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  1. The correlation between neonatal intensive care unit safety culture and quality of care. | PSNet

    psnet.ahrq.gov/issue/correlation-between-neonatal-intensive-care-unit-safety-culture-and-quality-care
    November 20, 2019 - Study The correlation between neonatal intensive care unit safety culture and quality of care. Citation Text: Profit J, Sharek PJ, Cui X, et al. The Correlation Between Neonatal Intensive Care Unit Safety Culture and Quality of Care. J Patient Saf. 2020;16(4):e310-e316. doi:10.1097/PTS.0…

  2. A new structure of attention? Open disclosure of adverse events to patients and their families. | PSNet

    psnet.ahrq.gov/issue/new-structure-attention-open-disclosure-adverse-events-patients-and-their-families
    March 04, 2009 - Study A new structure of attention? Open disclosure of adverse events to patients and their families. Citation Text: Iedema R, Jorm C, Wakefield JG, et al. A New Structure of Attention? J Lang Soc Psychol. 2009;28(2). doi:10.1177/0261927x08330614. Copy Citation Format: DOI …

  3. Reducing Preventable Patient Harm Due to Retained Surgical Items: The RSI Bundle | PSNet

    psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
    July 23, 2024 - workgroup review were (1) intraorganizational guidelines were not rooted in evidence and (2) policies varied … Additionally, policies varied around surgical count processes and whether to initiate a surgical stop

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49451/psn-pdf
    June 01, 2004 - The Result Stopped Here June 1, 2004 Astion ML. The Result Stopped Here. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/result-stopped-here The Case A 91-year-old female was transferred to a hospital-based skilled nursing unit from the acute care hospital for continued wound care and intravenous (IV) antib…

  5. Carpe Diem (Seize the Day) | PSNet

    psnet.ahrq.gov/web-mm/carpe-diem-seize-day
    September 01, 2012 - A single standard probably would not satisfy all because of varied culture, social and environmental

  6. Safety culture in the operating room: variability among perioperative healthcare workers. | PSNet

    psnet.ahrq.gov/issue/safety-culture-operating-room-variability-among-perioperative-healthcare-workers
    November 17, 2021 - Study Safety culture in the operating room: variability among perioperative healthcare workers. Citation Text: Pimentel MPT, Choi S, Fiumara K, et al. Safety culture in the operating room: variability among perioperative healthcare workers. J Patient Saf. 2021;17(6):412-416. doi:10.1097/…

  7. Missing the near miss: recognizing valuable learning opportunities in radiation oncology. | PSNet

    psnet.ahrq.gov/issue/missing-near-miss-recognizing-valuable-learning-opportunities-radiation-oncology
    November 18, 2020 - Study Missing the near miss: recognizing valuable learning opportunities in radiation oncology. Citation Text: Kundu P, Jung OS, Valle LF, et al. Missing the near miss: recognizing valuable learning opportunities in radiation oncology. Pract Radiat Oncol. 2021;11(3):e256-e262. doi:10.101…

  8. Comparing NICU teamwork and safety climate across two commonly used survey instruments. | PSNet

    psnet.ahrq.gov/issue/comparing-nicu-teamwork-and-safety-climate-across-two-commonly-used-survey-instruments
    November 20, 2019 - Study Comparing NICU teamwork and safety climate across two commonly used survey instruments. Citation Text: Profit J, Lee HC, Sharek PJ, et al. Comparing NICU teamwork and safety climate across two commonly used survey instruments. BMJ Qual Saf. 2016;25(12):954-961. doi:10.1136/bmjqs-20…

  9. The Result Stopped Here | PSNet

    psnet.ahrq.gov/web-mm/result-stopped-here
    December 01, 2006 - The Result Stopped Here Citation Text: Astion ML. The Result Stopped Here. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pub…

  10. The Safety Attitudes Questionnaire as a tool for benchmarking safety culture in the NICU. | PSNet

    psnet.ahrq.gov/issue/safety-attitudes-questionnaire-tool-benchmarking-safety-culture-nicu
    March 02, 2012 - Study The Safety Attitudes Questionnaire as a tool for benchmarking safety culture in the NICU. Citation Text: Profit J, Etchegaray J, Petersen L, et al. The Safety Attitudes Questionnaire as a tool for benchmarking safety culture in the NICU. Arch Dis Child Fetal Neonatal Ed. 2012;97(…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74121/psn-pdf
    November 30, 2021 - The leading causes also varied by race. … to distinguish between cases (79) and controls (123).10 The test performances of the four systems varied

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866638/psn-pdf
    September 04, 2024 - The problem with 'never events'. September 4, 2024 Zaslow J, Fortier J, Garber G. The problem with ‘never events’. BMJ Qual Saf. 2024;33(9):613-616. doi:10.1136/bmjqs-2023-016981. https://psnet.ahrq.gov/issue/problem-never-events Never events are serious, but preventable, adverse events that result in serious pati…

  13. Evaluating incident learning systems and safety culture in two radiation oncology departments. | PSNet

    psnet.ahrq.gov/issue/evaluating-incident-learning-systems-and-safety-culture-two-radiation-oncology-departments
    June 30, 2021 - Study Evaluating incident learning systems and safety culture in two radiation oncology departments. Citation Text: Adamson L, Beldham‐Collins R, Sykes J, et al. Evaluating incident learning systems and safety culture in two radiation oncology departments. J Med Radiat Sci. 2022;69(2):2…

  14. Association between measured teamwork and medical errors: an observational study of prehospital care in the USA | PSNet

    psnet.ahrq.gov/issue/association-between-measured-teamwork-and-medical-errors-observational-study-prehospital-care
    May 18, 2022 - Study Association between measured teamwork and medical errors: an observational study of prehospital care in the USA Citation Text: Herzberg S, Hansen M, Schoonover A, et al. Association between measured teamwork and medical errors: an observational study of prehospital care in the USA.…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50874/psn-pdf
    February 05, 2020 - Checking In on the Checklist. February 5, 2020 Buissonniere M. Brooklyn NY: Lifebox and Ariadne Labs; 2020. https://psnet.ahrq.gov/issue/checking-checklist Checklists are integrated into error reduction strategies and healthcare team communication efforts worldwide but implementation and impact of the tool varies …

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867639/psn-pdf
    February 26, 2025 - Framing diagnostic error: an epidemiological perspective. February 26, 2025 Hunter MK, Singareddy C, Mundt KA. Framing diagnostic error: an epidemiological perspective. Front Public Health. 2024;12:1479750. doi:10.3389/fpubh.2024.1479750. https://psnet.ahrq.gov/issue/framing-diagnostic-error-epidemiological-perspec…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35528/psn-pdf
    February 22, 2010 - The Swiss cheese model of safety incidents: are there holes in the metaphor? February 22, 2010 Perneger T. The Swiss cheese model of safety incidents: are there holes in the metaphor? BMC Health Serv Res. 2005;5:71. https://psnet.ahrq.gov/issue/swiss-cheese-model-safety-incidents-are-there-holes-metaphor The auth…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48156/psn-pdf
    January 01, 2020 - Study of a multisite prospective adverse event surveillance system. July 31, 2019 Forster AJ, Huang A, Lee TC, et al. Study of a multisite prospective adverse event surveillance system. BMJ Qual Saf. 2020;29(4). doi:10.1136/bmjqs-2018-008664. https://psnet.ahrq.gov/issue/study-multisite-prospective-adverse-event-s…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40269/psn-pdf
    January 01, 2016 - Rapid response systems in the Netherlands. March 9, 2011 Ludikhuize J, Hamming A, De Jonge E, et al. Rapid Response Systems in the Netherlands. Jt Comm J Qual Patient Saf. 2016;37(3):138-149. doi:10.1016/s1553-7250(11)37017-1. https://psnet.ahrq.gov/issue/rapid-response-systems-netherlands Nearly 80% of Dutch hosp…

  20. Patient safety events in out-of-hospital paediatric airway management: a medical record review by the CSI-EMS. | PSNet

    psnet.ahrq.gov/issue/patient-safety-events-out-hospital-paediatric-airway-management-medical-record-review-csi-ems
    June 25, 2018 - Study Patient safety events in out-of-hospital paediatric airway management: a medical record review by the CSI-EMS. Citation Text: Hansen M, Meckler G, Lambert W, et al. Patient safety events in out-of-hospital paediatric airway management: a medical record review by the CSI-EMS. BMJ Op…
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