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Systemic causes of in-hospital intravenous medication errors: a systematic review. | PSNet

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July 01, 2020 - Review Systemic causes of in-hospital intravenous medication errors: a systematic review. Citation Text: Kuitunen S, Niittynen I, Airaksinen M, et al. Systemic causes of in-hospital intravenous medication errors: a systematic review. J Patient Saf. 2021;17(8):e1660-e1668. doi:10.1097/pts…

Statewide NICU central-line–associated bloodstream infection rates decline after bundles and checklists. | PSNet

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September 23, 2020 - Study Statewide NICU central-line–associated bloodstream infection rates decline after bundles and checklists. Citation Text: Schulman J, Stricof R, Stevens TP, et al. Statewide NICU central-line-associated bloodstream infection rates decline after bundles and checklists. Pediatrics. 201…

Using incident reports to assess communication failures and patient outcomes. | PSNet

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February 06, 2019 - Study Using incident reports to assess communication failures and patient outcomes. Citation Text: Umberfield E, Ghaferi AA, Krein SL, et al. Using Incident Reports to Assess Communication Failures and Patient Outcomes. Jt Comm J Qual Patient Saf. 2019;45(6):406-413. doi:10.1016/j.jcjq.2…

Implementing root cause analysis and action: integrating human factors to create strong interventions and reduce risk of patient harm. | PSNet

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December 23, 2020 - Study Implementing root cause analysis and action: integrating human factors to create strong interventions and reduce risk of patient harm. Citation Text: Wolf L, Gorman K, Clark J, et al. Implementing root cause analysis and action: integrating human factors to create strong interventi…

Unscheduled radiologic examination orders in the electronic health record: a novel resource for targeting ambulatory diagnostic errors in radiology. | PSNet

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March 30, 2022 - Study Unscheduled radiologic examination orders in the electronic health record: a novel resource for targeting ambulatory diagnostic errors in radiology. Citation Text: Lacson R, Healey MJ, Cochon LR, et al. Unscheduled Radiologic Examination Orders in the Electronic Health Record: A No…

Patient safety measurement tools used in nursing homes: a systematic literature review. | PSNet

psnet.ahrq.gov/issue/patient-safety-measurement-tools-used-nursing-homes-systematic-literature-review

January 11, 2023 - Review Patient safety measurement tools used in nursing homes: a systematic literature review. Citation Text: Kim K-A, Lee J, Kim D, et al. Patient safety measurement tools used in nursing homes: a systematic literature review. BMC Health Serv Res. 2022;22(1):1376. doi:10.1186/s12913-022…

Associations of person-related, environment-related and communication-related factors on medication errors in public and private hospitals: a retrospective clinical audit. | PSNet

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January 19, 2022 - Study Associations of person-related, environment-related and communication-related factors on medication errors in public and private hospitals: a retrospective clinical audit. Citation Text: Manias E, Street M, Lowe G, et al. Associations of person-related, environment-related and comm…

A longitudinal study of clinical peer review's impact on quality and safety in US hospitals. | PSNet

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March 29, 2023 - Study A longitudinal study of clinical peer review's impact on quality and safety in US hospitals. Citation Text: Edwards MT. A longitudinal study of clinical peer review's impact on quality and safety in U.S. hospitals. J Healthc Manag. 2013;58(5):369-85. Copy Citation Format: …

Patient misidentification events in the Veterans Health Administration: a comprehensive review in the context of high-reliability health care. | PSNet

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November 24, 2021 - Study Patient misidentification events in the Veterans Health Administration: a comprehensive review in the context of high-reliability health care. Citation Text: Kulju S, Morrish W, King LA, et al. Patient misidentification events in the Veterans Health Administration: a comprehensive …

Through the Patient’s Eyes: Understanding and Promoting Patient-Centered Care. | PSNet

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October 04, 2006 - Book/Report Classic Through the Patient’s Eyes: Understanding and Promoting Patient-Centered Care. Citation Text: Through the Patient’s Eyes: Understanding and Promoting Patient-Centered Care. Gerteis M, Edgman-Levitan S, Daley J, et al. San Francisco: Jossey-Ba…

Towards safer, better healthcare: harnessing the natural properties of complex sociotechnical systems. | PSNet

psnet.ahrq.gov/issue/towards-safer-better-healthcare-harnessing-natural-properties-complex-sociotechnical-systems

April 08, 2011 - Commentary Towards safer, better healthcare: harnessing the natural properties of complex sociotechnical systems. Citation Text: Braithwaite J, Runciman WB, Merry AF. Towards safer, better healthcare: harnessing the natural properties of complex sociotechnical systems. Qual Saf Health …

Effect of a comprehensive obstetric patient safety program on compensation payments and sentinel events. | PSNet

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July 26, 2010 - Study Effect of a comprehensive obstetric patient safety program on compensation payments and sentinel events. Citation Text: Grunebaum A, Chervenak F, Skupski D. Effect of a comprehensive obstetric patient safety program on compensation payments and sentinel events. Am J Obstet Gyneco…

Free From Harm: Accelerating Patient Safety Improvement Fifteen Years After To Err Is Human. | PSNet

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November 15, 2016 - Book/Report Free From Harm: Accelerating Patient Safety Improvement Fifteen Years After To Err Is Human. Citation Text: Free From Harm: Accelerating Patient Safety Improvement Fifteen Years After To Err Is Human. Boston, MA: National Patient Safety Foundation; 2015. Copy Citation …

Medical Device Use Error: Root Cause Analysis. | PSNet

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January 10, 2018 - Book/Report Medical Device Use Error: Root Cause Analysis. Citation Text: Medical Device Use Error: Root Cause Analysis. Wiklund M, Dwyer A, Davis E. Boca Raton, FL: CRC Press; 2015. ISBN: 9781498705790. Copy Citation Save Save to your library Print Down…

IHI Skilled Nursing Facility Trigger Tool for Measuring Adverse Events. | PSNet

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February 15, 2017 - Book/Report IHI Skilled Nursing Facility Trigger Tool for Measuring Adverse Events. Citation Text: IHI Skilled Nursing Facility Trigger Tool for Measuring Adverse Events. Adler L, Moore J, Federico F. Cambridge, MA: Institute for Healthcare Improvement; November 2015. Copy Citation …

Piece of my mind. Stories doctors tell. | PSNet

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August 28, 2013 - Commentary Piece of my mind. Stories doctors tell. Citation Text: Moniz T, Lingard LA, Watling C. Stories Doctors Tell. JAMA. 2017;318(2):124-125. doi:10.1001/jama.2017.5518. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged …

Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use. | PSNet

psnet.ahrq.gov/issue/pain-management-and-opioid-epidemic-balancing-societal-and-individual-benefits-and-risks

March 29, 2006 - Book/Report Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use. Citation Text: Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use. Bonnie RJ, Ford M…

AHRQ Communication and Optimal Resolution (CANDOR) Toolkit. | PSNet

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May 25, 2016 - Toolkit AHRQ Communication and Optimal Resolution (CANDOR) Toolkit. Citation Text: AHRQ Communication and Optimal Resolution (CANDOR) Toolkit. Rockville, MD: Agency for Healthcare Research and Quality; May 2016. Copy Citation Save Save to your library Print …

Health Literacy: Past, Present, and Future: Workshop Summary. | PSNet

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December 17, 2014 - Meeting/Conference Proceedings Health Literacy: Past, Present, and Future: Workshop Summary. Citation Text: Health Literacy: Past, Present, and Future: Workshop Summary. Alper J; Roundtable on Health Literacy; Board on Population Health and Public Health Practice; Institute of Medicine. …

Pain Management and Prescription Opioid-related Harms: Exploring the State of the Evidence: Proceedings of a Workshop—in Brief. | PSNet

psnet.ahrq.gov/issue/pain-management-and-prescription-opioid-related-harms-exploring-state-evidence-proceedings

July 05, 2008 - Meeting/Conference Proceedings Pain Management and Prescription Opioid-related Harms: Exploring the State of the Evidence: Proceedings of a Workshop—in Brief. Citation Text: Pain Management and Prescription Opioid-related Harms: Exploring the State of the Evidence: Proceedings of a Works…

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