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Improving adverse drug event detection in critically ill patients through screening intensive care unit transfer summaries. | PSNet

psnet.ahrq.gov/issue/improving-adverse-drug-event-detection-critically-ill-patients-through-screening-intensive

February 19, 2014 - Study Improving adverse drug event detection in critically ill patients through screening intensive care unit transfer summaries. Citation Text: Anthes AM, Harinstein LM, Smithburger PL, et al. Improving adverse drug event detection in critically ill patients through screening intensive…

The clinical safety of disabled patients: proposal for a methodology for analysis of health care risks and specific measures for improvement. | PSNet

psnet.ahrq.gov/issue/clinical-safety-disabled-patients-proposal-methodology-analysis-health-care-risks-and

January 17, 2012 - Review The clinical safety of disabled patients: proposal for a methodology for analysis of health care risks and specific measures for improvement. Citation Text: Perea-Pérez B, Labajo-González E, Bratos-Murillo M, et al. The clinical safety of disabled patients: proposal for a method…

Unit-based care teams and the frequency and quality of physician–nurse communications. | PSNet

psnet.ahrq.gov/issue/unit-based-care-teams-and-frequency-and-quality-physician-nurse-communications

November 16, 2022 - Study Unit-based care teams and the frequency and quality of physician–nurse communications. Citation Text: Gordon M, Melvin P, Graham DA, et al. Unit-based care teams and the frequency and quality of physician-nurse communications. Arch Pediatr Adolesc Med. 2011;165(5):424-8. doi:10.100…

Stakeholders in safety: patient reports on unsafe clinical behaviors distinguish hospital mortality rates. | PSNet

psnet.ahrq.gov/issue/stakeholders-safety-patient-reports-unsafe-clinical-behaviors-distinguish-hospital-mortality

November 29, 2023 - Study Stakeholders in safety: patient reports on unsafe clinical behaviors distinguish hospital mortality rates. Citation Text: Reader TW, Gillespie A. Stakeholders in safety: patient reports on unsafe clinical behaviors distinguish hospital mortality rates. J Appl Psychol. 2021;106(3):4…

Evaluation of the suitability of root cause analysis frameworks for the investigation of community-acquired pressure ulcers: a systematic review and documentary analysis. | PSNet

psnet.ahrq.gov/issue/evaluation-suitability-root-cause-analysis-frameworks-investigation-community-acquired

June 16, 2021 - Review Evaluation of the suitability of root cause analysis frameworks for the investigation of community-acquired pressure ulcers: a systematic review and documentary analysis. Citation Text: McGraw C, Drennan VM. Evaluation of the suitability of root cause analysis frameworks for the i…

Evaluation of Quality, Safety, and Value in Veterans Health Administration Facilities, FY 2020. | PSNet

psnet.ahrq.gov/issue/evaluation-quality-safety-and-value-veterans-health-administration-facilities-fy-2020

September 10, 2014 - Book/Report Evaluation of Quality, Safety, and Value in Veterans Health Administration Facilities, FY 2020. Citation Text: Evaluation of Quality, Safety, and Value in Veterans Health Administration Facilities, FY 2020. Washington, DC: Veterans Affairs Office of Inspector General; August …

Preoperative communication between anesthesia, surgery, and primary care providers for older surgical patients. | PSNet

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April 11, 2011 - Study Preoperative communication between anesthesia, surgery, and primary care providers for older surgical patients. Citation Text: Ron D, Gunn CM, Havidich JE, et al. Preoperative communication between anesthesia, surgery, and primary care providers for older surgical patients. Jt Comm…

Risks in the implementation and use of smart pumps in a pediatric intensive care unit: application of the failure mode and effects analysis. | PSNet

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March 09, 2022 - Study Risks in the implementation and use of smart pumps in a pediatric intensive care unit: application of the failure mode and effects analysis. Citation Text: Manrique-Rodríguez S, Sánchez-Galindo AC, López-Herce J, et al. Risks in the implementation and use of smart pumps in a pediat…

The attributes of medical event reporting systems. | PSNet

psnet.ahrq.gov/issue/attributes-medical-event-reporting-systems

February 14, 2024 - Study Classic The attributes of medical event reporting systems. Citation Text: Battles JB, Kaplan HS, van der Schaaf TW, et al. The attributes of medical event-reporting systems: experience with a prototype medical event-reporting system for transfusion medicin…

Technological distractions—part 1 and part 2. | PSNet

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April 24, 2018 - Review Technological distractions—part 1 and part 2. Citation Text: Kane-Gill SL, O'Connor MF, Rothschild JM, et al. Technologic Distractions (Part 1): Summary of Approaches to Manage Alert Quantity With Intent to Reduce Alert Fatigue and Suggestions for Alert Fatigue Metrics. Crit Care …

Computer-assisted process modeling to enhance intraoperative safety in cardiac surgery. | PSNet

psnet.ahrq.gov/issue/computer-assisted-process-modeling-enhance-intraoperative-safety-cardiac-surgery

July 19, 2023 - Study Computer-assisted process modeling to enhance intraoperative safety in cardiac surgery. Citation Text: Tarola CL, Quin JA, Haime ME, et al. Computer-Assisted Process Modeling to Enhance Intraoperative Safety in Cardiac Surgery. JAMA Surg. 2016;151(12):1183-1186. doi:10.1001/jamasur…

Older adults' awareness of deprescribing: a population-based survey. | PSNet

psnet.ahrq.gov/issue/older-adults-awareness-deprescribing-population-based-survey

June 22, 2009 - Study Older adults' awareness of deprescribing: a population-based survey. Citation Text: Turner JP, Tannenbaum C. Older adults' awareness of deprescribing: a population-based survey. J Am Geriatr Soc. 2017;65(12):2691-2696. doi:10.1111/jgs.15079. Copy Citation Format: DOI …

Making a move: using simulation to identify latent safety threats before the care of injured patients in a new physical space. | PSNet

psnet.ahrq.gov/issue/making-move-using-simulation-identify-latent-safety-threats-care-injured-patients-new

December 30, 2014 - Commentary Making a move: using simulation to identify latent safety threats before the care of injured patients in a new physical space. Citation Text: Kotagal M, Falcone RA, Daugherty M, et al. Making a move: Using simulation to identify latent safety threats before the care of injured…

Cognitive engineering to improve patient safety and outcomes in cardiothoracic surgery | PSNet

psnet.ahrq.gov/issue/cognitive-engineering-improve-patient-safety-and-outcomes-cardiothoracic-surgery

January 23, 2017 - Commentary Cognitive engineering to improve patient safety and outcomes in cardiothoracic surgery Citation Text: Zenati MA, Kennedy-Metz L, Dias RD. Cognitive Engineering to Improve Patient Safety and Outcomes in Cardiothoracic Surgery. Semin Thorac Cardiovasc Surg. 2019. doi:10.1053/j.s…

Development and validation of a taxonomy of adverse handover events in hospital settings. | PSNet

psnet.ahrq.gov/issue/development-and-validation-taxonomy-adverse-handover-events-hospital-settings

March 05, 2014 - Study Development and validation of a taxonomy of adverse handover events in hospital settings. Citation Text: Andersen HB, Siemsen IMD, Petersen LF, et al. Development and validation of a taxonomy of adverse handover events in hospital settings. Cognition, Technology & Work. 2014;17(1).…

Impact of a daily huddle on safety in perioperative services. | PSNet

psnet.ahrq.gov/issue/impact-daily-huddle-safety-perioperative-services

March 03, 2021 - Study Impact of a daily huddle on safety in perioperative services. Citation Text: Tuyishime H, Claure RE, Balakrishnan K, et al. Impact of a daily huddle on safety in perioperative services. Jt Comm J Qual Patient Saf. 2024;50(9):678-683. doi:10.1016/j.jcjq.2024.04.012. Copy Citation …

Adapting to new technologies in the operating room. | PSNet

psnet.ahrq.gov/issue/adapting-new-technologies-operating-room

January 16, 2017 - Study Classic Adapting to new technologies in the operating room. Citation Text: Cook RI, Woods DD. Adapting to New Technology in the Operating Room. Hum Factors. 2006;38(4):593-613. doi:10.1518/001872096778827224. Copy Citation Format: DOI Google …

Huddling for high reliability and situation awareness. | PSNet

psnet.ahrq.gov/issue/huddling-high-reliability-and-situation-awareness

January 29, 2014 - Study Huddling for high reliability and situation awareness. Citation Text: Goldenhar LM, Brady PW, Sutcliffe K, et al. Huddling for high reliability and situation awareness. BMJ Qual Saf. 2013;22(11):899-906. doi:10.1136/bmjqs-2012-001467. Copy Citation Format: DOI Google …

Out-of-hospital medication errors: a 6-year analysis of the national poison data system. | PSNet

psnet.ahrq.gov/issue/out-hospital-medication-errors-6-year-analysis-national-poison-data-system

September 08, 2010 - Study Out-of-hospital medication errors: a 6-year analysis of the national poison data system. Citation Text: Shah K, Barker KA. Out-of-hospital medication errors: a 6-year analysis of the national poison data system. Pharmacoepidemiol Drug Saf. 2009;18(11):1080-5. doi:10.1002/pds.1823…

Error or "act of God"? A study of patients' and operating room team members' perceptions of error definition, reporting, and disclosure. | PSNet

psnet.ahrq.gov/issue/error-or-act-god-study-patients-and-operating-room-team-members-perceptions-error-definition

August 10, 2011 - Study Error or "act of God"? A study of patients' and operating room team members' perceptions of error definition, reporting, and disclosure. Citation Text: Espin S, Levinson W, Regehr G, et al. Error or "act of God"? A study of patients' and operating room team members' perceptions o…

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