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TRIAD VII: do prehospital providers understand Physician Orders for Life-Sustaining Treatment documents? | PSNet

psnet.ahrq.gov/issue/triad-vii-do-prehospital-providers-understand-physician-orders-life-sustaining-treatment

September 15, 2021 - Study TRIAD VII: do prehospital providers understand Physician Orders for Life-Sustaining Treatment documents? Citation Text: Mirarchi FL, Cammarata C, Zerkle SW, et al. TRIAD VII: do prehospital providers understand Physician Orders for Life-Sustaining Treatment documents? J Patient Saf…

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…

The effects of harm events on 30-day readmission in surgical patients. | PSNet

psnet.ahrq.gov/issue/effects-harm-events-30-day-readmission-surgical-patients

July 31, 2019 - Study The effects of harm events on 30-day readmission in surgical patients. Citation Text: Kandagatla P, Su W-TK, Adrianto I, et al. The effects of harm events on 30-day readmission in surgical patients. J Healthc Qual. 2021;43(2):101-109. doi:10.1097/jhq.0000000000000261. Copy Citati…

A comparison of hospital adverse events identified by three widely used detection methods. | PSNet

psnet.ahrq.gov/issue/comparison-hospital-adverse-events-identified-three-widely-used-detection-methods

January 04, 2012 - Study A comparison of hospital adverse events identified by three widely used detection methods. Citation Text: Naessens JM, Campbell CR, Huddleston JM, et al. A comparison of hospital adverse events identified by three widely used detection methods. Int J Qual Health Care. 2009;21(4):…

Computerized order entry with limited decision support to prevent prescription errors in a PICU. | PSNet

psnet.ahrq.gov/issue/computerized-order-entry-limited-decision-support-prevent-prescription-errors-picu

January 31, 2018 - Study Computerized order entry with limited decision support to prevent prescription errors in a PICU. Citation Text: Kadmon G, Bron-Harlev E, Nahum E, et al. Computerized order entry with limited decision support to prevent prescription errors in a PICU. Pediatrics. 2009;124(3):935-94…

Improving transfusion safety in the operating room with a barcode scanning system designed specifically for the surgical environment and existing electronic medical record systems: an interrupted time series analysis. | PSNet

psnet.ahrq.gov/issue/improving-transfusion-safety-operating-room-barcode-scanning-system-designed-specifically

February 01, 2023 - Study Improving transfusion safety in the operating room with a barcode scanning system designed specifically for the surgical environment and existing electronic medical record systems: an interrupted time series analysis. Citation Text: Vanneman MW, Balakrishna A, Lang AL, et al. Impro…

Automated identification of antibiotic overdoses and adverse drug events via analysis of prescribing alerts and medication administration records. | PSNet

psnet.ahrq.gov/issue/automated-identification-antibiotic-overdoses-and-adverse-drug-events-analysis-prescribing

May 08, 2017 - Study Automated identification of antibiotic overdoses and adverse drug events via analysis of prescribing alerts and medication administration records. Citation Text: Kirkendall ES, Kouril M, Dexheimer JW, et al. Automated identification of antibiotic overdoses and adverse drug events v…

Medication safety amid technological change: usability evaluation to inform inpatient nurses' electronic health record system transition. | PSNet

psnet.ahrq.gov/issue/medication-safety-amid-technological-change-usability-evaluation-inform-inpatient-nurses

March 22, 2023 - Study Medication safety amid technological change: usability evaluation to inform inpatient nurses' electronic health record system transition. Citation Text: Reale C, Ariosto DA, Weinger MB, et al. Medication safety amid technological change: usability evaluation to inform inpatient nur…

React, reframe and engage. Establishing a receiver mindset for more effective safety negotiations. | PSNet

psnet.ahrq.gov/issue/react-reframe-and-engage-establishing-receiver-mindset-more-effective-safety-negotiations

March 29, 2023 - Study React, reframe and engage. Establishing a receiver mindset for more effective safety negotiations. Citation Text: Barlow M, Watson B, Morse K, et al. React, reframe and engage. Establishing a receiver mindset for more effective safety negotiations. J Health Organ Manag. 2024;38(7):…

Quantifying the burden of opioid medication errors in adult oncology and palliative care settings: a systematic review. | PSNet

psnet.ahrq.gov/issue/quantifying-burden-opioid-medication-errors-adult-oncology-and-palliative-care-settings

May 22, 2019 - Review Quantifying the burden of opioid medication errors in adult oncology and palliative care settings: a systematic review. Citation Text: Heneka N, Shaw T, Rowett D, et al. Quantifying the burden of opioid medication errors in adult oncology and palliative care settings: A systematic…

Estimating deaths due to medical error: the ongoing controversy and why it matters. | PSNet

psnet.ahrq.gov/issue/estimating-deaths-due-medical-error-ongoing-controversy-and-why-it-matters

December 30, 2014 - Commentary Estimating deaths due to medical error: the ongoing controversy and why it matters. Citation Text: Shojania KG, Dixon-Woods M. Estimating deaths due to medical error: the ongoing controversy and why it matters. BMJ Qual Saf. 2017;26(5):423-428. doi:10.1136/bmjqs-2016-006144. …

Prevalence and Economic Burden of Medication Errors in the NHS England. | PSNet

psnet.ahrq.gov/issue/prevalence-and-economic-burden-medication-errors-nhs-england

September 11, 2018 - Book/Report Prevalence and Economic Burden of Medication Errors in the NHS England. Citation Text: Prevalence and Economic Burden of Medication Errors in the NHS England. Elliott RA, Camacho E, Campbell F, et al. Policy Research Unit in Economic Evaluation of Health and Care Intervention…

'I think we should just listen and get out': a qualitative exploration of views and experiences of Patient Safety Walkrounds. | PSNet

psnet.ahrq.gov/issue/i-think-we-should-just-listen-and-get-out-qualitative-exploration-views-and-experiences

June 22, 2022 - Study 'I think we should just listen and get out': a qualitative exploration of views and experiences of Patient Safety Walkrounds. Citation Text: Rotteau L, Shojania KG, Webster F. ‘I think we should just listen and get out’: a qualitative exploration of views and experiences of Patient…

Effect of crew resource management training in a multidisciplinary obstetrical setting. | PSNet

psnet.ahrq.gov/issue/effect-crew-resource-management-training-multidisciplinary-obstetrical-setting

March 06, 2005 - Study Effect of crew resource management training in a multidisciplinary obstetrical setting. Citation Text: Haller G, Garnerin P, Morales M-A, et al. Effect of crew resource management training in a multidisciplinary obstetrical setting. Int J Qual Health Care. 2008;20(4):254-63. doi:…

How reliable are clinical systems in the UK NHS? A study of seven NHS organisations. | PSNet

psnet.ahrq.gov/issue/how-reliable-are-clinical-systems-uk-nhs-study-seven-nhs-organisations

November 26, 2008 - Study How reliable are clinical systems in the UK NHS? A study of seven NHS organisations. Citation Text: Burnett S, Franklin BD, Moorthy K, et al. How reliable are clinical systems in the UK NHS? A study of seven NHS organisations. BMJ Qual Saf. 2012;21(6):466-72. doi:10.1136/bmjqs-2011…

Safety incidents in the primary care office setting. | PSNet

psnet.ahrq.gov/issue/safety-incidents-primary-care-office-setting

October 12, 2016 - Study Safety incidents in the primary care office setting. Citation Text: Rees P, Edwards A, Panesar S, et al. Safety incidents in the primary care office setting. Pediatrics. 2015;135(6):1027-35. doi:10.1542/peds.2014-3259. Copy Citation Format: DOI Google Scholar PubMed B…

Impact of extended-duration shifts on medical errors, adverse events, and attentional failures. | PSNet

psnet.ahrq.gov/issue/impact-extended-duration-shifts-medical-errors-adverse-events-and-attentional-failures

February 02, 2011 - Study Impact of extended-duration shifts on medical errors, adverse events, and attentional failures. Citation Text: Barger LK, Ayas N, Cade BE, et al. Impact of extended-duration shifts on medical errors, adverse events, and attentional failures. PLoS Med. 2006;3(12):e487. Copy Cita…

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…

Trends in healthcare incident reporting and relationship to safety and quality data in acute hospitals: results from the National Reporting and Learning System. | PSNet

psnet.ahrq.gov/issue/trends-healthcare-incident-reporting-and-relationship-safety-and-quality-data-acute-hospitals

March 28, 2011 - Study Trends in healthcare incident reporting and relationship to safety and quality data in acute hospitals: results from the National Reporting and Learning System. Citation Text: Hutchinson A, Young TA, Cooper KL, et al. Trends in healthcare incident reporting and relationship to sa…

The vulnerabilities of computerized physician order entry systems: a qualitative study. | PSNet

psnet.ahrq.gov/issue/vulnerabilities-computerized-physician-order-entry-systems-qualitative-study

July 02, 2019 - Study The vulnerabilities of computerized physician order entry systems: a qualitative study. Citation Text: Slight SP, Eguale T, Amato MG, et al. The vulnerabilities of computerized physician order entry systems: a qualitative study: Table 1. J Am Med Inform Assoc. 2015;23(2):311-316. d…

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