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psnet.ahrq.gov/issue/injection-practices-among-clinicians-united-states-health-care-settings
January 06, 2017 - elements of unsafe injection practices , including use of single-dose/use vials for more than one patient … August 2, 2015
Evaluation of clinical practice guidelines on fall prevention and management … Preventability and causes of readmissions in a national cohort of general medicine patients … January 9, 2024
Structural racism and impact on sickle cell disease: sickle cell lives
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psnet.ahrq.gov/issue/patient-handoffs-and-multi-specialty-trainee-perspectives-across-institution-informing
February 23, 2022 - handoff training (critical handoff elements, the impact of systems-level factors, impact of the handoff on … providers and patients, professional duty, and addressing blame or guilt related to poor handoff experiences … 20, 2023
The effects of leadership curricula with and without implicit bias training on … September 13, 2017
Mixed-methods evaluation of real-time safety reporting by hospitalized patients … March 14, 2012
Patterns of communication breakdowns resulting in injury to surgical patients
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psnet.ahrq.gov/issue/girl-who-cried-pain-bias-against-women-treatment-pain
February 08, 2023 - This review summarizes studies on gender differences in experiences and treatment of pain, and assessment … February 8, 2023
Patients who die by suicide: a study of treatment patterns and patient … hygiene in health-care facilities: results from the WHO Hand Hygiene Self-Assessment Framework global survey
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psnet.ahrq.gov/issue/health-care-associated-infections-among-hospitalized-patients-covid-19-march-2020-march-2022
May 12, 2021 - Study
Health care-associated infections among hospitalized patients with COVID-19 … September 23, 2020
Impact of pharmacist-led admission medication reconciliation on patient … February 14, 2017
A patient feedback reporting tool for OpenNotes: implications for patient–clinician … Process failures that increase the risk of infection through respiratory droplets: a study of patient … September 23, 2020
Hospital ward adaptation during the COVID-19 pandemic: a national survey
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psnet.ahrq.gov/issue/trauma-resuscitation-errors-and-computer-assisted-decision-support
January 28, 2010 - resuscitation, and used video capture of trauma resuscitations to assess the effects of the CDSS on … patient outcomes. … wrong-patient order errors: a randomized clinical trial. … , 2022
Analysis of clinical decision support system malfunctions: a case series and survey … early recognition and intervention in deteriorating hospital patients.
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psnet.ahrq.gov/perspective/conversation-withkaveh-g-shojania-md
September 01, 2011 - Shojania is a leading expert on evidence-based patient safety strategies and translating research into … electronic reporting interfaces, excluding reported information from performance reviews, improving safety … culture, and focusing on errors rather than adverse events. … The senior leadership defines what the safety culture should look like, seeks out new safety technologies … Adverse-event-reporting practices by US hospitals: results of a national survey.
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psnet.ahrq.gov/issue/speaking-across-drapes-communication-strategies-anesthesiologists-and-obstetricians-during
May 08, 2017 - September 23, 2020
A cross-cultural survey of residents' perceived barriers in questioning … maximizing training while sensing patient safety threats. … May 22, 2019
ACOG Committee Opinion No. 447: patient safety in obstetrics and gynecology … May 22, 2019
Recommendations from a national panel on quality improvement in obstetrics … The effect of a program to shorten the decision-to-delivery interval for emergent cesarean section on
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psnet.ahrq.gov/node/49419/psn-pdf
October 01, 2003 - for both physicians and patients. … of hand
surgeons revealed that 20% of the 1000 respondents had operated on the wrong site at least … In addition, the chance of
error is increased when multiple procedures are performed on the same patient … What will the impact of disclosure be on
the patient and her family? … Error, stress and teamwork in medicine and aviation: cross
sectional surveys.
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psnet.ahrq.gov/issue/relationships-within-inpatient-physician-housestaff-teams-and-their-association-hospitalized
December 18, 2013 - relationships and behaviors of inpatient medicine teams were associated with complication rates for patients … The presence of trust, defined as a willingness to be vulnerable to others (e.g., an attending on rounds … September 23, 2020
Multistate point-prevalence survey of health care-associated infections … and Creating a Safer Workplace
October 31, 2023
Perspectives on … September 28, 2011
Teamwork on inpatient medical units: assessing attitudes and barriers
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psnet.ahrq.gov/issue/emergency-intubation-children-outside-operating-room
May 27, 2011 - Potential solutions to reduce intubation-related adverse events and improve patient safety are discussed … May 21, 2009
Are dental patients concerned about safety? An exploratory study. … Cracking the code for quality: the interrelationships of culture, nurse demographics, advocacy, and patient … Hypoxemia after Emergency Intubation
December 18, 2024
Survey … September 1, 2021
A qualitative exploration of the impact of a distressed family member on
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psnet.ahrq.gov/issue/comparison-military-and-civilian-methods-determining-potentially-preventable-deaths
October 19, 2022 - Citation
Related Resources From the Same Author(s)
Optimizing Pediatric Patient … the covid-19 pandemic using OpenSAFELY: population based, retrospective cohort study of 57 million patients … mortality conference that incorporates the clinical and educational missions of improving quality and patient
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psnet.ahrq.gov/issue/implementation-second-victim-program-pediatric-hospital
December 18, 2013 - January 23, 2019
ASPEN survey of parenteral nutrition access issues: how the system fails … the patients. … January 31, 2024
Validation and use of the Second Victim Experience and Support Tool questionnaire … December 20, 2023
Multispecialty physician online survey reveals that burnout related … incident and association with the level of patient harm: a cross-sectional study in the Netherlands.
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psnet.ahrq.gov/print/pdf/node/73848
July 01, 2022 - unit-based safety program (CUSP) to improve safety culture and perinatal care processes
in 15 Michigan … This toolkit focuses on identification of, and rapid response to, sepsis in obstetric patients. … A vital component of engaging patients in safety is eliciting their perspective on how they experience … This toolkit focuses on identification of, and rapid response to, sepsis in obstetric patients. … unit-based safety program (CUSP) to improve safety culture and perinatal care processes
in 15 Michigan
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psnet.ahrq.gov/issue/language-barriers-and-understanding-hospital-discharge-instructions
July 07, 2010 - among all patients regardless of language ability. … Related Resources From the Same Author(s)
Influence of language barriers on … March 4, 2011
Hospital ward adaptation during the COVID-19 pandemic: a national survey … October 16, 2012
The effects of a 'discharge time-out' on the quality of hospital discharge … August 25, 2011
Culture, language, and patient safety: making the link.
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psnet.ahrq.gov/issue/prevalence-copied-information-attendings-and-residents-critical-care-progress-notes
September 28, 2017 - standards-based electronic prescribing systems as implemented in outpatient primary care: a physician survey … September 23, 2020
Preventing harm in the ICU—building a culture of safety and engaging patients … May 31, 2023
Patient harm and institutional avoidability of out-of-hours discharge from … March 23, 2022
Investigating the impact of intensive care unit interruptions on patient … July 24, 2019
Data omission by physician trainees on ICU rounds.
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psnet.ahrq.gov/issue/intercepting-wrong-patient-orders-computerized-provider-order-entry-system
May 29, 2019 - Effect of restriction of the number of concurrently open records in an electronic health record on … September 4, 2019
The role of housestaff in implementing medication reconciliation on … December 27, 2014
A national survey assessing the number of records allowed open in electronic … July 9, 2018
Engaging hospital patients in the medication reconciliation process using … May 29, 2019
Effect of number of open charts on intercepted wrong-patient medication
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psnet.ahrq.gov/issue/passing-baton-grounded-practical-theory-handoff-communication-between-multidisciplinary
November 16, 2022 - March 31, 2010
Patient outcomes in dose reduction or discontinuation of long-term opioid … Department of Veterans Affairs' National Surgical Quality Improvement Program in the private sector: the Patient … June 3, 2020
Impact of the communication and patient hand-off tool SBAR on patient safety … January 3, 2017
Transfers of patient care between house staff on internal medicine wards … : a national survey.
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psnet.ahrq.gov/web-mm/other-side
May 01, 2007 - for both physicians and patients. … of hand surgeons revealed that 20% of the 1000 respondents had operated on the wrong site at least once … In addition, the chance of error is increased when multiple procedures are performed on the same patient … What will the impact of disclosure be on the patient and her family? … Error, stress and teamwork in medicine and aviation: cross sectional surveys.
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psnet.ahrq.gov/issue/impact-sars-cov-2-hospital-acquired-infection-rates-united-states-predictions-and-early
August 15, 2012 - Study
Impact of SARS-CoV-2 on hospital acquired infection rates in the United States … December 16, 2020
The psychological experience of obstetric patients and health care … February 7, 2022
View More
Related Resources
Patient … June 9, 2021
Flow accuracy of IV smart pumps outside of patient rooms during COVID-19 … September 23, 2020
Hospital ward adaptation during the COVID-19 pandemic: a national survey
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psnet.ahrq.gov/issue/what-are-experiences-team-members-involved-root-cause-analysis-qualitative-study
August 16, 2023 - August 16, 2023
Issues and complexities in safety culture assessment in healthcare. … December 13, 2023
Improving patient safety governance and systems through learning from … successes and failures: qualitative surveys and interviews with international experts. … December 6, 2023
A mixed-methods analysis of patient safety incidents involving opioid … October 21, 2020
Is one-pen, one-patient achievable in the hospital?