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psnet.ahrq.gov/issue/better-surgeons-notes-performance
February 06, 2018 - Book/Report
Better: A Surgeon's Notes on Performance.
Citation Text:
Better: A Surgeon's Notes on Performance. Gawande A. New York, NY: Metropolitan; 2007.
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psnet.ahrq.gov/issue/are-operating-room-distractions-interruptions-and-disruptions-associated-performance-and
December 02, 2020 - Review
Are operating room distractions, interruptions, and disruptions associated with performance and patient safety? A systematic review and meta-analysis.
Citation Text:
Mcmullan RD, Urwin R, Gates PJ, et al. Are operating room distractions, interruptions and disruptions associated wi…
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psnet.ahrq.gov/issue/systematic-review-and-meta-analysis-interventions-operating-room-intensive-care-unit-handoffs
July 08, 2020 - Review
Emerging Classic
Systematic review and meta-analysis of interventions for operating room to intensive care unit handoffs.
Citation Text:
Abraham J, Meng A, Tripathy S, et al. Systematic review and meta-analysis of interventions for operating room to inten…
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psnet.ahrq.gov/issue/so-many-ways-be-wrong-completeness-and-accuracy-prospective-study-or-icu-handoff
April 28, 2021 - Study
So many ways to be wrong: completeness and accuracy in a prospective study of OR-to-ICU handoff standardization.
Citation Text:
Conn Busch J, Wu J, Anglade E, et al. So many ways to be wrong: completeness and accuracy in a prospective study of OR-to-ICU handoff standardization. Jt …
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psnet.ahrq.gov/issue/impact-surgical-count-technology-retained-surgical-items-rates-veterans-health-administration
January 17, 2019 - Study
The impact of surgical count technology on retained surgical items rates in the Veterans Health Administration.
Citation Text:
Gunnar W, Soncrant C, Lynn MM, et al. The impact of surgical count technology on retained surgical items rates in the Veterans Health Administration. J Pat…
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psnet.ahrq.gov/issue/using-radiofrequency-technology-prevent-retained-sponges-and-improve-patient-outcomes
November 25, 2020 - Study
Using radiofrequency technology to prevent retained sponges and improve patient outcomes.
Citation Text:
Primiano M, Sparks D, Murphy J, et al. Using radiofrequency technology to prevent retained sponges and improve patient outcomes. AORN J. 2020;112(4):345-352. doi:10.1002/aorn.13…
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psnet.ahrq.gov/issue/evaluation-perioperative-medication-errors-and-adverse-drug-events
July 16, 2019 - Study
Classic
Evaluation of perioperative medication errors and adverse drug events.
Citation Text:
Nanji KC, Patel A, Shaikh S, et al. Evaluation of Perioperative Medication Errors and Adverse Drug Events. Anesthesiology. 2016;124(1):25-34. doi:10.1097/ALN.0000…
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psnet.ahrq.gov/issue/developing-standard-handoff-process-operating-room-icu-transitions-multidisciplinary
February 06, 2019 - Study
Developing a standard handoff process for operating room–to-ICU transitions: multidisciplinary clinician perspectives from the Handoffs and Transitions in Critical Care (HATRICC) study.
Citation Text:
Lane-Fall MB, Pascual JL, Massa S, et al. Developing a Standard Handoff Process f…
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psnet.ahrq.gov/issue/perioperative-safety-determinants-ethnic-patient-groups
February 09, 2022 - Study
Perioperative safety determinants in ethnic patient groups.
Citation Text:
Bloo G, Calsbeek H, Westert GP, et al. Perioperative safety determinants in ethnic patient groups. J Patient Saf Risk Manag. 2023;28(1):31-46. doi:10.1177/25160435231151545.
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psnet.ahrq.gov/issue/how-do-nurses-use-early-warning-scoring-systems-detect-and-act-patient-deterioration-ensure
June 16, 2021 - Review
Emerging Classic
How do nurses use early warning scoring systems to detect and act on patient deterioration to ensure patient safety? A scoping review.
Citation Text:
Wood C, Chaboyer W, Carr P. How do nurses use early warning scoring systems to detect an…
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psnet.ahrq.gov/issue/systematic-review-teamwork-intensive-care-unit-what-do-we-know-about-teamwork-team-tasks-and
January 23, 2019 - Review
A systematic review of teamwork in the intensive care unit: what do we know about teamwork, team tasks, and improvement strategies?
Citation Text:
Dietz AS, Pronovost P, Mendez-Tellez PA, et al. A systematic review of teamwork in the intensive care unit: what do we know about team…
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psnet.ahrq.gov/issue/opioid-stewardship-program-and-postoperative-adverse-events-difference-differences-cohort
June 30, 2021 - Study
Opioid stewardship program and postoperative adverse events: a difference-in-differences cohort study.
Citation Text:
Barreveld AM, McCarthy RJ, Elkassabany N, et al. Opioid stewardship program and postoperative adverse events: a difference-in-differences cohort study. Anesthesiolo…
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psnet.ahrq.gov/issue/correlates-missed-or-late-versus-timely-diagnosis-dementia-healthcare-settings
March 09, 2022 - Study
Correlates of missed or late versus timely diagnosis of dementia in healthcare settings.
Citation Text:
Chen Y, Power MC, Grodstein F, et al. Correlates of missed or late versus timely diagnosis of dementia in healthcare settings. Alzheimers Dement. 2024;20(8):5551-5560. doi:10.100…
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psnet.ahrq.gov/print/pdf/node/842920
December 14, 2022 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Diagnostic Errors Case Studies
Curated Library
Web M&Ms
A Postpartum Woman with an Erroneous SARS-CoV-2 Test
Stephen A. Martin, MD, EdM, Gordon D. Schiff, MD, and Sanjat Kanjilal, MD, MPH | April 28, 2021
A pregnant patient was admitted for…
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psnet.ahrq.gov/issue/failure-rescue-comparing-definitions-measure-quality-care
April 17, 2013 - Study
Failure-to-rescue: comparing definitions to measure quality of care.
Citation Text:
Silber JH, Romano PS, Rosen AK, et al. Failure-to-rescue: comparing definitions to measure quality of care. Med Care. 2007;45(10):918-25.
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psnet.ahrq.gov/issue/sentinel-event-statistics-1995-2019
February 28, 2018 - Measurement Tool/Indicator
Sentinel Event Data Summary.
Citation Text:
Sentinel Event Data Summary. Joint Commission.
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psnet.ahrq.gov/web-mm/failure-rescue-mother
September 23, 2020 - Failure to Rescue the Mother
Citation Text:
Vivero A, Klapper EB, Gregory KD, et al. Failure to Rescue the Mother. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/issue/sops-surveys
December 24, 2008 - Meeting/Conference Proceedings
SOPS Surveys.
Citation Text:
SOPS Surveys. Agency for Healthcare Research and Quality.
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psnet.ahrq.gov/issue/fatal-outcome-after-inadvertent-injection-topical-epinephrine
May 07, 2018 - Newspaper/Magazine Article
Fatal outcome after inadvertent injection of topical epinephrine.
Citation Text:
Fatal outcome after inadvertent injection of topical epinephrine. ISMP Medication Safety Alert! Acute Care Edition. March 26, 2009;14:1-2.
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psnet.ahrq.gov/issue/diagnostic-safety-supplemental-item-set-medical-office-sops
December 24, 2008 - Multi-use Website
Diagnostic Safety Supplemental Item Set for Medical Office SOPS.
Citation Text:
Diagnostic Safety Supplemental Item Set for Medical Office SOPS. Agency for Healthcare Research and Quality.
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