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Integrating incident data from five reporting systems to assess patient safety: making sense of the elephant. | PSNet

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November 25, 2009 - Study Classic Integrating incident data from five reporting systems to assess patient safety: making sense of the elephant. Citation Text: Levtzion-Korach O, Frankel A, Alcalai H, et al. Integrating incident data from five reporting systems to assess patient saf…

Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries. | PSNet

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January 09, 2019 - Book/Report Classic Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries. Citation Text: Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries. Levinson DR. Washington, DC: US Departmen…

The barriers and enhancers to trust in a just culture in hospital settings: a systematic review. | PSNet

psnet.ahrq.gov/issue/barriers-and-enhancers-trust-just-culture-hospital-settings-systematic-review

February 02, 2022 - Review The barriers and enhancers to trust in a just culture in hospital settings: a systematic review. Citation Text: van Marum S, Verhoeven D, de Rooy D. The barriers and enhancers to trust in a just culture in hospital settings: a systematic review. J Patient Saf. 2022;18(7):e1067-e10…

The impact of pharmacists-led medicines reconciliation on healthcare outcomes in secondary care: a systematic review and meta-analysis of randomized controlled trials. | PSNet

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August 07, 2024 - Review Emerging Classic The impact of pharmacists-led medicines reconciliation on healthcare outcomes in secondary care: a systematic review and meta-analysis of randomized controlled trials. Citation Text: Cheema E, Alhomoud FK, Kinsara ASA-D, et al. The impact…

How often are potential patient safety events present on admission? | PSNet

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January 26, 2022 - Study Classic How often are potential patient safety events present on admission? Citation Text: Houchens RL, Elixhauser A, Romano PS. How often are potential patient safety events present on admission? Jt Comm J Qual Patient Saf. 2008;34(3):154-63. Copy Citat…

Does root cause analysis improve patient safety? A systematic review at the Department of Veterans Affairs. | PSNet

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March 24, 2021 - Review Does root cause analysis improve patient safety? A systematic review at the Department of Veterans Affairs. Citation Text: Shah F, Falconer EA, Cimiotti JP. Does root cause analysis improve patient safety? A systematic review at the Department of Veterans Affairs. Qual Manag Healt…

Using human factors methods to mitigate bias in artificial intelligence-based clinical decision support. | PSNet

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July 10, 2019 - Commentary Using human factors methods to mitigate bias in artificial intelligence-based clinical decision support. Citation Text: Militello LG, Diiulio J, Wilson DL, et al. Using human factors methods to mitigate bias in artificial intelligence-based clinical decision support. J Am Med …

Learning environments, reliability enhancing work practices, employee engagement, and safety climate in VA cardiac catheterization laboratories. | PSNet

psnet.ahrq.gov/issue/learning-environments-reliability-enhancing-work-practices-employee-engagement-and-safety

August 12, 2020 - Study Learning environments, reliability enhancing work practices, employee engagement, and safety climate in VA cardiac catheterization laboratories. Citation Text: Gilmartin HM, Hess E, Mueller C, et al. Learning environments, reliability enhancing work practices, employee engagement, …

Incorrect surgical procedures within and outside of the operating room. | PSNet

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November 21, 2011 - Study Incorrect surgical procedures within and outside of the operating room. Citation Text: Neily J, Mills PD, Eldridge N, et al. Incorrect surgical procedures within and outside of the operating room. Arch Surg. 2009;144(11):1028-34. doi:10.1001/archsurg.2009.126. Copy Citation F…

Characterization of interventions to reduce the frequency of critical medication doses missed or delayed during perioperative and unit-to-unit patient transfers. | PSNet

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November 16, 2016 - Study Characterization of interventions to reduce the frequency of critical medication doses missed or delayed during perioperative and unit-to-unit patient transfers. Citation Text: Cole E, Duncan R, Grucz T, et al. Characterization of interventions to reduce the frequency of critical m…

Predictive power of the "trigger tool" for the detection of adverse events in general surgery: a multicenter observational validation study. | PSNet

psnet.ahrq.gov/issue/predictive-power-trigger-tool-detection-adverse-events-general-surgery-multicenter

September 13, 2023 - Study Predictive power of the "trigger tool" for the detection of adverse events in general surgery: a multicenter observational validation study. Citation Text: Pérez Zapata AI, Rodríguez Cuéllar E, de la Fuente Bartolomé M, et al. Predictive power of the "Trigger Tool" for the detectio…

Exploring situational awareness in diagnostic errors in primary care. | PSNet

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September 20, 2011 - Study Exploring situational awareness in diagnostic errors in primary care. Citation Text: Singh H, Giardina TD, Petersen LA, et al. Exploring situational awareness in diagnostic errors in primary care. BMJ Qual Saf. 2011;21(1):30-38. doi:10.1136/bmjqs-2011-000310. Copy Citation Fo…

Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain? | PSNet

psnet.ahrq.gov/issue/notification-abnormal-lab-test-results-electronic-medical-record-do-any-safety-concerns

April 04, 2011 - Study Classic Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain? Citation Text: Singh H, Thomas EJ, Sittig DF, et al. Notification of abnormal lab test results in an electronic medical record: do any safet…

Death by suicide within 1 week of hospital discharge: a retrospective study of root cause analysis reports. | PSNet

psnet.ahrq.gov/issue/death-suicide-within-1-week-hospital-discharge-retrospective-study-root-cause-analysis

May 04, 2022 - Study Death by suicide within 1 week of hospital discharge: a retrospective study of root cause analysis reports. Citation Text: Riblet N, Shiner B, Watts B, et al. Death by Suicide Within 1 Week of Hospital Discharge: A Retrospective Study of Root Cause Analysis Reports. J Nerv Ment Dis…

Medication errors in pediatric emergency departments: a systematic review and recommendations for enhancing medication safety. | PSNet

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January 11, 2023 - Review Medication errors in pediatric emergency departments: a systematic review and recommendations for enhancing medication safety. Citation Text: Alsabri M, Eapen D, Sabesan V, et al. Medication errors in pediatric emergency departments: a systematic review and recommendations for enh…

The impact of a diagnostic decision support system on the consultation: perceptions of GPs and patients. | PSNet

psnet.ahrq.gov/issue/impact-diagnostic-decision-support-system-consultation-perceptions-gps-and-patients

June 28, 2017 - Study The impact of a diagnostic decision support system on the consultation: perceptions of GPs and patients. Citation Text: Porat T, Delaney B, Kostopoulou O. The impact of a diagnostic decision support system on the consultation: perceptions of GPs and patients. BMC Med Inform Decis M…

Comparison of appendectomy outcomes between senior general surgeons and general surgery residents. | PSNet

psnet.ahrq.gov/issue/comparison-appendectomy-outcomes-between-senior-general-surgeons-and-general-surgery

May 03, 2023 - Study Comparison of appendectomy outcomes between senior general surgeons and general surgery residents. Citation Text: Siam B, Al-Kurd A, Simanovsky N, et al. Comparison of Appendectomy Outcomes Between Senior General Surgeons and General Surgery Residents. JAMA Surg. 2017;152(7):679-68…

The contribution of staffing to medication administration errors: a text mining analysis of incident report data. | PSNet

psnet.ahrq.gov/issue/contribution-staffing-medication-administration-errors-text-mining-analysis-incident-report

December 21, 2022 - Study The contribution of staffing to medication administration errors: a text mining analysis of incident report data. Citation Text: Härkänen M, Vehviläinen‐Julkunen K, Murrells T, et al. The Contribution of Staffing to Medication Administration Errors: A Text Mining Analysis of Incide…

In Conversation With… Mark L. Graber, MD | PSNet

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January 01, 2016 - The problem of diagnostic error was analyzed by an incredibly talented and knowledgeable committee that … In a famous paper , Georges Bordage analyzed diagnostic error and concluded that the most common reason

Patient Mix-Up | PSNet

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December 01, 2007 - To get a broader picture of the problem, we recently analyzed the hospital's medical service (which accounts

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