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psnet.ahrq.gov/issue/policy-and-practice-use-root-cause-analysis-investigate-clinical-adverse-events-mind-gap
December 09, 2020 - Study
Policy and practice in the use of root cause analysis to investigate clinical adverse events: mind the gap.
Citation Text:
Nicolini D, Waring J, Mengis J. Policy and practice in the use of root cause analysis to investigate clinical adverse events: mind the gap. Soc Sci Med. 2011…
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psnet.ahrq.gov/issue/case-transfusion-error-trauma-patient-subsequent-root-cause-analysis-leading-institutional
March 30, 2022 - Commentary
A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional change.
Citation Text:
Clifford SP, Mick PB, Derhake BM. A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional ch…
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psnet.ahrq.gov/issue/analysis-patient-physician-concordance-understanding-chemotherapy-treatment-plans-among
January 11, 2023 - Study
Analysis of patient-physician concordance in the understanding of chemotherapy treatment plans among patients with cancer.
Citation Text:
Almalki H, Absi A, Alghamdi A, et al. Analysis of patient-physician concordance in the understanding of chemotherapy treatment plans among patie…
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psnet.ahrq.gov/issue/medication-administration-errors-nursing-homes-using-automated-medication-dispensing-system
January 23, 2019 - Study
Medication administration errors in nursing homes using an automated medication dispensing system.
Citation Text:
van den Bemt PMLA, Idzinga JC, Robertz H, et al. Medication administration errors in nursing homes using an automated medication dispensing system. J Am Med Inform As…
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psnet.ahrq.gov/issue/effect-electronic-medication-reconciliation-intervention-adverse-drug-events-cluster
April 29, 2018 - Study
Effect of an Electronic Medication Reconciliation Intervention on Adverse Drug Events: A Cluster Randomized Trial
Citation Text:
Tamblyn R, Abrahamowicz M, Buckeridge DL, et al. Effect of an Electronic Medication Reconciliation Intervention on Adverse Drug Events: A Cluster Randomi…
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psnet.ahrq.gov/issue/correlates-diagnostic-accuracy-patients-nonspecific-complaints
August 18, 2021 - Study
Correlates of diagnostic accuracy in patients with nonspecific complaints.
Citation Text:
Hertwig R, Meier N, Nickel C, et al. Correlates of diagnostic accuracy in patients with nonspecific complaints. Med Decis Making. 2013;33(4):533-43. doi:10.1177/0272989X12470975.
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psnet.ahrq.gov/issue/patient-safety-begins-proper-planning-quantitative-method-improve-hospital-design
July 19, 2023 - Study
Patient safety begins with proper planning: a quantitative method to improve hospital design.
Citation Text:
Birnbach DJ, Nevo I, Scheinman SR, et al. Patient safety begins with proper planning: a quantitative method to improve hospital design. Qual Saf Health Care. 2010;19(5):46…
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psnet.ahrq.gov/issue/analysis-risk-medical-errors-using-structural-equation-modelling-6-month-prospective-cohort
June 10, 2020 - Study
Analysis of risk of medical errors using structural-equation modelling: a 6-month prospective cohort study.
Citation Text:
Tanaka M, Tanaka K, Takano T, et al. Analysis of risk of medical errors using structural-equation modelling: a 6-month prospective cohort study. BMJ Qual Saf…
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psnet.ahrq.gov/issue/medication-accuracy-electronic-health-records-microbial-keratitis
September 29, 2021 - Study
Medication accuracy in electronic health records for microbial keratitis.
Citation Text:
Ashfaq HA, Lester CA, Ballouz D, et al. Medication Accuracy in Electronic Health Records for Microbial Keratitis. JAMA Ophthalmal. 2019;137(8):929-931. doi:10.1001/jamaophthalmol.2019.1444.
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psnet.ahrq.gov/issue/improving-resident-morning-sign-out-use-daily-events-reports
March 04, 2020 - Study
Improving resident morning sign-out by use of daily events reports.
Citation Text:
Nabors C, Patel D, Khera S, et al. Improving resident morning sign-out by use of daily events reports. J Patient Saf. 2015;11(1):36-41. doi:10.1097/PTS.0b013e31829e4f56.
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psnet.ahrq.gov/issue/leading-causes-anesthesia-related-liability-claims-ambulatory-surgery-centers
December 16, 2020 - Study
Leading causes of anesthesia-related liability claims in ambulatory surgery centers.
Citation Text:
Ranum D, Beverly A, Shapiro FE, et al. Leading causes of anesthesia-related liability claims in ambulatory surgery centers. J Patient Saf. 2021;17(7):513-521. doi:10.1097/pts.0000000…
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psnet.ahrq.gov/issue/exploring-relationships-between-hospital-patient-safety-culture-and-adverse-events
August 27, 2012 - Study
Exploring relationships between hospital patient safety culture and adverse events.
Citation Text:
Mardon RE, Khanna K, Sorra J, et al. Exploring relationships between hospital patient safety culture and adverse events. J Patient Saf. 2010;6(4):226-32. doi:10.1097/PTS.0b013e3181fd1…
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psnet.ahrq.gov/issue/american-college-surgeons-and-surgical-infection-society-surgical-site-infection-guidelines
October 23, 2018 - Review
American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update.
Citation Text:
Ban KA, Minei JP, Laronga C, et al. American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update. J Am Coll …
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psnet.ahrq.gov/issue/underlying-risk-factors-prescribing-errors-long-term-aged-care-qualitative-study
August 26, 2020 - Study
Underlying risk factors for prescribing errors in long-term aged care: a qualitative study.
Citation Text:
Tariq A, Georgiou A, Raban MZ, et al. Underlying risk factors for prescribing errors in long-term aged care: a qualitative study. BMJ Qual Saf. 2016;25(9):704-15. doi:10.1136/…
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psnet.ahrq.gov/issue/hidden-costs-reconciling-surgical-sponge-counts
May 08, 2013 - Study
The hidden costs of reconciling surgical sponge counts.
Citation Text:
Steelman VM, Schaapveld AG, Perkhounkova Y, et al. The Hidden Costs of Reconciling Surgical Sponge Counts. AORN J. 2015;102(5):498-506. doi:10.1016/j.aorn.2015.09.002.
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psnet.ahrq.gov/issue/capturing-patients-perspectives-medication-safety-development-patient-centered-medication
February 17, 2021 - Study
Capturing patients' perspectives on medication safety: the development of a patient-centered medication safety framework.
Citation Text:
Giles SJ, Lewis PJ, Phipps D, et al. Capturing Patients' Perspectives on Medication Safety: The Development of a Patient-Centered Medication Safe…
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psnet.ahrq.gov/issue/non-intercepted-dose-errors-prescribing-antineoplastic-treatment-prospective-comparative
June 18, 2013 - Study
Non-intercepted dose errors in prescribing antineoplastic treatment: a prospective, comparative cohort study.
Citation Text:
Mattsson TO, Holm B, Michelsen H, et al. Non-intercepted dose errors in prescribing anti-neoplastic treatment: a prospective, comparative cohort study. Ann O…
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psnet.ahrq.gov/issue/serious-experience-events-applying-patient-safety-concepts-improve-patient-experience
August 04, 2021 - Commentary
Serious experience events: applying patient safety concepts to improve patient experience.
Citation Text:
Donnelly LF, Uhlhorn E, Bargmann-Losche J, et al. Serious experience events: applying patient safety concepts to improve patient experience. J Patient Exp. 2022;9:23743735…
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psnet.ahrq.gov/issue/practice-and-quality-improvement-successful-implementation-teamstepps-tools-academic
April 17, 2019 - Study
Practice and quality improvement: successful implementation of TeamSTEPPS tools into an academic interventional ultrasound practice.
Citation Text:
Gupta RT, Sexton B, Milne J, et al. Practice and quality improvement: successful implementation of TeamSTEPPS tools into an academic i…
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psnet.ahrq.gov/issue/risk-factors-retained-instruments-and-sponges-after-surgery
February 17, 2011 - Study
Classic
Risk factors for retained instruments and sponges after surgery.
Citation Text:
Gawande AA, Studdert DM, Orav J, et al. Risk factors for retained instruments and sponges after surgery. N Engl J Med. 2003;348(3):229-35.
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