-surgery-united-states

May 06, 2020 - Study Classic Underlying reasons associated with hospital readmission following surgery in the United States. Citation Text: Merkow RP, Ju MH, Chung JW, et al. Underlying reasons associated with hospital readmission following surgery in the United States. JAMA. …

Surgical case listing accuracy: failure analysis at a high-volume academic medical center. | PSNet

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September 25, 2011 - Study Surgical case listing accuracy: failure analysis at a high-volume academic medical center. Citation Text: Cima RR, Hale C, Kollengode A, et al. Surgical case listing accuracy: failure analysis at a high-volume academic medical center. Arch Surg. 2010;145(7):641-6. doi:10.1001/archs…

Role-modeling and medical error disclosure: a national survey of trainees. | PSNet

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December 21, 2017 - Study Role-modeling and medical error disclosure: a national survey of trainees. Citation Text: Martinez W, Hickson GB, Miller BM, et al. Role-modeling and medical error disclosure: a national survey of trainees. Acad Med. 2014;89(3):482-9. doi:10.1097/ACM.0000000000000156. Copy Citati…

Differential safety between top-ranked cancer hospitals and their affiliates for complex cancer surgery. | PSNet

psnet.ahrq.gov/issue/differential-safety-between-top-ranked-cancer-hospitals-and-their-affiliates-complex-cancer

July 24, 2019 - Study Differential safety between top-ranked cancer hospitals and their affiliates for complex cancer surgery. Citation Text: Hoag JR, Resio BJ, Monsalve AF, et al. Differential Safety Between Top-Ranked Cancer Hospitals and Their Affiliates for Complex Cancer Surgery. JAMA Netw Open. 20…

Improving detection of intraoperative medical errors (iMEs) and intraoperative adverse events (iAEs) and their contribution to postoperative outcomes. | PSNet

psnet.ahrq.gov/issue/improving-detection-intraoperative-medical-errors-imes-and-intraoperative-adverse-events-iaes

June 04, 2014 - Study Improving detection of intraoperative medical errors (iMEs) and intraoperative adverse events (iAEs) and their contribution to postoperative outcomes. Citation Text: Chen Q, Rosen AK, Amirfarzan H, et al. Improving detection of intraoperative medical errors (iMEs) and intraoperativ…

Detection of postoperative respiratory failure: how predictive is the Agency for Healthcare Research and Quality's Patient Safety Indicator? | PSNet

psnet.ahrq.gov/issue/detection-postoperative-respiratory-failure-how-predictive-agency-healthcare-research-and

January 13, 2010 - Study Detection of postoperative respiratory failure: how predictive is the Agency for Healthcare Research and Quality's Patient Safety Indicator? Citation Text: Utter GH, Cuny J, Sama P, et al. Detection of postoperative respiratory failure: how predictive is the Agency for Healthcare…

Exploring the association between organizational culture and large-scale adverse events: evidence from the Veterans Health Administration. | PSNet

psnet.ahrq.gov/issue/exploring-association-between-organizational-culture-and-large-scale-adverse-events-evidence

August 18, 2021 - Study Exploring the association between organizational culture and large-scale adverse events: evidence from the Veterans Health Administration. Citation Text: George J, Elwy AR, Charns MP, et al. Exploring the Association Between Organizational Culture and Large-Scale Adverse Events: Ev…

Floating to intensive care units: nurses' messages for instant action to promote patient safety. | PSNet

psnet.ahrq.gov/issue/floating-intensive-care-units-nurses-messages-instant-action-promote-patient-safety

August 15, 2018 - Study Floating to intensive care units: nurses' messages for instant action to promote patient safety. Citation Text: Ahmed FR, Timmins F, Dias JM, et al. Floating to intensive care units: nurses' messages for instant action to promote patient safety. Nurs Crit Care. 2023;28(6):902-912. …

Does nurse use of a standardized flowsheet to document communication with advanced providers provide a mechanism to detect pulse oximetry failures? A retrospective study of electronic health record data. | PSNet

psnet.ahrq.gov/issue/does-nurse-use-standardized-flowsheet-document-communication-advanced-providers-provide

June 22, 2022 - Study Does nurse use of a standardized flowsheet to document communication with advanced providers provide a mechanism to detect pulse oximetry failures? A retrospective study of electronic health record data. Citation Text: Gleason KT, Tran A, Fawzy A, et al. Does nurse use of a standar…

Improving the Working Environment for Safe Surgical Care. | PSNet

psnet.ahrq.gov/issue/improving-working-environment-safe-surgical-care

July 29, 2015 - Book/Report Improving the Working Environment for Safe Surgical Care. Citation Text: Improving the Working Environment for Safe Surgical Care. Short-Life Working Group on Hospital Reports. Edinburgh, Scotland: Royal College of Surgeons of Edinburgh; July 31, 2017. Copy Citation …

Situational Awareness and Patient Safety: A Learning Package. | PSNet

psnet.ahrq.gov/issue/situational-awareness-and-patient-safety-learning-package

September 13, 2017 - Book/Report Situational Awareness and Patient Safety: A Learning Package. Citation Text: Situational Awareness and Patient Safety: A Learning Package. Parush A, Campbell C, Hunter A, et al. Ottawa, Ontario: The Royal College of Physicians and Surgeons of Canada; 2011. ISBN: 9781926588100…

Optimal Resources for Surgical Quality and Safety. | PSNet

psnet.ahrq.gov/issue/optimal-resources-surgical-quality-and-safety

September 29, 2017 - Book/Report Optimal Resources for Surgical Quality and Safety. Citation Text: Optimal Resources for Surgical Quality and Safety. Hoyt DB, Ko CY, eds. Chicago, IL: American College of Surgeons; 2017. ISBN: 9780996826242. Copy Citation Save Save to your library …

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