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Analysis of clinical decision support system malfunctions: a case series and survey. | PSNet

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April 29, 2018 - Study Analysis of clinical decision support system malfunctions: a case series and survey. Citation Text: Wright A, Hickman T-TT, McEvoy D, et al. Analysis of clinical decision support system malfunctions: a case series and survey. J Am Med Inform Assoc. 2016;23(6):1068-1076. doi:10.1093…

Evaluating incident learning systems and safety culture in two radiation oncology departments. | PSNet

psnet.ahrq.gov/issue/evaluating-incident-learning-systems-and-safety-culture-two-radiation-oncology-departments

June 30, 2021 - Study Evaluating incident learning systems and safety culture in two radiation oncology departments. Citation Text: Adamson L, Beldham‐Collins R, Sykes J, et al. Evaluating incident learning systems and safety culture in two radiation oncology departments. J Med Radiat Sci. 2022;69(2):2…

Effectiveness of a barcode medication administration system in reducing preventable adverse drug events in a neonatal intensive care unit: a prospective cohort study. | PSNet

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December 14, 2022 - Study Effectiveness of a barcode medication administration system in reducing preventable adverse drug events in a neonatal intensive care unit: a prospective cohort study. Citation Text: Morriss FH, Abramowitz PW, Nelson S, et al. Effectiveness of a barcode medication administration s…

Preliminary study of patient safety and quality use cases for ICD-11 MMS. | PSNet

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July 22, 2020 - Study Preliminary study of patient safety and quality use cases for ICD-11 MMS. Citation Text: Fenton SH, Giannangelo KL, Stanfill MH. Preliminary study of patient safety and quality use cases for ICD-11 MMS. J Am Med Inform Assoc. 2021;28(11):2346-2353. doi:10.1093/jamia/ocab163. Copy…

Power and conflict: the effect of a superior's interpersonal behaviour on trainees' ability to challenge authority during a simulated airway emergency. | PSNet

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December 13, 2017 - Study Power and conflict: the effect of a superior's interpersonal behaviour on trainees' ability to challenge authority during a simulated airway emergency. Citation Text: Friedman Z, Hayter MA, Everett TC, et al. Power and conflict: the effect of a superior's interpersonal behaviour on…

Validity of the Agency for Healthcare Research and Quality Patient Safety Indicators and the Centers for Medicare and Medicaid Hospital-acquired Conditions: a systematic review and meta-analysis. | PSNet

psnet.ahrq.gov/issue/validity-agency-healthcare-research-and-quality-patient-safety-indicators-and-centers

June 14, 2017 - Review Classic Validity of the Agency for Healthcare Research and Quality Patient Safety Indicators and the Centers for Medicare and Medicaid Hospital-acquired Conditions: a systematic review and meta-analysis. Citation Text: Winters BD, Bharmal A, Wilson RF, et…

Mitigating imperfect data validity in administrative data PSIs: a method for estimating true adverse event rates. | PSNet

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March 17, 2021 - Study Mitigating imperfect data validity in administrative data PSIs: a method for estimating true adverse event rates. Citation Text: Boussat B, Quan H, Labarere J, et al. Mitigating imperfect data validity in administrative data PSIs: a method for estimating true adverse event rates. I…

Association between workarounds and medication administration errors in bar-code-assisted medication administration in hospitals. | PSNet

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August 26, 2020 - Study Classic Association between workarounds and medication administration errors in bar-code-assisted medication administration in hospitals. Citation Text: van der Veen W, van den Bemt PMLA, Wouters H, et al. Association between workarounds and medication adm…

To make or buy patient safety solutions: a resource dependence and transaction cost economics perspective. | PSNet

psnet.ahrq.gov/issue/make-or-buy-patient-safety-solutions-resource-dependence-and-transaction-cost-economics

April 08, 2008 - Study To make or buy patient safety solutions: a resource dependence and transaction cost economics perspective. Citation Text: Fareed N, Mick SS. To make or buy patient safety solutions: a resource dependence and transaction cost economics perspective. Health Care Manage Rev. 2011;36(…

Association of open communication and the emotional and behavioural impact of medical error on patients and families: state-wide cross-sectional survey. | PSNet

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February 16, 2022 - Study Association of open communication and the emotional and behavioural impact of medical error on patients and families: state-wide cross-sectional survey. Citation Text: Prentice JC, Bell SK, Thomas EJ, et al. Association of open communication and the emotional and behavioural impact…

Design and reliability of a specific instrument to evaluate patient safety for patients with acute myocardial infarction treated in a predefined care track: a retrospective patient record review study in a single tertiary hospital in the Netherlands. | PSNet

psnet.ahrq.gov/issue/design-and-reliability-specific-instrument-evaluate-patient-safety-patients-acute-myocardial

October 18, 2023 - Study Design and reliability of a specific instrument to evaluate patient safety for patients with acute myocardial infarction treated in a predefined care track: a retrospective patient record review study in a single tertiary hospital in the Netherlands. Citation Text: Eindhoven DC, Bo…

Trends of diagnostic adverse events in hospital deaths: longitudinal analyses of four retrospective record review studies. | PSNet

psnet.ahrq.gov/issue/trends-diagnostic-adverse-events-hospital-deaths-longitudinal-analyses-four-retrospective

May 18, 2022 - Study Trends of diagnostic adverse events in hospital deaths: longitudinal analyses of four retrospective record review studies. Citation Text: Hooftman J, Zwaan L, Sikkens JJ, et al. Trends of diagnostic adverse events in hospital deaths: longitudinal analyses of four retrospective reco…

Why is learning from patient safety incidents (still) so hard? A sociocultural perspective on learning from incidents in healthcare organizations. | PSNet

psnet.ahrq.gov/issue/why-learning-patient-safety-incidents-still-so-hard-sociocultural-perspective-learning

June 29, 2011 - Study Why is learning from patient safety incidents (still) so hard? A sociocultural perspective on learning from incidents in healthcare organizations. Citation Text: Rowland P, Lan MF, Wan C, et al. Why is learning from patient safety incidents (still) so hard? A sociocultural perspect…

Simulation-debriefing enhanced needs assessment to address quality markers in health care: an innovation for prospective hazard analysis. | PSNet

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June 22, 2022 - Study Simulation-debriefing enhanced needs assessment to address quality markers in health care: an innovation for prospective hazard analysis. Citation Text: Barker LT, Bond WF, Willemsen-Dunlap AM, et al. Simulation-debriefing enhanced needs assessment to address quality markers in hea…

Improving formal incivility reporting in ambulatory oncology: implementing the CIVIC Duty program. | PSNet

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March 14, 2022 - EMERGING INNOVATIONS Improving formal incivility reporting in ambulatory oncology: implementing the CIVIC Duty program. Citation Text: Gordon JN. Improving formal incivility reporting in ambulatory oncology: implementing the CIVIC Duty program. Clin J Oncol Nurs. 2023;27(6):602-606. doi:10.1188/23…

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, …

Toward safer opioid prescribing in HIV care (TOWER): a mixed-methods, cluster-randomized trial. | PSNet

psnet.ahrq.gov/issue/toward-safer-opioid-prescribing-hiv-care-tower-mixed-methods-cluster-randomized-trial

September 07, 2022 - Study Toward safer opioid prescribing in HIV care (TOWER): a mixed-methods, cluster-randomized trial. Citation Text: Cedillo G, George MC, Deshpande R, et al. Toward safer opioid prescribing in HIV care (TOWER): a mixed-methods, cluster-randomized trial. Addict Sci Clin Pract. 2022;17(1)…

Towards safer healthcare: qualitative insights from a process view of organisational learning from failure. | PSNet

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July 21, 2021 - Study Towards safer healthcare: qualitative insights from a process view of organisational learning from failure. Citation Text: Monazam Tabrizi N, Masri F. Towards safer healthcare: qualitative insights from a process view of organisational learning from failure. BMJ Open. 2021;11(8):e0…

The $17.1 billion problem: the annual cost of measurable medical errors. | PSNet

psnet.ahrq.gov/issue/171-billion-problem-annual-cost-measurable-medical-errors

May 26, 2021 - Study Classic The $17.1 billion problem: the annual cost of measurable medical errors. Citation Text: Van Den Bos J, Rustagi K, Gray T, et al. The $17.1 Billion Problem: The Annual Cost Of Measurable Medical Errors. Health Aff. 2011;30(4):596-603. doi:10.1377/hl…

Helping healthcare teams to debrief effectively: associations of debriefers' actions and participants' reflections during team debriefings. | PSNet

psnet.ahrq.gov/issue/helping-healthcare-teams-debrief-effectively-associations-debriefers-actions-and-participants

February 02, 2022 - Study Helping healthcare teams to debrief effectively: associations of debriefers' actions and participants' reflections during team debriefings. Citation Text: Kolbe M, Grande B, Lehmann-Willenbrock N, et al. Helping healthcare teams to debrief effectively: associations of debriefers’ a…

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