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  1. Use of design thinking and human factors approach to improve situation awareness in the pediatric intensive care unit. | PSNet

    psnet.ahrq.gov/issue/use-design-thinking-and-human-factors-approach-improve-situation-awareness-pediatric
    January 19, 2022 - Study Use of design thinking and human factors approach to improve situation awareness in the pediatric intensive care unit. Citation Text: Gifford A, Butcher B, Chima RS, et al. Use of design thinking and human factors approach to improve situation awareness in the pediatric intensive c…

  2. CANDOR Event Checklist | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/checklist4.html
    August 01, 2022 - CANDOR Event Checklist AHRQ Communication and Optimal Resolution Toolkit Purpose: To provide a checklist for the required actions that need to be taken following an event. Who should use this tool?   The Communication and Optimal Resolution (CANDOR) Response Team or designee, unless otherwise indicated. …

  3. Mod4-Event-Checklist (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4/mod4-event-checklist.pdf
    April 01, 2016 - Purpose: To provide a checklist for the required actions that need to be taken following an event. Who should use this tool? The Communication and Optimal Resolution Toolkit (CANDOR) Response Team or designee, unless otherwise indicated. How to use this tool: Use the checklist to ensure that appropriate action is t…

  4. Development of a trigger tool to identify adverse events and harm in emergency medical services. | PSNet

    psnet.ahrq.gov/issue/development-trigger-tool-identify-adverse-events-and-harm-emergency-medical-services
    August 07, 2024 - Study Development of a trigger tool to identify adverse events and harm in emergency medical services. Citation Text: Howard IL, Bowen JM, Shaikh LAHA, et al. Development of a trigger tool to identify adverse events and harm in Emergency Medical Services. Emerg Med J. 2017;34(6):391-397.…

  5. Embracing errors in simulation-based training: the effect of error training on retention and transfer of central venous catheter skills. | PSNet

    psnet.ahrq.gov/issue/embracing-errors-simulation-based-training-effect-error-training-retention-and-transfer
    May 23, 2013 - Study Embracing errors in simulation-based training: the effect of error training on retention and transfer of central venous catheter skills. Citation Text: Gardner AK, Abdelfattah K, Wiersch J, et al. Embracing Errors in Simulation-Based Training: The Effect of Error Training on Retent…

  6. Impact of a relocation to a new critical care building on pediatric safety events. | PSNet

    psnet.ahrq.gov/issue/impact-relocation-new-critical-care-building-pediatric-safety-events
    May 27, 2020 - Study Impact of a relocation to a new critical care building on pediatric safety events. Citation Text: Furthmiller A, Sahay R, Zhang B, et al. Impact of a relocation to a new critical care building on pediatric safety events. J Hosp Med. 2024;19(5):589-595. doi:10.1002/jhm.13324. Copy…

  7. Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the MedTeams project. | PSNet

    psnet.ahrq.gov/issue/error-reduction-and-performance-improvement-emergency-department-through-formal-teamwork
    June 24, 2015 - Study Classic Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the MedTeams project. Citation Text: Morey JC, Simon R, Jay G, et al. Error reduction and performance improvement in t…

  8. An electronic checklist improves transfer and retention of critical information at intraoperative handoff of care. | PSNet

    psnet.ahrq.gov/issue/electronic-checklist-improves-transfer-and-retention-critical-information-intraoperative
    July 21, 2021 - Study An electronic checklist improves transfer and retention of critical information at intraoperative handoff of care. Citation Text: Agarwala A, Firth PG, Albrecht MA, et al. An electronic checklist improves transfer and retention of critical information at intraoperative handoff of c…

  9. Patients' willingness and ability to participate actively in the reduction of clinical errors: a systematic literature review. | PSNet

    psnet.ahrq.gov/issue/patients-willingness-and-ability-participate-actively-reduction-clinical-errors-systematic
    February 24, 2021 - Review Patients' willingness and ability to participate actively in the reduction of clinical errors: a systematic literature review. Citation Text: DOHERTY CAROLE, STAVROPOULOU CHARITINI. Patients' willingness and ability to participate actively in the reduction of clinical errors: a …

  10. Information-gathering patterns associated with higher rates of diagnostic error. | PSNet

    psnet.ahrq.gov/issue/information-gathering-patterns-associated-higher-rates-diagnostic-error
    June 27, 2018 - Study Information-gathering patterns associated with higher rates of diagnostic error. Citation Text: Delzell JE, Chumley H, Webb R, et al. Information-gathering patterns associated with higher rates of diagnostic error. Adv Health Sci Educ Theory Pract. 2009;14(5):697-711. doi:10.1007…

  11. Pediatric medication safety considerations for pharmacists in an adult hospital setting. | PSNet

    psnet.ahrq.gov/issue/pediatric-medication-safety-considerations-pharmacists-adult-hospital-setting
    January 29, 2020 - Commentary Pediatric medication safety considerations for pharmacists in an adult hospital setting. Citation Text: Kennedy AR, Massey LR. Pediatric medication safety considerations for pharmacists in an adult hospital setting. Am J Health Syst Pharm. 2019;76(19):1481-1491. doi:10.1093/aj…

  12. Pathologists' perspectives on disclosing harmful pathology error. | PSNet

    psnet.ahrq.gov/issue/pathologists-perspectives-disclosing-harmful-pathology-error
    January 22, 2020 - Study Pathologists' perspectives on disclosing harmful pathology error. Citation Text: Dintzis SM, Clennon EK, Prouty CD, et al. Pathologists' Perspectives on Disclosing Harmful Pathology Error. Arch Pathol Lab Med. 2017;141(6):841-845. doi:10.5858/arpa.2016-0136-OA. Copy Citation …

  13. Impact of crisis resource management simulation-based training for interprofessional and interdisciplinary teams: a systematic review. | PSNet

    psnet.ahrq.gov/issue/impact-crisis-resource-management-simulation-based-training-interprofessional-and
    November 13, 2019 - Review Impact of crisis resource management simulation-based training for interprofessional and interdisciplinary teams: a systematic review. Citation Text: Fung L, Boet S, Bould D, et al. Impact of crisis resource management simulation-based training for interprofessional and interdisci…

  14. Lack of emergency medical services documentation is associated with poor patient outcomes: a validation of audit filters for prehospital trauma care. | PSNet

    psnet.ahrq.gov/issue/lack-emergency-medical-services-documentation-associated-poor-patient-outcomes-validation
    June 14, 2017 - Study Lack of emergency medical services documentation is associated with poor patient outcomes: a validation of audit filters for prehospital trauma care. Citation Text: Laudermilch DJ, Schiff MA, Nathens AB, et al. Lack of emergency medical services documentation is associated with p…

  15. Appendix N. Part 1: A Clear View of Flexible Endoscope Processing: Transport, Leak Testing, Cleaning - Implementation Guide | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/implementation-guide/app-n.html
    May 01, 2017 - Appendix N. Part 1: A Clear View of Flexible Endoscope Processing: Transport, Leak Testing, Cleaning - Implementation Guide Slide 1: Appendix N. Part 1: A Clear View of Flexible Endoscope Processing: Transport, Leak Testing, Cleaning Susan Klacik B.S., CRCST, CIS, FCS Slide 2: Objectives After this v…

  16. Emergency intubation of children outside of the operating room. | PSNet

    psnet.ahrq.gov/issue/emergency-intubation-children-outside-operating-room
    May 27, 2011 - Study Emergency intubation of children outside of the operating room. Citation Text: Long E, Barrett MJ, Peters C, et al. Emergency intubation of children outside of the operating room. Paediatr Anaesth. 2020;30(3):319-330. doi:10.1111/pan.13784. Copy Citation Format: DOI G…

  17. Ten years later, alarm fatigue is still a safety concern. | PSNet

    psnet.ahrq.gov/issue/ten-years-later-alarm-fatigue-still-safety-concern
    October 25, 2023 - Commentary Ten years later, alarm fatigue is still a safety concern. Citation Text: Albanowski K, Burdick KJ, Bonafide CP, et al. Ten years later, alarm fatigue is still a safety concern. AACN Adv Crit Care. 2023;34(3):189-197. doi:10.4037/aacnacc2023662. Copy Citation Format: …

  18. A method for measuring system safety and latent errors associated with pediatric procedural sedation. | PSNet

    psnet.ahrq.gov/issue/method-measuring-system-safety-and-latent-errors-associated-pediatric-procedural-sedation
    April 11, 2011 - Study A method for measuring system safety and latent errors associated with pediatric procedural sedation. Citation Text: Blike G, Christoffersen K, Cravero JP, et al. A method for measuring system safety and latent errors associated with pediatric procedural sedation. Anesth Analg. 2…

  19. Frontline providers' and patients' perspectives on improving diagnostic safety in the emergency department: a qualitative study. | PSNet

    psnet.ahrq.gov/issue/frontline-providers-and-patients-perspectives-improving-diagnostic-safety-emergency
    May 15, 2024 - Study Frontline providers' and patients' perspectives on improving diagnostic safety in the emergency department: a qualitative study. Citation Text: Mangus CW, James TG, Parker SJ, et al. Frontline providers' and patients' perspectives on improving diagnostic safety in the emergency dep…

  20. What causes delays in diagnosing blood cancers? A rapid review of the evidence. | PSNet

    psnet.ahrq.gov/issue/what-causes-delays-diagnosing-blood-cancers-rapid-review-evidence
    August 14, 2019 - Review What causes delays in diagnosing blood cancers? A rapid review of the evidence. Citation Text: Black GB, Boswell L, Harris J, et al. What causes delays in diagnosing blood cancers? A rapid review of the evidence. Prim Health Care Res Dev. 2023;24:e26. doi:10.1017/s1463423623000129…
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