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psnet.ahrq.gov/node/33777/psn-pdf
January 01, 2015 - Innovation and Lean Thinking: Mutually Supportive
Partners in the Transformation of Health Care
January 1, 2015
Plsek PE. Innovation and Lean Thinking: Mutually Supportive Partners in the Transformation of Health
Care. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/innovation-and-lean-thinking-mutually…
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psnet.ahrq.gov/node/49602/psn-pdf
April 01, 2010 - Anticoagulation: Held Too Long
April 1, 2010
Dunn AS. Anticoagulation: Held Too Long. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/anticoagulation-held-too-long
The Case
A 68-year-old woman with a history of mitral valve replacement with a mechanical valve was admitted with
abdominal pain. Because of the…
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psnet.ahrq.gov/issue/surgeon-second-victim-results-boston-intraoperative-adverse-events-surgeons-attitude-bisa
January 23, 2017 - Study
The surgeon as the second victim? Results of the Boston Intraoperative Adverse Events Surgeons' Attitude (BISA) study.
Citation Text:
Han K, Bohnen JD, Peponis T, et al. The surgeon as the second victim? Results of the Boston Intraoperative Adverse Events Surgeons' Attitude (BISA) …
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psnet.ahrq.gov/issue/what-has-airbus-a380-captain-got-do-omfs-lessons-aviation-improve-patient-safety
October 04, 2023 - Commentary
What has an Airbus A380 captain got to do with OMFS? Lessons from aviation to improve patient safety.
Citation Text:
Davidson M, Brennan PA. Leading article: What has an Airbus A380 Captain got to do with OMFS? Lessons from aviation to improve patient safety. Br J Oral Maxillo…
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psnet.ahrq.gov/issue/development-and-pilot-evaluation-preoperative-briefing-protocol-cardiovascular-surgery
September 27, 2016 - Study
Development and pilot evaluation of a preoperative briefing protocol for cardiovascular surgery.
Citation Text:
Henrickson SE, Wadhera RK, Elbardissi AW, et al. Development and pilot evaluation of a preoperative briefing protocol for cardiovascular surgery. J Am Coll Surg. 2009;20…
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psnet.ahrq.gov/issue/surgical-never-events-and-contributing-human-factors
August 20, 2018 - Study
Classic
Surgical never events and contributing human factors.
Citation Text:
Thiels CA, Lal TM, Nienow JM, et al. Surgical never events and contributing human factors. Surgery. 2015;158(2):515-21. doi:10.1016/j.surg.2015.03.053.
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psnet.ahrq.gov/issue/near-miss-events-are-really-missed-reflections-incident-reporting-department-pediatric
March 08, 2023 - Study
Near-miss events are really missed! Reflections on incident reporting in a department of pediatric surgery.
Citation Text:
Mattioli G, Guida E, Montobbio G, et al. Near-miss events are really missed! Reflections on incident reporting in a department of pediatric surgery. Pediatr …
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psnet.ahrq.gov/issue/sustaining-teamwork-behaviors-through-reinforcement-teamstepps-principles
September 02, 2015 - Study
Sustaining teamwork behaviors through reinforcement of TeamSTEPPS principles.
Citation Text:
Lee S-H, Khanuja HS, Blanding RJ, et al. Sustaining Teamwork Behaviors Through Reinforcement of TeamSTEPPS Principles. J Patient Saf. 2021;17(7):e582-e586. doi:10.1097/pts.0000000000000414.…
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psnet.ahrq.gov/issue/clinical-handover-critically-ill-postoperative-patient-integrative-review
March 23, 2016 - Review
Clinical handover of the critically ill postoperative patient: an integrative review.
Citation Text:
Gardiner TM, Marshall AP, Gillespie BM. Clinical handover of the critically ill postoperative patient: an integrative review. Aust Crit Care. 2015;28(4):226-34. doi:10.1016/j.aucc.…
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psnet.ahrq.gov/issue/surgical-specimen-identification-errors-new-measure-quality-surgical-care
June 16, 2011 - Study
Surgical specimen identification errors: a new measure of quality in surgical care.
Citation Text:
Makary MA, Epstein J, Pronovost P, et al. Surgical specimen identification errors: a new measure of quality in surgical care. Surgery. 2007;141(4):450-5.
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psnet.ahrq.gov/issue/multistep-approach-improving-biopsy-site-identification-dermatology-physician-staff-and
October 12, 2022 - Study
A multistep approach to improving biopsy site identification in dermatology: physician, staff, and patient roles based on a Delphi consensus.
Citation Text:
Alam M, Lee A, Ibrahimi OA, et al. A multistep approach to improving biopsy site identification in dermatology: physician, st…
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psnet.ahrq.gov/issue/exclusion-residents-surgery-intensive-care-team-communication-qualitative-study
December 04, 2015 - Study
Exclusion of residents from surgery-intensive care team communication: a qualitative study.
Citation Text:
Conn LG, Haas B, Rubenfeld GD, et al. Exclusion of Residents From Surgery-Intensive Care Team Communication: A Qualitative Study. J Surg Educ. 2016;73(4):639-47. doi:10.1016/j…
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psnet.ahrq.gov/issue/getting-teams-talk-development-and-pilot-implementation-checklist-promote-interprofessional
April 06, 2011 - Study
Getting teams to talk: development and pilot implementation of a checklist to promote interprofessional communication in the OR.
Citation Text:
Lingard L, Espin S, Rubin B, et al. Getting teams to talk: development and pilot implementation of a checklist to promote interprofessio…
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psnet.ahrq.gov/issue/quality-and-safety-orthopaedics-learning-and-teaching-same-time-aoa-critical-issues
July 16, 2015 - Review
Quality and safety in orthopaedics: learning and teaching at the same time: AOA critical issues.
Citation Text:
Black KP, Armstrong AD, Hutzler L, et al. Quality and Safety in Orthopaedics: Learning and Teaching at the Same Time: AOA Critical Issues. J Bone Joint Surg Am. 2015;97(…
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psnet.ahrq.gov/issue/failures-communication-and-information-transfer-across-surgical-care-pathway-interview-study
August 09, 2013 - Study
Failures in communication and information transfer across the surgical care pathway: interview study.
Citation Text:
Nagpal K, Arora S, Vats A, et al. Failures in communication and information transfer across the surgical care pathway: interview study. BMJ Qual Saf. 2012;21(10):8…
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psnet.ahrq.gov/issue/factors-associated-emergency-department-visits-and-hospital-admissions-after-invasive
August 17, 2018 - Study
Factors associated with emergency department visits and hospital admissions after invasive outpatient procedures in the Veterans Health Administration.
Citation Text:
Mull HJ, Gellad ZF, Gupta RT, et al. Factors Associated With Emergency Department Visits and Hospital Admissions Af…
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psnet.ahrq.gov/issue/error-traps-pediatric-patient-blood-management-perioperative-period
January 12, 2022 - Commentary
Error traps in pediatric patient blood management in the perioperative period.
Citation Text:
Tan GM, Murto K, Downey LA, et al. Error traps in pediatric patient blood management in the perioperative period. Paediatr Anaesth. 2023;33(8):609-619. doi:10.1111/pan.14683.
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psnet.ahrq.gov/issue/investigating-workplace-support-and-importance-psychological-safety-general-surgery-residency
July 16, 2015 - Study
Investigating workplace support and the importance of psychological safety in general surgery residency training.
Citation Text:
Ojute F, Gonzales PA, Berler M, et al. Investigating workplace support and the importance of psychological safety in general surgery residency training. …
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psnet.ahrq.gov/issue/promoting-culture-patient-safety-review-florida-moratoria-data-what-we-have-learned-6-years
August 04, 2021 - Review
Promoting a culture of patient safety: a review of the Florida moratoria data: what we have learned in 6 years and the need for continued patient education.
Citation Text:
Clayman MA, Clayman SM, Steele MH, et al. Promoting a culture of patient safety: a review of the Florida mo…
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psnet.ahrq.gov/issue/operative-team-communication-during-simulated-emergencies-too-busy-respond
March 04, 2020 - Study
Operative team communication during simulated emergencies: too busy to respond?
Citation Text:
Davis A, Jones S, Crowell-Kuhnberg AM, et al. Operative team communication during simulated emergencies: Too busy to respond? Surgery. 2017;161(5):1348-1356. doi:10.1016/j.surg.2016.09.02…