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The source of purchased medications and its impact on medication mistakes and hospitalizations. | PSNet

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March 11, 2020 - Study The source of purchased medications and its impact on medication mistakes and hospitalizations. Citation Text: Coates MC, Granche J, Sefcik JS, et al. The source of purchased medications and its impact on medication mistakes and hospitalizations. Res Gerontol Nurs. 2022;15(2):69-75…

The nature, severity and causes of medication incidents from an Australian community pharmacy incident reporting system: the QUMwatch study. | PSNet

psnet.ahrq.gov/issue/nature-severity-and-causes-medication-incidents-australian-community-pharmacy-incident

May 05, 2021 - Study The nature, severity and causes of medication incidents from an Australian community pharmacy incident reporting system: the QUMwatch study. Citation Text: Adie K, Fois RA, McLachlan AJ, et al. The nature, severity and causes of medication incidents from an Australian community pha…

Safety hazards in cancer care: findings using three different methods. | PSNet

psnet.ahrq.gov/issue/safety-hazards-cancer-care-findings-using-three-different-methods

September 27, 2017 - Study Safety hazards in cancer care: findings using three different methods. Citation Text: Lipczak H, Knudsen JL, Nissen A. Safety hazards in cancer care: findings using three different methods. BMJ Qual Saf. 2011;20(12):1052-6. doi:10.1136/bmjqs.2010.050856. Copy Citation Forma…

A mixed-methods analysis of patient safety incidents involving opioid substitution treatment with methadone or buprenorphine in community-based care in England and Wales. | PSNet

psnet.ahrq.gov/issue/mixed-methods-analysis-patient-safety-incidents-involving-opioid-substitution-treatment

August 25, 2021 - Study A mixed-methods analysis of patient safety incidents involving opioid substitution treatment with methadone or buprenorphine in community-based care in England and Wales. Citation Text: Gibson R, MacLeod N, Donaldson LJ, et al. A mixed‐methods analysis of patient safety incidents i…

A multilevel analysis of U.S. hospital patient safety culture relationships with perceptions of voluntary event reporting. | PSNet

psnet.ahrq.gov/issue/multilevel-analysis-us-hospital-patient-safety-culture-relationships-perceptions-voluntary

December 21, 2016 - Study Classic A multilevel analysis of U.S. hospital patient safety culture relationships with perceptions of voluntary event reporting. Citation Text: Burlison JD, Quillivan RR, Kath LM, et al. A Multilevel Analysis of U.S. Hospital Patient Safety Culture Relat…

Electronic approaches to making sense of the text in the adverse event reporting system. | PSNet

psnet.ahrq.gov/issue/electronic-approaches-making-sense-text-adverse-event-reporting-system

August 03, 2022 - Study Electronic approaches to making sense of the text in the adverse event reporting system. Citation Text: Benin AL, Fodeh SJ, Lee K, et al. Electronic approaches to making sense of the text in the adverse event reporting system. J Healthc Risk Manag. 2016;36(2):10-20. doi:10.1002/jhr…

Improving detection of intraoperative medical errors (iMEs) and intraoperative adverse events (iAEs) and their contribution to postoperative outcomes. | PSNet

psnet.ahrq.gov/issue/improving-detection-intraoperative-medical-errors-imes-and-intraoperative-adverse-events-iaes

June 04, 2014 - Study Improving detection of intraoperative medical errors (iMEs) and intraoperative adverse events (iAEs) and their contribution to postoperative outcomes. Citation Text: Chen Q, Rosen AK, Amirfarzan H, et al. Improving detection of intraoperative medical errors (iMEs) and intraoperativ…

Incidence of wrong-site surgery list errors for a 2-year period in a single national health service board. | PSNet

psnet.ahrq.gov/issue/incidence-wrong-site-surgery-list-errors-2-year-period-single-national-health-service-board

March 27, 2019 - Study Incidence of wrong-site surgery list errors for a 2-year period in a single national health service board. Citation Text: Geraghty A, Ferguson L, McIlhenny C, et al. Incidence of wrong-site surgery list errors for a 2-year period in a single national health service board. J Patient…

Reported clinical incidents of children with intellectual disability: a qualitative analysis. | PSNet

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March 16, 2022 - Study Reported clinical incidents of children with intellectual disability: a qualitative analysis. Citation Text: Ong N, Mimmo L, Barnett D, et al. Reported clinical incidents of children with intellectual disability: a qualitative analysis. Dev Med Child Neurol. 2022;64(11):1359-1365. …

Critical incidents involving the medical emergency team: a 5-year retrospective assessment for healthcare improvement. | PSNet

psnet.ahrq.gov/issue/critical-incidents-involving-medical-emergency-team-5-year-retrospective-assessment

November 11, 2020 - Study Critical incidents involving the medical emergency team: a 5-year retrospective assessment for healthcare improvement. Citation Text: Danielis M, Destrebecq A, Terzoni S, et al. Critical incidents involving the medical emergency team: a 5-year retrospective assessment for healthcar…

Mortality among hospitalized Medicare beneficiaries in the first 2 years following ACGME resident duty hour reform. | PSNet

psnet.ahrq.gov/issue/mortality-among-hospitalized-medicare-beneficiaries-first-2-years-following-acgme-resident

February 17, 2009 - Study Classic Mortality among hospitalized Medicare beneficiaries in the first 2 years following ACGME resident duty hour reform. Citation Text: Meltzer DO, Arora VM. Evaluating Resident Duty Hour Reforms. JAMA. 2007;298(9). doi:10.1001/jama.298.9.1055. Copy…

Prevalence, underlying causes, and preventability of sepsis-associated mortality in US acute care hospitals. | PSNet

psnet.ahrq.gov/issue/prevalence-underlying-causes-and-preventability-sepsis-associated-mortality-us-acute-care

August 20, 2018 - Study Classic Prevalence, underlying causes, and preventability of sepsis-associated mortality in US acute care hospitals. Citation Text: Rhee C, Jones TM, Hamad Y, et al. Prevalence, Underlying Causes, and Preventability of Sepsis-Associated Mortality in US Acu…

Adherence to Surgical Care Improvement Project measures and the association with postoperative infections. | PSNet

psnet.ahrq.gov/issue/adherence-surgical-care-improvement-project-measures-and-association-postoperative-infections

November 25, 2020 - Study Classic Adherence to Surgical Care Improvement Project measures and the association with postoperative infections. Citation Text: Stulberg JJ, Delaney CP, Neuhauser D, et al. Adherence to surgical care improvement project measures and the association wit…

Disorganized care: the findings of an iterative, in-depth analysis of surgical morbidity and mortality. | PSNet

psnet.ahrq.gov/issue/disorganized-care-findings-iterative-depth-analysis-surgical-morbidity-and-mortality

October 19, 2022 - Study Disorganized care: the findings of an iterative, in-depth analysis of surgical morbidity and mortality. Citation Text: Anderson CI, Nelson CS, Graham CF, et al. Disorganized care: the findings of an iterative, in-depth analysis of surgical morbidity and mortality. J Surg Res. 201…

Medication safety event reporting: factors that contribute to safety events during times of organizational stress. | PSNet

psnet.ahrq.gov/issue/medication-safety-event-reporting-factors-contribute-safety-events-during-times

June 21, 2023 - Study Medication safety event reporting: factors that contribute to safety events during times of organizational stress. Citation Text: Cohen TN, Berdahl CT, Coleman BL, et al. Medication safety event reporting: factors that contribute to safety events during times of organizational stre…

Systematic root cause analysis of adverse drug events in a tertiary referral hospital. | PSNet

psnet.ahrq.gov/issue/systematic-root-cause-analysis-adverse-drug-events-tertiary-referral-hospital

November 16, 2022 - Study Classic Systematic root cause analysis of adverse drug events in a tertiary referral hospital. Citation Text: Rex JH, Turnbull JE, Allen SJ, et al. Systematic Root Cause Analysis of Adverse Drug Events in a Tertiary Referral Hospital. Jt Comm J Qual Improv…

Observer-based tools for non-technical skills assessment in simulated and real clinical environments in healthcare: a systematic review. | PSNet

psnet.ahrq.gov/issue/observer-based-tools-non-technical-skills-assessment-simulated-and-real-clinical-environments

September 02, 2015 - Review Emerging Classic Observer-based tools for non-technical skills assessment in simulated and real clinical environments in healthcare: a systematic review. Citation Text: Higham H, Greig PR, Rutherford J, et al. Observer-based tools for non-technical skills…

Outpatient CPOE orders discontinued due to 'erroneous entry': prospective survey of prescribers' explanations for errors. | PSNet

psnet.ahrq.gov/issue/outpatient-cpoe-orders-discontinued-due-erroneous-entry-prospective-survey-prescribers

October 13, 2018 - Study Outpatient CPOE orders discontinued due to 'erroneous entry': prospective survey of prescribers' explanations for errors. Citation Text: Hickman T-TT, Quist AJL, Salazar A, et al. Outpatient CPOE orders discontinued due to 'erroneous entry': prospective survey of prescribers' expla…

Surgical checklist implementation project: the impact of variable WHO checklist compliance on risk-adjusted clinical outcomes after national implementation: a longitudinal study. | PSNet

psnet.ahrq.gov/issue/surgical-checklist-implementation-project-impact-variable-who-checklist-compliance-risk

June 22, 2016 - Study Surgical checklist implementation project: the impact of variable WHO checklist compliance on risk-adjusted clinical outcomes after national implementation: a longitudinal study. Citation Text: Mayer EK, Sevdalis N, Rout S, et al. Surgical Checklist Implementation Project: The Impa…

Learning from different lenses: reports of medical errors in primary care by clinicians, staff, and patients: a project of the American Academy of Family Physicians National Research Network. | PSNet

psnet.ahrq.gov/issue/learning-different-lenses-reports-medical-errors-primary-care-clinicians-staff-and-patients

June 11, 2008 - Study Learning from different lenses: reports of medical errors in primary care by clinicians, staff, and patients: a project of the American Academy of Family Physicians National Research Network. Citation Text: Phillips RL, Dovey SM, Graham D, et al. Learning From Different Lenses: R…

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