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Coping with errors in the operating room: intraoperative strategies, postoperative strategies, and sex differences. | PSNet

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September 09, 2020 - March 10, 2021 Operating room to intensive care unit handoffs and the risks of patient … September 9, 2015 Diagnostic error experiences of patients and families with limited … English-language health literacy or disadvantaged socioeconomic position in a cross-sectional US population-based survey … July 18, 2019 Clinical impact of intraoperative electronic health record downtime on … surgical patients.

Development of a core drug list towards improving prescribing education and reducing errors in the UK. | PSNet

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April 13, 2022 - This list included most of the medications associated with adverse events in geriatric patients and … performance of a drug-drug interaction clinical decision support system: quantitative evaluation and end-user survey … Drug-drug interactions and prescription appropriateness at hospital discharge: experience with COVID-19 patients … the prevalence and association of polypharmacy and drug administration errors in hospitalized adult patients … May 24, 2015 Improving teamwork: impact of structured interdisciplinary rounds on a medical

Hospital characteristics associated with penalties in the Centers for Medicare & Medicaid Services Hospital-Acquired Condition Reduction Program. | PSNet

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November 18, 2016 - Teaching institutions, hospitals whose case mix included more complex patients, and safety-net hospitals … were all more likely to face penalties than nonteaching, nonsafety institutions with healthier patients … June 7, 2017 Development and validation of a brief culture-of-safety survey. … September 19, 2012 Effect of illness severity and comorbidity on patient safety and adverse … January 4, 2012 Effect of critical access hospital conversion on patient safety.

Quality improvement initiative to decrease central line-associated bloodstream infections during the COVID-19 pandemic: a "zero harm" approach. | PSNet

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November 16, 2022 - A systematic review of the effects of resident duty hour restrictions in surgery: impact on … July 3, 2016 Ward round template: enhancing patient safety on ward rounds. … October 4, 2023 Operational failures in general practice: a consensus-building study on … device-associated infections during the coronavirus disease 2019 (COVID-19) pandemic: results from a national survey … 2023 Eliminating central line associated bloodstream infections in pediatric oncology patients

Can first-year medical students acquire quality improvement knowledge prior to substantial clinical exposure? A mixed-methods evaluation of a pre-clerkship curriculum that uses education as the context for learning. | PSNet

psnet.ahrq.gov/issue/can-first-year-medical-students-acquire-quality-improvement-knowledge-prior-substantial

April 24, 2019 - The National Patient Safety Foundation has called for medical educators to emphasize quality, safety … September 23, 2020 Optimizing Pediatric Patient Safety in the Emergency Care Setting. … November 28, 2018 Sustaining quality improvement and patient safety training in graduate … and postgraduate trainees: a cross-sectional survey. … January 18, 2012 Graduate medical education and patient safety: a busy--and occasionally

"It's like two worlds apart": an analysis of vulnerable patient handover practices at discharge from hospital. | PSNet

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January 15, 2025 - This qualitative study from Spain used in-depth interviews with patients, hospital staff, and primary … processes are often haphazard and a major source of frustration for hospital providers, and that patients … -Routine measurement of patient experience with patient safety in ambulatory care: a mixed-mode survey … September 24, 2016 The effects of patient handoff characteristics on subsequent care: … and delivery: development, validation, and application of the Coordination of Handoff Effectiveness Questionnaire

Adverse Events in Dentistry | PSNet

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December 22, 2020 - Dental patients receive medications, tests, and procedures and many of the same patient safety risks … We have data on about 4-4.5 million patients now. … and a module on patient safety in dentistry. … safety culture in primary dental care. … May 6, 2020 Factors affecting patient safety culture among dental healthcare workers:

Using evidence, rigorous measurement, and collaboration to eliminate central catheter-associated bloodstream infections. | PSNet

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January 15, 2014 - program report highlights the implementation processes of the AHRQ-funded CUSP initiative that builds on … Same Author(s) Eliminating central line-associated bloodstream infections: a national patient … device-associated infections during the coronavirus disease 2019 (COVID-19) pandemic: results from a national survey … May 22, 2019 AHRQ patient safety project reduces bloodstream infections by 40 percent … April 21, 2015 Tennessee Center for Patient Safety.

Preventable harm in the Canadian organ donation and transplantation system: a descriptive study of missed organ donor identification and referral. | PSNet

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October 19, 2022 - July 5, 2023 Postoperative opioid prescribing and the pain scores on Hospital Consumer … Assessment of Healthcare Providers and Systems survey. … Safety Initiatives July 10, 2024 Perspectives on Safety … Health Plan Patient Safety Initiatives July 10, 2024 Structural … March 1, 2023 Healthcare-associated adverse events in alternate level of care patients

Weekly Resource | PSNet

psnet.ahrq.gov/periodic-issue/weekly-resource

March 25, 2025 - This methodology ensured the audit was patient-centered and focused on the patient's journey through … Findings from this cross-sectional survey with 255 nurse leaders highlight the important role of authentic … Survey respondents also endorsed the importance of formal support programs, including peer support, education … Patients presenting with non-specific symptoms (NSSs) suggestive of cancer may experience diagnostic … Updates, WebM&M, and Perspectives on Safety.

An empirically derived taxonomy of factors affecting physicians' willingness to disclose medical errors. | PSNet

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February 15, 2011 - In this study, researchers reviewed the medical literature on error disclosure and conducted focus groups … The authors were able to identify four facilitating factors, which primarily centered on physicians' … safety: a survey of physicians in teaching hospitals. … April 12, 2023 Impact of providing patients access to electronic health records on quality … Disclosure Provider-Patient Communication

Has improved hand hygiene compliance reduced the risk of hospital-acquired infections among hospitalized patients in Ontario? Analysis of publicly reported patient safety data from 2008 to 2011. | PSNet

psnet.ahrq.gov/issue/has-improved-hand-hygiene-compliance-reduced-risk-hospital-acquired-infections-among

July 10, 2024 - Analysis of publicly reported patient safety data from 2008 to 2011. … Analysis of publicly reported patient safety data from 2008 to 2011. … attitudes and barriers to a medical emergency team among nurses and medical doctors: a multi-centre survey … April 21, 2015 Impact of a hospital-wide hand hygiene initiative on healthcare-associated … December 30, 2014 The effect of hospital-acquired Clostridium difficile infection on

Implementation of the Josie King Care Journal in a pediatric intensive care unit: a quality improvement project. | PSNet

psnet.ahrq.gov/issue/implementation-josie-king-care-journal-pediatric-intensive-care-unit-quality-improvement

November 21, 2016 - This study reports on the implementation of the journal in a pediatric intensive care unit. … December 6, 2017 Parents' perspective on safety in neonatal intensive care: a mixed-methods … November 23, 2016 The effect of an electronic SBAR communication tool on documentation … 2014 The morbidity and mortality conference in PICUs in the United States: a national survey … More About The Topic Intensive Care Units Children's Hospitals Health Care Providers Patients

How can interventions more directly address drivers of unprofessional behaviour between healthcare staff? | PSNet

psnet.ahrq.gov/issue/how-can-interventions-more-directly-address-drivers-unprofessional-behaviour-between

October 09, 2024 - Rapid response systems, antibiotic stewardship and medication reconciliation: a scoping review on … June 26, 2024 What can safety cases offer for patient safety? … July 12, 2023 Identifying safety practices perceived as low value: an exploratory survey … March 8, 2023 National patient safety goal to improve health care equity. … July 7, 2021 Improving America's Hospitals: The Joint Commission's Annual Report on Quality

Systematic review of the prevalence of medication errors resulting in hospitalization and death of nursing home residents. | PSNet

psnet.ahrq.gov/issue/systematic-review-prevalence-medication-errors-resulting-hospitalization-and-death-nursing

July 23, 2008 - revealed that a significant number of errors were related to handoffs and that 75% of these older patients … Related Resources From the Same Author(s) Measurement for improvement: a survey … August 12, 2009 Optimizing Pediatric Patient Safety in the Emergency Care Setting. … , and management of the psychological effects of emerging virus outbreaks on healthcare workers: rapid … November 2, 2018 Effects of interdisciplinary collaboration in hospitals on medication

Clinical impact and economic burden of hospital-acquired conditions following common surgical procedures. | PSNet

psnet.ahrq.gov/issue/clinical-impact-and-economic-burden-hospital-acquired-conditions-following-common-surgical

October 21, 2020 - the prevalence and association of polypharmacy and drug administration errors in hospitalized adult patients … May 18, 2022 Hospital ward adaptation during the COVID-19 pandemic: a national survey … diagnostic stewardship for blood cultures in critically ill children with culture rates, antibiotic use, and patient … February 5, 2020 View More Related Resources How satisfied are patients … January 23, 2019 Healthy life-years lost and excess bed-days due to 6 patient safety

Large language models for preventing medication direction errors in online pharmacies. | PSNet

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February 27, 2019 - March 15, 2023 Optimizing Pediatric Patient Safety in the Emergency Care Setting. … October 19, 2022 ASHP Guidelines on the Safe Use of Automated Compounding Devices for … telephone-based self-management support program to identify adverse events among ambulatory diabetes patients … February 22, 2011 Development of a high-value care culture survey: a modified Delphi … A multi-method exploratory evaluation of a service designed to improve medication safety for patients

Fall prevention implementation strategies in use at 60 United States hospitals: a descriptive study. | PSNet

psnet.ahrq.gov/issue/fall-prevention-implementation-strategies-use-60-united-states-hospitals-descriptive-study

November 11, 2020 - Fall prevention remains a patient safety priority . … May 19, 2021 Impact of structured interdisciplinary bedside rounding on patient outcomes … Safety and Quality April 26, 2023 Distractions in the operating room: a survey … October 19, 2022 Keeping patients at risk for self-harm safe in the emergency department … December 2, 2020 Clinical deterioration and hospital‐acquired complications in adult patients

Situation, background, assessment, and recommendation–guided huddles improve communication and teamwork in the emergency department. | PSNet

psnet.ahrq.gov/issue/situation-background-assessment-and-recommendation-guided-huddles-improve-communication-and

September 23, 2020 - July 29, 2020 Medical harm: patient perceptions and follow-up actions. … November 21, 2017 Evaluation of clinical practice guidelines on fall prevention and management … patient simulation for agitation management in the emergency department. … : effects on behaviour and attitude. … management course for emergency medicine, phase 1: results from an interdisciplinary needs assessment survey

Empowerment failure: how shortcomings in physician communication unwittingly undermine patient autonomy. | PSNet

psnet.ahrq.gov/issue/empowerment-failure-how-shortcomings-physician-communication-unwittingly-undermine-patient

January 17, 2019 - The authors argue that well-intentioned physicians fail to empower patients and recommend communication … are patients aware of when they do not understand? … Health Organization Trauma Care Checklist Program in 11 centers across multiple economic strata: effect on … symptoms and work-related behavior among healthcare workers and other professionals: results of a global survey … and patient experience.

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