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7521. Responding to unprofessional behavior by trainees - a "just culture" framework. | PSNet
      psnet.ahrq.gov/issue/responding-unprofessional-behavior-trainees-just-culture-framework
      June 24, 2020 - Commentary Responding to unprofessional behavior by trainees - a "just culture" framework. Citation Text: Wasserman JA, Redinger M, Gibb T. Responding to Unprofessional Behavior by Trainees — A “Just Culture” Framework. New England Journal of Medicine. 2020;382(8). doi:10.1056/nejmms191…

7522. Classification of opioid dependence, abuse, or overdose in opioid-naive patients as a "Never Event". | PSNet
      psnet.ahrq.gov/issue/classification-opioid-dependence-abuse-or-overdose-opioid-naive-patients-never-event
      September 21, 2022 - Commentary Classification of opioid dependence, abuse, or overdose in opioid-naive patients as a "Never Event". Citation Text: Barth RJ, Waljee JF. Classification of opioid dependence, abuse, or overdose in opioid-naive patients as a "Never Event". JAMA Surg. 2020;155(7):543-544. doi:10.…

7523. Intraoperative adverse events in abdominal surgery: what happens in the operating room does not stay in the operating room. | PSNet
      psnet.ahrq.gov/issue/intraoperative-adverse-events-abdominal-surgery-what-happens-operating-room-does-not-stay
      January 23, 2017 - Study Intraoperative adverse events in abdominal surgery: what happens in the operating room does not stay in the operating room. Citation Text: Bohnen JD, Mavros MN, Ramly EP, et al. Intraoperative Adverse Events in Abdominal Surgery: What Happens in the Operating Room Does Not Stay in …

7524. The safety of Australian healthcare: 10 years after QAHCS. | PSNet
      psnet.ahrq.gov/issue/safety-australian-healthcare-10-years-after-qahcs
      January 12, 2022 - Commentary The safety of Australian healthcare: 10 years after QAHCS. Citation Text: Wilson RML, Van Der Weyden MB. The safety of Australian healthcare: 10 years after QAHCS. Med J Aust. 2005;182(6):260-1. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML E…

7525. Case outcomes in a communication-and-resolution program in New York hospitals. | PSNet
      psnet.ahrq.gov/issue/case-outcomes-communication-and-resolution-program-new-york-hospitals
      February 05, 2014 - Study Case outcomes in a communication-and-resolution program in New York hospitals. Citation Text: Mello MM, Greenberg Y, Senecal SK, et al. Case Outcomes in a Communication-and-Resolution Program in New York Hospitals. Health Serv Res. 2016;51 Suppl 3:2583-2599. doi:10.1111/1475-6773.1…

7526. Healthcare professionals' encounters with ethnic minority patients: the critical incident approach. | PSNet
      psnet.ahrq.gov/issue/healthcare-professionals-encounters-ethnic-minority-patients-critical-incident-approach
      July 29, 2020 - Study Healthcare professionals' encounters with ethnic minority patients: the critical incident approach. Citation Text: Debesay J, Kartzow AH, Fougner M. Healthcare professionals’ encounters with ethnic minority patients: the critical incident approach. Nurs Inq. 2021;29(1):e12421. doi:…

7527. Discrepant advanced directives and code status orders: a preventable medical error. | PSNet
      psnet.ahrq.gov/issue/discrepant-advanced-directives-and-code-status-orders-preventable-medical-error
      October 31, 2018 - Journal Article Discrepant advanced directives and code status orders: a preventable medical error. Citation Text: Meisenberg B, Zaidi S, Franks L, et al. Discrepant Advanced Directives and Code Status Orders: A Preventable Medical Error. J Hosp Med. 2019;14(10):716-718. doi:10.12788/jhm…

7528. Specificity of computerized physician order entry has a significant effect on the efficiency of workflow for critically ill patients. | PSNet
      psnet.ahrq.gov/issue/specificity-computerized-physician-order-entry-has-significant-effect-efficiency-workflow
      March 14, 2022 - Study Specificity of computerized physician order entry has a significant effect on the efficiency of workflow for critically ill patients. Citation Text: Ali NA, Mekhjian HS, Kuehn L, et al. Specificity of computerized physician order entry has a significant effect on the efficiency o…

7529. AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/8.html
      December 01, 2017 - AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention Functional Specifications 3. Specifications for Each Pressure Ulcer Prevention Report (continued) 3.8. Completeness Report 3.8.1. Report Description The Completeness Report is a check of CNA documentation to determine how much of…

7530. Implementation of safety checklists in surgery: a realist synthesis of evidence. | PSNet
      psnet.ahrq.gov/issue/implementation-safety-checklists-surgery-realist-synthesis-evidence
      November 20, 2015 - Review Implementation of safety checklists in surgery: a realist synthesis of evidence. Citation Text: Gillespie BM, Marshall AP. Implementation of safety checklists in surgery: a realist synthesis of evidence. Implement Sci. 2015;10:137. doi:10.1186/s13012-015-0319-9. Copy Citation …

7531. Framing patient safety initiatives: working model and case example. | PSNet
      psnet.ahrq.gov/issue/framing-patient-safety-initiatives-working-model-and-case-example
      April 05, 2017 - Commentary Framing patient safety initiatives: working model and case example. Citation Text: Kruger N, Hurley A, Gustafson M. Framing patient safety initiatives: working model and case example. J Nurs Adm. 2006;36(4):200-204. Copy Citation Format: Google Scholar PubMed B…

7532. On the ball: leadership for patient safety and learning in critical care. | PSNet
      psnet.ahrq.gov/issue/ball-leadership-patient-safety-and-learning-critical-care
      October 16, 2013 - Study On the ball: leadership for patient safety and learning in critical care. Citation Text: Tregunno D, Jeffs L, Hall LMG, et al. On the ball: leadership for patient safety and learning in critical care. J Nurs Adm. 2009;39(7-8):334-9. doi:10.1097/NNA.0b013e3181ae9653. Copy Citatio…

7533. Heparin-containing medical devices and combination products: recommendations for labeling and safety testing. Draft guidance for industry and Food and Drug Administration staff. | PSNet
      psnet.ahrq.gov/issue/heparin-containing-medical-devices-and-combination-products-recommendations-labeling-and
      November 23, 2015 - Regulation Heparin-containing medical devices and combination products: recommendations for labeling and safety testing. Draft guidance for industry and Food and Drug Administration staff. Citation Text: Heparin-containing medical devices and combination products: recommendations for lab…

7534. Perioperative safety: learning, not taking, from aviation. | PSNet
      psnet.ahrq.gov/issue/perioperative-safety-learning-not-taking-aviation
      June 26, 2019 - Commentary Perioperative safety: learning, not taking, from aviation. Citation Text: Neuhaus C, Hofer S, Hofmann G, et al. Perioperative Safety: Learning, Not Taking, from Aviation. Anesth Analg. 2016;122(6):2059-63. doi:10.1213/ANE.0000000000001315. Copy Citation Format: D…

7535. Interprofessional teamwork and team interventions in chronic care: a systematic review. | PSNet
      psnet.ahrq.gov/issue/interprofessional-teamwork-and-team-interventions-chronic-care-systematic-review
      April 24, 2019 - Review Interprofessional teamwork and team interventions in chronic care: a systematic review. Citation Text: Körner M, Bütof S, Müller C, et al. Interprofessional teamwork and team interventions in chronic care: A systematic review. J Interprof Care. 2016;30(1):15-28. doi:10.3109/135618…

7536. Inpatient suicide in a general hospital. | PSNet
      psnet.ahrq.gov/issue/inpatient-suicide-general-hospital
      May 27, 2020 - Study Inpatient suicide in a general hospital. Citation Text: Cheng I-C, Hu F-C, Tseng M-CM. Inpatient suicide in a general hospital. Gen Hosp Psychiatry. 2009;31(2):110-5. doi:10.1016/j.genhosppsych.2008.12.008. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNot…

7537. ‘Ladder’-based safety culture assessments inversely predict safety outcomes. | PSNet
      psnet.ahrq.gov/issue/ladder-based-safety-culture-assessments-inversely-predict-safety-outcomes
      January 22, 2025 - Commentary ‘Ladder’-based safety culture assessments inversely predict safety outcomes. Citation Text: Boskeljon‐Horst L, Sillem S, Dekker SWA. ‘Ladder’‐based safety culture assessments inversely predict safety outcomes. J Contingencies Crisis Manag. 2022;31(3):372-391. doi:10.1111/1468-…

7538. Using simulation to improve root cause analysis of adverse surgical outcomes. | PSNet
      psnet.ahrq.gov/issue/using-simulation-improve-root-cause-analysis-adverse-surgical-outcomes
      May 19, 2021 - Study Using simulation to improve root cause analysis of adverse surgical outcomes. Citation Text: Slakey DP, Simms ER, Rennie K, et al. Using simulation to improve root cause analysis of adverse surgical outcomes. Int J Qual Health Care. 2014;26(2):144-50. doi:10.1093/intqhc/mzu011. C…

7539. First, Do No Harm: Marshaling Clinician Leadership to Counter the Opioid Epidemic. | PSNet
      psnet.ahrq.gov/issue/first-do-no-harm-marshaling-clinician-leadership-counter-opioid-epidemic
      July 19, 2017 - Book/Report First, Do No Harm: Marshaling Clinician Leadership to Counter the Opioid Epidemic. Citation Text: First, Do No Harm: Marshaling Clinician Leadership to Counter the Opioid Epidemic. Adams SM, Blanco C, Chaudhry HJ, et al. Washington, DC: National Academy of Medicine; 2017. ISB…

7540. Hospital deaths in patients with sepsis from 2 independent cohorts. | PSNet
      psnet.ahrq.gov/issue/hospital-deaths-patients-sepsis-2-independent-cohorts
      November 21, 2021 - Study Hospital deaths in patients with sepsis from 2 independent cohorts. Citation Text: Liu V, Escobar GJ, Greene JD, et al. Hospital deaths in patients with sepsis from 2 independent cohorts. JAMA. 2014;312(1):90-2. Copy Citation Format: Google Scholar PubMed BibTeX EndNo…