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  1. Development and testing of tools to detect ambulatory surgical adverse events. | PSNet

    psnet.ahrq.gov/issue/development-and-testing-tools-detect-ambulatory-surgical-adverse-events
    June 04, 2014 - Study Development and testing of tools to detect ambulatory surgical adverse events. Citation Text: Mull HJ, Borzecki A, Hickson K, et al. Development and testing of tools to detect ambulatory surgical adverse events. J Patient Saf. 2013;9(2):96-102. doi:10.1097/PTS.0b013e31827d1a88. …

  2. Resident physicians' advice seeking and error making: a social networks approach. | PSNet

    psnet.ahrq.gov/issue/resident-physicians-advice-seeking-and-error-making-social-networks-approach
    July 13, 2010 - Study Resident physicians' advice seeking and error making: a social networks approach. Citation Text: Katz-Navon T, Naveh E. Resident physicians' advice seeking and error making: a social networks approach. Health Care Manage Rev. 2022;47(3):e41-e49. doi:10.1097/hmr.0000000000000333. …

  3. Identification of poor performance in a national medical workforce over 11 years: an observational study. | PSNet

    psnet.ahrq.gov/issue/identification-poor-performance-national-medical-workforce-over-11-years-observational-study
    August 12, 2014 - Study Identification of poor performance in a national medical workforce over 11 years: an observational study. Citation Text: Donaldson LJ, Panesar S, McAvoy PA, et al. Identification of poor performance in a national medical workforce over 11 years: an observational study. BMJ Qual Sa…

  4. The emotional impact of medical error involvement on physicians: a call for leadership and organisational accountability. | PSNet

    psnet.ahrq.gov/issue/emotional-impact-medical-error-involvement-physicians-call-leadership-and-organisational
    June 14, 2023 - Review The emotional impact of medical error involvement on physicians: a call for leadership and organisational accountability. Citation Text: Schwappach DL, Boluarte TA. The emotional impact of medical error involvement on physicians: a call for leadership and organisational accountabi…

  5. A review of the current evidence base for significant event analysis. | PSNet

    psnet.ahrq.gov/issue/review-current-evidence-base-significant-event-analysis
    October 14, 2009 - Review A review of the current evidence base for significant event analysis. Citation Text: Bowie P, Pope L, Lough M. A review of the current evidence base for significant event analysis. J Eval Clin Pract. 2008;14(4):520-36. doi:10.1111/j.1365-2753.2007.00908.x. Copy Citation Fo…

  6. Perceptions of effective and ineffective nurse–physician communication in hospitals. | PSNet

    psnet.ahrq.gov/issue/perceptions-effective-and-ineffective-nurse-physician-communication-hospitals
    June 28, 2017 - Study Perceptions of effective and ineffective nurse–physician communication in hospitals. Citation Text: Robinson P, Gorman G, Slimmer LW, et al. Perceptions of effective and ineffective nurse-physician communication in hospitals. Nurs Forum. 2010;45(3):206-16. doi:10.1111/j.1744-6198…

  7. Patient safety in the operating room—part 1 and part 2. | PSNet

    psnet.ahrq.gov/issue/patient-safety-operating-room-part-1-and-part-2
    October 19, 2022 - Review Patient safety in the operating room—part 1 and part 2. Citation Text: Poore SO, Sillah NM, Mahajan AY, et al. Patient safety in the operating room: II. Intraoperative and postoperative. Plast Reconstr Surg. 2012;130(5):1048-58. doi:10.1097/PRS.0b013e318267d531. Copy Citation …

  8. The effects of safety checklists in medicine: a systematic review. | PSNet

    psnet.ahrq.gov/issue/effects-safety-checklists-medicine-systematic-review
    December 07, 2011 - Review The effects of safety checklists in medicine: a systematic review. Citation Text: Thomassen Ø, Storesund A, Søfteland E, et al. The effects of safety checklists in medicine: a systematic review. Acta Anaesthesiol Scand. 2014;58(1):5-18. doi:10.1111/aas.12207. Copy Citation …

  9. Responding to serious medical error in general practice—consequences for the GPs involved: analysis of 75 cases from Germany. | PSNet

    psnet.ahrq.gov/issue/responding-serious-medical-error-general-practice-consequences-gps-involved-analysis-75-cases
    June 19, 2019 - Study Responding to serious medical error in general practice—consequences for the GPs involved: analysis of 75 cases from Germany. Citation Text: Fisseni G, Pentzek M, Abholz H-H. Responding to serious medical error in general practice--consequences for the GPs involved: analysis of 7…

  10. Look-alike, sound-alike drugs review: include look-alike packaging as an additional safety check. | PSNet

    psnet.ahrq.gov/issue/look-alike-sound-alike-drugs-review-include-look-alike-packaging-additional-safety-check
    March 24, 2021 - Study Look-alike, sound-alike drugs review: include look-alike packaging as an additional safety check. Citation Text: McCoy LK. Look-alike, sound-alike drugs review: include look-alike packaging as an additional safety check. Jt Comm J Qual Patient Saf. 2005;31(1):47-53. Copy Citation…

  11. Mistaken identity of skin cleansing solution leading to extensive chemical burns in an extremely preterm infant. | PSNet

    psnet.ahrq.gov/issue/mistaken-identity-skin-cleansing-solution-leading-extensive-chemical-burns-extremely-preterm
    October 19, 2022 - Commentary Mistaken identity of skin cleansing solution leading to extensive chemical burns in an extremely preterm infant. Citation Text: Mannan K, Chow P, Lissauer T, et al. Mistaken identity of skin cleansing solution leading to extensive chemical burns in an extremely preterm infan…

  12. Interventions to increase clinical incident reporting in health care. | PSNet

    psnet.ahrq.gov/issue/interventions-increase-clinical-incident-reporting-health-care
    September 02, 2009 - Review Interventions to increase clinical incident reporting in health care. Citation Text: Parmelli E, Flodgren G, Fraser SG, et al. Interventions to increase clinical incident reporting in health care. Cochrane Database Syst Rev. 2012;8(8):CD005609. doi:10.1002/14651858.cd005609.pub2…

  13. A multiobserver study of the effects of including point-of-care patient photographs with portable radiography: a means to detect wrong-patient errors. | PSNet

    psnet.ahrq.gov/issue/multiobserver-study-effects-including-point-care-patient-photographs-portable-radiography
    March 04, 2015 - Study A multiobserver study of the effects of including point-of-care patient photographs with portable radiography: a means to detect wrong-patient errors. Citation Text: Tridandapani S, Ramamurthy S, Provenzale J, et al. A multiobserver study of the effects of including point-of-care p…

  14. Scale, nature, preventability and causes of adverse events in hospitalised older patients. | PSNet

    psnet.ahrq.gov/issue/scale-nature-preventability-and-causes-adverse-events-hospitalised-older-patients
    July 26, 2011 - Study Scale, nature, preventability and causes of adverse events in hospitalised older patients. Citation Text: Merten H, Zegers M, de Bruijne M, et al. Scale, nature, preventability and causes of adverse events in hospitalised older patients. Age Ageing. 2013;42(1):87-93. doi:10.1093/…

  15. Implementation of a colour-coded universal protocol safety initiative in Guatemala. | PSNet

    psnet.ahrq.gov/issue/implementation-colour-coded-universal-protocol-safety-initiative-guatemala
    October 31, 2017 - Study Implementation of a colour-coded universal protocol safety initiative in Guatemala. Citation Text: Taicher BM, Tew S, Figueroa L, et al. Implementation of a colour-coded universal protocol safety initiative in Guatemala. BMJ Qual Saf. 2018;27(8). doi:10.1136/bmjqs-2017-007217. Co…

  16. Anesthesia machine as a cause of intraoperative "code red" in the labor and delivery suite. | PSNet

    psnet.ahrq.gov/issue/anesthesia-machine-cause-intraoperative-code-red-labor-and-delivery-suite
    August 16, 2023 - Commentary Anesthesia machine as a cause of intraoperative "code red" in the labor and delivery suite. Citation Text: Kuczkowski KM. Anesthesia machine as a cause of intraoperative "code red" in the labor and delivery suite. Arch Gynecol Obstet. 2008;278(5):477-8. doi:10.1007/s00404-008-…

  17. Association between organisational and workplace cultures, and patient outcomes: systematic review. | PSNet

    psnet.ahrq.gov/issue/association-between-organisational-and-workplace-cultures-and-patient-outcomes-systematic
    February 03, 2011 - Review Association between organisational and workplace cultures, and patient outcomes: systematic review. Citation Text: Braithwaite J, Herkes J, Ludlow K, et al. Association between organisational and workplace cultures, and patient outcomes: systematic review. BMJ Open. 2017;7(11). do…

  18. Intensive care unit readmissions in U.S. hospitals: patient characteristics, risk factors, and outcomes. | PSNet

    psnet.ahrq.gov/issue/intensive-care-unit-readmissions-us-hospitals-patient-characteristics-risk-factors-and
    August 04, 2021 - Study Intensive care unit readmissions in U.S. hospitals: patient characteristics, risk factors, and outcomes. Citation Text: Kramer AA, Higgins TL, Zimmerman JE. Intensive care unit readmissions in U.S. hospitals: patient characteristics, risk factors, and outcomes. Crit Care Med. 201…

  19. Pediatric residents' decision-making around disclosing and reporting adverse events: the importance of social context. | PSNet

    psnet.ahrq.gov/issue/pediatric-residents-decision-making-around-disclosing-and-reporting-adverse-events-importance
    January 25, 2017 - Study Pediatric residents' decision-making around disclosing and reporting adverse events: the importance of social context. Citation Text: Coffey M, Thomson K, Tallett S, et al. Pediatric residents' decision-making around disclosing and reporting adverse events: the importance of social…

  20. A review of best practices for intravenous push medication administration. | PSNet

    psnet.ahrq.gov/issue/review-best-practices-intravenous-push-medication-administration
    February 21, 2018 - Review A review of best practices for intravenous push medication administration. Citation Text: Lenz JR, Degnan DD, Hertig JB, et al. A Review of Best Practices for Intravenous Push Medication Administration. J Infus Nurs. 2017;40(6):354-358. doi:10.1097/NAN.0000000000000247. Copy Cit…
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