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Implementation of a high-reliability organization framework in a large integrated health care system: a pre-post quasi-experimental quality improvement project. | PSNet

psnet.ahrq.gov/issue/implementation-high-reliability-organization-framework-large-integrated-health-care-system

July 14, 2018 - Study Implementation of a high-reliability organization framework in a large integrated health care system: a pre-post quasi-experimental quality improvement project. Citation Text: Sawyer AM, Thiyarajan S, Essen KE, et al. Implementation of a high-reliability organization framework in a…

Delays in care during the COVID-19 pandemic in the Veterans Health Administration. | PSNet

psnet.ahrq.gov/issue/delays-care-during-covid-19-pandemic-veterans-health-administration

May 17, 2023 - Study Delays in care during the COVID-19 pandemic in the Veterans Health Administration. Citation Text: Mills PD, Louis RP, Yackel E. Delays in care during the COVID-19 pandemic in the Veterans Health Administration. J Healthc Qual. 2023;45(4):242-253. doi:10.1097/jhq.0000000000000383. …

Towards diagnostic excellence on academic ward teams: building a conceptual model of team dynamics in the diagnostic process. | PSNet

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August 20, 2018 - Study Towards diagnostic excellence on academic ward teams: building a conceptual model of team dynamics in the diagnostic process. Citation Text: Choi JJ, Rosen MA, Shapiro MF, et al. Towards diagnostic excellence on academic ward teams: building a conceptual model of team dynamics in t…

Analysing potential harm in Australian general practice: an incident-monitoring study. | PSNet

psnet.ahrq.gov/issue/analysing-potential-harm-australian-general-practice-incident-monitoring-study

July 29, 2020 - Study Classic Analysing potential harm in Australian general practice: an incident-monitoring study. Citation Text: Bhasale AL, Miller GC, Reid SE, et al. Analysing potential harm in Australian general practice: an incident-monitoring study. Med J Aust. 1998;1…

Performance of International Classification of Diseases, 9th Revision, Clinical Modification codes as an adverse drug event surveillance system. | PSNet

psnet.ahrq.gov/issue/performance-international-classification-diseases-9th-revision-clinical-modification-codes

May 07, 2008 - Study Performance of International Classification of Diseases, 9th Revision, Clinical Modification codes as an adverse drug event surveillance system. Citation Text: Hougland P, Xu W, Pickard S, et al. Performance of International Classification Of Diseases, 9th Revision, Clinical Modi…

Debunking the myth that the majority of medical errors are attributed to communication. | PSNet

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February 14, 2024 - Journal Article Debunking the myth that the majority of medical errors are attributed to communication. Citation Text: Clapper TC, Ching K. Debunking the myth that the majority of medical errors are attributed to communication. Med Educ. 2020;54(1):74-81. doi:10.1111/medu.13821. Copy C…

Using inpatient hospital discharge data to monitor patient safety events. | PSNet

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March 02, 2011 - Study Using inpatient hospital discharge data to monitor patient safety events. Citation Text: Taylor JA, Pandian RS, Mao L, et al. Using inpatient hospital discharge data to monitor patient safety events. J Healthc Risk Manag. 2013;32(4):26-33. doi:10.1002/jhrm.21107. Copy Citation …

Microbiological evaluation of two hand hygiene procedures achieved by healthcare workers during routine patient care: a randomized study. | PSNet

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June 13, 2011 - Study Microbiological evaluation of two hand hygiene procedures achieved by healthcare workers during routine patient care: a randomized study. Citation Text: Kac G, Podglajen I, Gueneret M, et al. Microbiological evaluation of two hand hygiene procedures achieved by healthcare workers…

The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. | PSNet

psnet.ahrq.gov/issue/nature-adverse-events-hospitalized-patients-results-harvard-medical-practice-study-ii

February 18, 2011 - Study Classic The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. Citation Text: Leape L, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Pra…

Targeted implementation of the Comprehensive Unit-Based Safety Program through an assessment of safety culture to minimize central line-associated bloodstream infections. | PSNet

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November 20, 2015 - Study Targeted implementation of the Comprehensive Unit-Based Safety Program through an assessment of safety culture to minimize central line-associated bloodstream infections. Citation Text: Richter J, McAlearney AS. Targeted implementation of the Comprehensive Unit-Based Safety Program…

Changing the "working while sick" culture. | PSNet

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March 14, 2018 - Commentary Changing the "working while sick" culture. Citation Text: Tanksley AL, Wolfson RK, Arora V. Changing the "Working While Sick" Culture: Promoting Fitness for Duty in Health Care. JAMA. 2016;315(6):603-4. doi:10.1001/jama.2016.0094. Copy Citation Format: DOI Google…

Effectiveness and efficiency of root cause analysis in medicine. | PSNet

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July 11, 2012 - Commentary Classic Effectiveness and efficiency of root cause analysis in medicine. Citation Text: Wu AW. Effectiveness and Efficiency of Root Cause Analysis in Medicine. JAMA. 2008;299(6):685-687. doi:10.1001/jama.299.6.685. Copy Citation Format: …

Accident analysis of large-scale technological disasters applied to an anaesthetic complication. | PSNet

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November 16, 2022 - Study Classic Accident analysis of large-scale technological disasters applied to an anaesthetic complication. Citation Text: Eagle CJ, Davies JM, Reason J. Accident analysis of large-scale technological disasters applied to an anaesthetic complication. Can J An…

Tying up loose ends: discharging patients with unresolved medical issues. | PSNet

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February 24, 2011 - Study Tying up loose ends: discharging patients with unresolved medical issues. Citation Text: Moore C, McGinn T, Halm E. Tying up loose ends: discharging patients with unresolved medical issues. Arch Intern Med. 2007;167(12):1305-11. Copy Citation Format: Google Scholar …

The 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: patient experiences, human factors, sedation, consent and medicolegal issues. | PSNet

psnet.ahrq.gov/issue/5th-national-audit-project-nap5-accidental-awareness-during-general-anaesthesia-patient

October 01, 2014 - Study The 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: patient experiences, human factors, sedation, consent and medicolegal issues. Citation Text: Cook TM, Andrade J, Bogod DG, et al. The 5th National Audit Project (NAP5) on accidental awareness …

Using social and behavioural science to support COVID-19 pandemic response. | PSNet

psnet.ahrq.gov/issue/using-social-and-behavioural-science-support-covid-19-pandemic-response

March 02, 2022 - Commentary Classic Using social and behavioural science to support COVID-19 pandemic response. Citation Text: Bavel JJV, Baicker K, Boggio PS, et al. Using social and behavioural science to support COVID-19 pandemic response. Nat Hum Behav. 2020;4(5):460-471. do…

Ergonomic and human factors affecting anesthetic vigilance and monitoring performance in the operating room environment. | PSNet

psnet.ahrq.gov/issue/ergonomic-and-human-factors-affecting-anesthetic-vigilance-and-monitoring-performance

May 31, 2011 - Review Classic Ergonomic and human factors affecting anesthetic vigilance and monitoring performance in the operating room environment. Citation Text: Biebuyck J F, Weinger M B, Englund C E. Ergonomic and Human Factors Affecting Anesthetic Vigilance and Monitori…

Mind the gap between recommendation and implementation—principles and lessons in the aftermath of incident investigations: a semi-quantitative and qualitative study of factors leading to the successful implementation of recommendations. | PSNet

psnet.ahrq.gov/issue/mind-gap-between-recommendation-and-implementation-principles-and-lessons-aftermath-incident

March 11, 2020 - Study Mind the gap between recommendation and implementation—principles and lessons in the aftermath of incident investigations: a semi-quantitative and qualitative study of factors leading to the successful implementation of recommendations. Citation Text: Wrigstad J, Bergström J, Gusta…

Creating highly reliable health care: how reliability-enhancing work practices affect patient safety in hospitals. | PSNet

psnet.ahrq.gov/issue/creating-highly-reliable-health-care-how-reliability-enhancing-work-practices-affect-patient

January 12, 2022 - Study Creating highly reliable health care: how reliability-enhancing work practices affect patient safety in hospitals. Citation Text: Vogus TJ, Iacobucci D. Creating Highly Reliable Health Care. ILR Review. 2016;69(4). doi:10.1177/0019793916642759. Copy Citation Format: D…

Methodological approaches for analyzing medication error reports in patient safety reporting systems: a scoping review. | PSNet

psnet.ahrq.gov/issue/methodological-approaches-analyzing-medication-error-reports-patient-safety-reporting-systems

May 11, 2022 - Review Methodological approaches for analyzing medication error reports in patient safety reporting systems: a scoping review. Citation Text: Tchijevitch O, Hansen SM-B, Hallas J, et al. Methodological approaches for analyzing medication error reports in patient safety reporting systems:…

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