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Failure mode and effects analysis to reduce risk of heparin use. | PSNet

psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-reduce-risk-heparin-use

July 19, 2023 - Study Failure mode and effects analysis to reduce risk of heparin use. Citation Text: Pino FA, Weidemann DK, Schroeder LL, et al. Failure mode and effects analysis to reduce risk of heparin use. Am J Health Syst Pharm. 2019;76(23):1972-1979. doi:10.1093/ajhp/zxz229. Copy Citation F…

Navigating a ship with a broken compass: evaluating standard algorithms to measure patient safety. | PSNet

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January 23, 2017 - Study Navigating a ship with a broken compass: evaluating standard algorithms to measure patient safety. Citation Text: Hefner JL, Huerta T, McAlearney AS, et al. Navigating a ship with a broken compass: evaluating standard algorithms to measure patient safety. J Am Med Inform Assoc. 201…

Forum: The 100,000 Lives Campaign: a scientific and policy review [with IHI response]. | PSNet

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March 13, 2013 - Commentary Classic Forum: The 100,000 Lives Campaign: a scientific and policy review [with IHI response]. Citation Text: Wachter R, Pronovost P. The 100,000 Lives Campaign: A scientific and policy review. Jt Comm J Qual Patient Saf. 2006;32(11):621-7. Copy Cit…

Adverse drug event reporting systems: a systematic review. | PSNet

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December 21, 2017 - Review Adverse drug event reporting systems: a systematic review. Citation Text: Bailey C, Peddie D, Wickham ME, et al. Adverse drug event reporting systems: a systematic review. Br J Clin Pharm. 2016;82(1):17-29. doi:10.1111/bcp.12944. Copy Citation Format: DOI Google Scho…

Risk factors for retained instruments and sponges after surgery. | PSNet

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February 17, 2011 - Study Classic Risk factors for retained instruments and sponges after surgery. Citation Text: Gawande AA, Studdert DM, Orav J, et al. Risk factors for retained instruments and sponges after surgery. N Engl J Med. 2003;348(3):229-35. Copy Citation Format:…

Comparing process- and outcome-oriented approaches to voluntary incident reporting in two hospitals. | PSNet

psnet.ahrq.gov/issue/comparing-process-and-outcome-oriented-approaches-voluntary-incident-reporting-two-hospitals

June 15, 2011 - Study Comparing process- and outcome-oriented approaches to voluntary incident reporting in two hospitals. Citation Text: Nuckols TK, Bell D, Paddock SM, et al. Comparing process- and outcome-oriented approaches to voluntary incident reporting in two hospitals. Jt Comm J Qual Patient Saf…

The hidden costs of reconciling surgical sponge counts. | PSNet

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May 08, 2013 - Study The hidden costs of reconciling surgical sponge counts. Citation Text: Steelman VM, Schaapveld AG, Perkhounkova Y, et al. The Hidden Costs of Reconciling Surgical Sponge Counts. AORN J. 2015;102(5):498-506. doi:10.1016/j.aorn.2015.09.002. Copy Citation Format: DOI Goo…

Night-time communication at Stanford University Hospital: perceptions, reality and solutions. | PSNet

psnet.ahrq.gov/issue/night-time-communication-stanford-university-hospital-perceptions-reality-and-solutions

March 24, 2019 - Study Night-time communication at Stanford University Hospital: perceptions, reality and solutions. Citation Text: Sun AJ, Wang L, Go M, et al. Night-time communication at Stanford University Hospital: perceptions, reality and solutions. BMJ Qual Saf. 2018;27(2):156-162. doi:10.1136/bmjq…

Reducing failures in daily medical practice: healthcare failure mode and effect analysis combined with computer simulation. | PSNet

psnet.ahrq.gov/issue/reducing-failures-daily-medical-practice-healthcare-failure-mode-and-effect-analysis-combined

August 10, 2022 - Study Reducing failures in daily medical practice: healthcare failure mode and effect analysis combined with computer simulation. Citation Text: Leeftink AG, Visser J, de Laat JM, et al. Reducing failures in daily medical practice: healthcare failure mode and effect analysis combined wit…

Online patient feedback as a safety valve: an automated language analysis of unnoticed and unresolved safety incidents. | PSNet

psnet.ahrq.gov/issue/online-patient-feedback-safety-valve-automated-language-analysis-unnoticed-and-unresolved

August 05, 2020 - Study Online patient feedback as a safety valve: an automated language analysis of unnoticed and unresolved safety incidents. Citation Text: Gillespie A, Reader TW. Online patient feedback as a safety valve: an automated language analysis of unnoticed and unresolved safety incidents. Ris…

Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer. | PSNet

psnet.ahrq.gov/issue/estimating-hospital-deaths-due-medical-errors-preventability-eye-reviewer

February 24, 2011 - Study Classic Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer. Citation Text: Hayward RA, Hofer TP. Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer. JAMA. 2001;286(4)…

Toward improving patient safety through voluntary peer-to-peer assessment. | PSNet

psnet.ahrq.gov/issue/toward-improving-patient-safety-through-voluntary-peer-peer-assessment

August 25, 2015 - Commentary Toward improving patient safety through voluntary peer-to-peer assessment. Citation Text: Hudson DW, Holzmueller CG, Pronovost P, et al. Toward improving patient safety through voluntary peer-to-peer assessment. Am J Med Qual. 2012;27(3):201-9. doi:10.1177/1062860611421981. …

Interventions to improve safe and effective medicines use by consumers: an overview of systematic reviews. | PSNet

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July 19, 2023 - Review Interventions to improve safe and effective medicines use by consumers: an overview of systematic reviews. Citation Text: Ryan R, Santesso N, Lowe D, et al. Interventions to improve safe and effective medicines use by consumers: an overview of systematic reviews. Cochrane Database…

Adverse events in healthcare: learning from mistakes. | PSNet

psnet.ahrq.gov/issue/adverse-events-healthcare-learning-mistakes

February 08, 2017 - Commentary Adverse events in healthcare: learning from mistakes. Citation Text: Rafter N, Hickey A, Condell S, et al. Adverse events in healthcare: learning from mistakes. QJM. 2015;108(4):273-7. doi:10.1093/qjmed/hcu145. Copy Citation Format: DOI Google Scholar PubMed BibT…

Supplemental nurse staffing in hospitals and quality of care. | PSNet

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February 09, 2011 - Study Supplemental nurse staffing in hospitals and quality of care. Citation Text: Aiken LH, Xue Y, Clarke SP, et al. Supplemental Nurse Staffing in Hospitals and Quality of Care. JONA: The Journal of Nursing Administration. 2007;37(7). doi:10.1097/01.nna.0000285119.53066.ae. Copy Ci…

Who pays for medical errors? An analysis of adverse event costs, the medical liability system, and incentives for patient safety improvement. | PSNet

psnet.ahrq.gov/issue/who-pays-medical-errors-analysis-adverse-event-costs-medical-liability-system-and-incentives

April 13, 2011 - Study Classic Who pays for medical errors? An analysis of adverse event costs, the medical liability system, and incentives for patient safety improvement. Citation Text: Mello MM, Studdert DM, Thomas EJ, et al. Who Pays for Medical Errors? An Analysis of Advers…

Cause and effect analysis of closed claims in obstetrics and gynecology. | PSNet

psnet.ahrq.gov/issue/cause-and-effect-analysis-closed-claims-obstetrics-and-gynecology

April 05, 2017 - Study Cause and effect analysis of closed claims in obstetrics and gynecology. Citation Text: White AA, Pichert JW, Bledsoe SH, et al. Cause and effect analysis of closed claims in obstetrics and gynecology. Obstet Gynecol. 2005;105(5 Pt 1):1031-1038. Copy Citation Format: …

Interventions for preventing falls in acute- and chronic-care hospitals: a systematic review and meta-analysis. | PSNet

psnet.ahrq.gov/issue/interventions-preventing-falls-acute-and-chronic-care-hospitals-systematic-review-and-meta

December 12, 2014 - Review Interventions for preventing falls in acute- and chronic-care hospitals: a systematic review and meta-analysis. Citation Text: Coussement J, De Paepe L, Schwendimann R, et al. Interventions for preventing falls in acute- and chronic-care hospitals: a systematic review and meta-a…

Work system barriers and facilitators in inpatient care transitions of pediatric trauma patients. | PSNet

psnet.ahrq.gov/issue/work-system-barriers-and-facilitators-inpatient-care-transitions-pediatric-trauma-patients

September 11, 2019 - Study Work system barriers and facilitators in inpatient care transitions of pediatric trauma patients. Citation Text: Wooldridge AR, Carayon P, Hoonakker P, et al. Work system barriers and facilitators in inpatient care transitions of pediatric trauma patients. App Ergon. 2020;85:103059…

Medical line entanglement: the unspoken patient safety hazard of medical devices. | PSNet

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May 08, 2019 - Study Medical line entanglement: the unspoken patient safety hazard of medical devices. Citation Text: Larimer C, Sumner V, Wander D. Medical line entanglement: the unspoken patient safety hazard of medical devices. Nutr Clin Pract. 2023;38(6):1296-1308. doi:10.1002/ncp.11000. Copy Cit…

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