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psnet.ahrq.gov/node/33579/psn-pdf
September 15, 2024 - Systems Approach
September 15, 2024
Systems Approach. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/systems-approach
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in …
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psnet.ahrq.gov/issue/safety-culture-patient-safety-practice-alarm-fatigue
July 07, 2021 - Commentary
Safety culture as a patient safety practice for alarm fatigue.
Citation Text:
Winters BD, Slota JM, Bilimoria KY. Safety culture as a patient safety practice for alarm fatigue. JAMA. 2021;326(12):1207-1208. doi:10.1001/jama.2021.8316.
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psnet.ahrq.gov/issue/problem-checklists
March 29, 2023 - Commentary
The problem with checklists.
Citation Text:
Catchpole K, Russ S. The problem with checklists. BMJ Qual Saf. 2015;24(9):545-9. doi:10.1136/bmjqs-2015-004431.
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psnet.ahrq.gov/issue/examination-factors-predict-perioperative-culture-safety
May 12, 2021 - Study
An examination of factors that predict the perioperative culture of safety.
Citation Text:
Wright MI, Polivka B, Abusalem S. An examination of factors that predict the perioperative culture of safety. AORN J. 2021;113(5):465-475. doi:10.1002/aorn.13373.
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psnet.ahrq.gov/issue/safety-performance-and-satisfaction-outcomes-operating-room-literature-review
April 03, 2019 - Review
Emerging Classic
Safety, performance, and satisfaction outcomes in the operating room: a literature review.
Citation Text:
Joseph A, Bayramzadeh S, Zamani Z, et al. Safety, Performance, and Satisfaction Outcomes in the Operating Room: A Literature Review.…
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psnet.ahrq.gov/issue/childrens-hospitals-solutions-patient-safety
January 09, 2024 - Multi-use Website
Childrens' Hospitals' Solutions for Patient Safety.
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July 30, 2015
This Web site provides resources related to a …
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psnet.ahrq.gov/issue/patterns-communication-breakdowns-resulting-injury-surgical-patients
March 03, 2011 - Study
Classic
Patterns of communication breakdowns resulting in injury to surgical patients.
Citation Text:
Greenberg CC, Regenbogen SE, Studdert DM, et al. Patterns of communication breakdowns resulting in injury to surgical patients. J Am Coll Surg. 2007;204…
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psnet.ahrq.gov/issue/failure-rescue-deteriorating-patients-systematic-review-root-causes-and-improvement
January 18, 2013 - Review
Emerging Classic
Failure to rescue deteriorating patients: a systematic review of root causes and improvement strategies.
Citation Text:
Burke JR, Downey C, Almoudaris AM. Failure to rescue deteriorating patients: a systematic review of root causes and im…
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psnet.ahrq.gov/issue/surgeon-information-transfer-and-communication-factors-affecting-quality-and-efficiency
December 21, 2014 - Study
Surgeon information transfer and communication: factors affecting quality and efficiency of inpatient care.
Citation Text:
Williams RG, Silverman R, Schwind C, et al. Surgeon information transfer and communication: factors affecting quality and efficiency of inpatient care. Ann S…
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psnet.ahrq.gov/issue/facilitators-and-barriers-implementation-surgical-safety-checklist-ssc-integrative-review
September 07, 2016 - Review
Facilitators and barriers to the implementation of surgical safety checklist (SSC): an integrative review.
Citation Text:
Lim PJH, Chen L, Siow S, et al. Facilitators and barriers to the implementation of surgical safety checklist: an integrative review. Int J Qual Health Care. 20…
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psnet.ahrq.gov/issue/retained-surgical-items-problem-yet-be-solved
September 24, 2014 - Study
Retained surgical items: a problem yet to be solved.
Citation Text:
Stawicki SPA, Moffatt-Bruce SD, Ahmed HM, et al. Retained surgical items: a problem yet to be solved. J Am Coll Surg. 2013;216(1):15-22. doi:10.1016/j.jamcollsurg.2012.08.026.
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psnet.ahrq.gov/issue/coping-and-recovery-surgical-residents-after-adverse-events-second-victim-phenomenon
July 11, 2012 - Study
Coping and recovery in surgical residents after adverse events: the second victim phenomenon.
Citation Text:
Khansa I, Pearson GD. Coping and recovery in surgical residents after adverse events: the second victim phenomenon. Plast Reconstr Surg Glob Open. 2022;10(3):e4203. doi:10.1…
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psnet.ahrq.gov/issue/outcomes-daytime-procedures-performed-attending-surgeons-after-night-work
December 18, 2014 - Study
Classic
Outcomes of daytime procedures performed by attending surgeons after night work.
Citation Text:
Govindarajan A, Urbach DR, Kumar M, et al. Outcomes of Daytime Procedures Performed by Attending Surgeons after Night Work. N Engl J Med. 2015;373(9):84…
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psnet.ahrq.gov/issue/surgical-safety-checklist-reduce-morbidity-and-mortality-global-population
February 09, 2011 - Study
Classic
A surgical safety checklist to reduce morbidity and mortality in a global population.
Citation Text:
Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;3…
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psnet.ahrq.gov/issue/association-between-paediatric-intraoperative-anaesthesia-handover-and-adverse-postoperative
July 21, 2021 - Study
Association between paediatric intraoperative anaesthesia handover and adverse postoperative outcomes.
Citation Text:
Kannampallil TG, Lew D, Pfeifer EE, et al. Association between paediatric intraoperative anaesthesia handover and adverse postoperative outcomes. BMJ Qual Saf. 2021…
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psnet.ahrq.gov/issue/modes-failure-venous-thromboembolism-prophylaxis
October 19, 2022 - Study
Modes of failure in venous thromboembolism prophylaxis.
Citation Text:
Richie CD, Castle JT, Davis GA, et al. Modes of failure in venous thromboembolism prophylaxis. Angiology. 2022;73(8):712-715. doi:10.1177/00033197221083724.
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psnet.ahrq.gov/issue/barriers-and-facilitators-associated-implementation-surgical-safety-checklists-qualitative
August 17, 2022 - Review
Barriers and facilitators associated with the implementation of surgical safety checklists: a qualitative systematic review.
Citation Text:
Paterson C, Mckie A, Turner M, et al. Barriers and facilitators associated with the implementation of surgical safety checklists: a qualitati…
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psnet.ahrq.gov/issue/surgeons-disclosures-clinical-adverse-events
August 18, 2021 - Study
Surgeons' disclosures of clinical adverse events.
Citation Text:
Elwy R, Itani KMF, Bokhour BG, et al. Surgeons' Disclosures of Clinical Adverse Events. JAMA Surg. 2016;151(11):1015-1021. doi:10.1001/jamasurg.2016.1787.
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psnet.ahrq.gov/issue/comparative-effectiveness-analysis-implementation-surgical-safety-checklists-tertiary-care
December 20, 2023 - Study
A comparative effectiveness analysis of the implementation of surgical safety checklists in a tertiary care hospital.
Citation Text:
Bock M, Fanolla A, Segur-Cabanac I, et al. A Comparative Effectiveness Analysis of the Implementation of Surgical Safety Checklists in a Tertiary Car…
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psnet.ahrq.gov/web-mm/add-case-and-missing-checklist
September 01, 2012 - Add-on Case and the Missing Checklist
Citation Text:
Catchpole K. Add-on Case and the Missing Checklist. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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