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psnet.ahrq.gov/issue/intraoperative-sentinel-events-era-surgical-safety-checklists-results-national-survey
August 04, 2021 - Study
Intraoperative sentinel events in the era of surgical safety checklists: results of a national survey.
Citation Text:
Cramer JD, Balakrishnan K, Roy S, et al. Intraoperative sentinel events in the era of surgical safety checklists: results of a national survey. OTO Open. 2020;4(4):…
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psnet.ahrq.gov/issue/state-medical-board-regulation-compounding-physician-offices
July 13, 2022 - Study
State medical board regulation of compounding in physician offices.
Citation Text:
Reynolds KA, Hellquist K, Ibrahim SA, et al. State medical board regulation of compounding in physician offices. Arch Dermatol Res. 2022;314(4):363-367. doi:10.1007/s00403-021-02237-8.
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psnet.ahrq.gov/issue/causes-adverse-events-home-mechanical-ventilation-nursing-perspective
November 10, 2021 - Study
Causes of adverse events in home mechanical ventilation: a nursing perspective.
Citation Text:
Lipprandt M, Liedtke W, Langanke M, et al. Causes of adverse events in home mechanical ventilation: a nursing perspective. BMC Nurs. 2022;21(1):264. doi:10.1186/s12912-022-01038-2.
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psnet.ahrq.gov/issue/toward-increased-patient-safety-electronic-communication-medication-information-between
June 23, 2021 - Study
Toward increased patient safety? Electronic communication of medication information between nurses in home health care and general practitioners.
Citation Text:
Lyngstad M, Melby L, Grimsmo A, et al. Toward Increased Patient Safety? Electronic Communication of Medication Informat…
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psnet.ahrq.gov/issue/readiness-report-medical-treatment-errors-effects-safety-procedures-safety-information-and
July 11, 2007 - Study
Readiness to report medical treatment errors: the effects of safety procedures, safety information, and priority of safety.
Citation Text:
Naveh E, Katz-Navon T, Stern Z. Readiness to report medical treatment errors: the effects of safety procedures, safety information, and prior…
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psnet.ahrq.gov/issue/looking-back-history-patient-safety-opportunity-reflect-and-ponder-future-challenges
July 10, 2019 - Commentary
Looking back on the history of patient safety: an opportunity to reflect and ponder future challenges.
Citation Text:
Schiff G, Shojania KG. Looking back on the history of patient safety: an opportunity to reflect and ponder future challenges. BMJ Qual Saf. 2022;31(2):148-152.…
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psnet.ahrq.gov/issue/safety-gaps-medical-team-communication-closing-loop-quality-improvement-efforts-cardiac
June 01, 2022 - Study
Safety gaps in medical team communication: closing the loop on quality improvement efforts in the cardiac catheterization lab.
Citation Text:
Doorey AJ, Turi ZG, Lazzara EH, et al. Safety gaps in medical team communication: closing the loop on quality improvement efforts in the car…
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psnet.ahrq.gov/issue/adverse-events-and-perceived-abandonment-learning-patients-accounts-medical-mishaps
February 12, 2020 - Study
Adverse events and perceived abandonment: learning from patients' accounts of medical mishaps.
Citation Text:
Schlesinger M, Dhingra I, Fain BA, et al. Adverse events and perceived abandonment: learning from patients’ accounts of medical mishaps. BMJ Open Qual. 2024;13(3):e002848. …
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psnet.ahrq.gov/issue/are-temporary-staff-associated-more-severe-emergency-department-medication-errors
June 29, 2011 - Study
Are temporary staff associated with more severe emergency department medication errors?
Citation Text:
Pham JC, Andrawis M, Shore AD, et al. Are temporary staff associated with more severe emergency department medication errors? J Healthc Qual. 2011;33(4):9-18. doi:10.1111/j.1945…
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psnet.ahrq.gov/issue/does-time-pressure-have-negative-effect-diagnostic-accuracy
January 16, 2019 - Study
Does time pressure have a negative effect on diagnostic accuracy?
Citation Text:
ALQahtani DA, Rotgans JI, Mamede S, et al. Does Time Pressure Have a Negative Effect on Diagnostic Accuracy? Acad Med. 2016;91(5):710-716. doi:10.1097/ACM.0000000000001098.
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psnet.ahrq.gov/issue/implementation-communication-didactics-obgyn-residents-disclosure-adverse-perioperative
July 21, 2021 - Study
The implementation of communication didactics for OB/GYN residents on the disclosure of adverse perioperative events.
Citation Text:
Chung EH, Truong T, Jooste KR, et al. The implementation of communication didactics for OB/GYN residents on the disclosure of adverse perioperative e…
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psnet.ahrq.gov/issue/patterns-nursing-home-medication-errors-disproportionality-analysis-novel-method-identify
August 07, 2013 - Study
Patterns in nursing home medication errors: disproportionality analysis as a novel method to identify quality improvement opportunities.
Citation Text:
Hansen RA, Cornell PY, Ryan PB, et al. Patterns in nursing home medication errors: disproportionality analysis as a novel method…
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psnet.ahrq.gov/issue/relationship-between-hospital-systems-load-and-patient-harm
November 12, 2008 - Study
The relationship between hospital systems load and patient harm.
Citation Text:
Pedroja AT, Blegen MA, Abravanel R, et al. The relationship between hospital systems load and patient harm. J Patient Saf. 2014;10(3):168-75. doi:10.1097/PTS.0b013e31829e4f82.
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psnet.ahrq.gov/issue/morbidity-and-mortality-caused-noncompliance-california-hospital-licensure-immediate
May 19, 2021 - Study
Morbidity and mortality caused by noncompliance with California hospital licensure: immediate jeopardies in California hospitals, 2007-2017.
Citation Text:
Zheng MY, Lui H, Patino G, et al. Morbidity and mortality caused by noncompliance with California hospital licensure: immediat…
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psnet.ahrq.gov/issue/systematic-review-computerized-prescriber-order-entry-and-clinical-decision-support
August 23, 2017 - Review
Systematic review of computerized prescriber order entry and clinical decision support.
Citation Text:
Vélez-Díaz-Pallarés M, Pérez-Menéndez-Conde C, Bermejo-Vicedo T. Systematic review of computerized prescriber order entry and clinical decision support. Am J Health Syst Pharm. 2…
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psnet.ahrq.gov/issue/evaluation-wound-photography-remote-postoperative-assessment-surgical-site-infections
July 03, 2014 - Study
Evaluation of wound photography for remote postoperative assessment of surgical site infections.
Citation Text:
Broman KK, Gaskill CE, Faqih A, et al. Evaluation of Wound Photography for Remote Postoperative Assessment of Surgical Site Infections. JAMA Surg. 2019;154(2):117-124. do…
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psnet.ahrq.gov/issue/detection-adverse-events-affected-record-review-methodology-evaluation-harvard-medical
August 05, 2020 - Study
Is detection of adverse events affected by record review methodology? An evaluation of the "Harvard Medical Practice Study" method and the "Global Trigger Tool."
Citation Text:
Unbeck M, Schildmeijer K, Henriksson P, et al. Is detection of adverse events affected by record review …
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psnet.ahrq.gov/issue/identifying-systems-failures-pathway-catastrophic-event-analysis-national-incident-report
January 22, 2014 - Study
Identifying systems failures in the pathway to a catastrophic event: an analysis of national incident report data relating to vinca alkaloids.
Citation Text:
Franklin BD, Panesar S, Vincent CA, et al. Identifying systems failures in the pathway to a catastrophic event: an analysis …
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psnet.ahrq.gov/issue/delivery-optimized-inpatient-anticoagulation-therapy-consensus-statement-anticoagulation
March 04, 2020 - Commentary
Delivery of optimized inpatient anticoagulation therapy: consensus statement from the Anticoagulation Forum.
Citation Text:
Nutescu EA, Wittkowsky AK, Burnett A, et al. Delivery of optimized inpatient anticoagulation therapy: consensus statement from the anticoagulation forum…
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psnet.ahrq.gov/issue/prevalence-harmful-diagnostic-errors-hospitalised-adults-systematic-review-and-meta-analysis
April 01, 2020 - Review
Emerging Classic
Prevalence of harmful diagnostic errors in hospitalised adults: a systematic review and meta-analysis.
Citation Text:
Gunderson CG, Bilan VP, Holleck JL, et al. Prevalence of harmful diagnostic errors in hospitalised adults: a systematic …