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Unscheduled radiologic examination orders in the electronic health record: a novel resource for targeting ambulatory diagnostic errors in radiology. | PSNet

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March 30, 2022 - Study Unscheduled radiologic examination orders in the electronic health record: a novel resource for targeting ambulatory diagnostic errors in radiology. Citation Text: Lacson R, Healey MJ, Cochon LR, et al. Unscheduled Radiologic Examination Orders in the Electronic Health Record: A No…

A longitudinal study of clinical peer review's impact on quality and safety in US hospitals. | PSNet

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March 29, 2023 - Study A longitudinal study of clinical peer review's impact on quality and safety in US hospitals. Citation Text: Edwards MT. A longitudinal study of clinical peer review's impact on quality and safety in U.S. hospitals. J Healthc Manag. 2013;58(5):369-85. Copy Citation Format: …

Vital signs: pregnancy-related deaths, United States, 2011-2015, and strategies for prevention, 13 states, 2013-2017. | PSNet

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September 06, 2023 - Study Classic Vital signs: pregnancy-related deaths, United States, 2011-2015, and strategies for prevention, 13 states, 2013-2017. Citation Text: Petersen EE, Davis NL, Goodman D, et al. Vital Signs: Pregnancy-Related Deaths, United States, 2011-2015, and Strat…

Patient safety in inpatient mental health settings: a systematic review. | PSNet

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November 13, 2019 - Review Emerging Classic Patient safety in inpatient mental health settings: a systematic review. Citation Text: Thibaut BI, Dewa LH, Ramtale SC, et al. Patient safety in inpatient mental health settings: a systematic review. BMJ Open. 2019;9(12):e030230. doi:10.…

Patient activation related to fall prevention: a multisite study | PSNet

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February 01, 2023 - Study Patient activation related to fall prevention: a multisite study Citation Text: Christiansen TL, Lipsitz S, Scanlan M, et al. Patient activation related to fall prevention: a multisite study . Jt Comm J Qual Patient Saf. 2020. doi:10.1016/j.jcjq.2019.11.010. Copy Citation Fo…

Comparative accuracy of diagnosis by collective intelligence of multiple physicians vs individual physicians. | PSNet

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January 23, 2017 - Study Emerging Classic Comparative accuracy of diagnosis by collective intelligence of multiple physicians vs individual physicians. Citation Text: Barnett ML, Boddupalli D, Nundy S, et al. Comparative Accuracy of Diagnosis by Collective Intelligence of Multiple…

Insurance claims for wrong-side, wrong-organ, wrong-procedure, or wrong-person surgical errors: a retrospective study for 10 years. | PSNet

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October 20, 2021 - Study Insurance claims for wrong-side, wrong-organ, wrong-procedure, or wrong-person surgical errors: a retrospective study for 10 years. Citation Text: Vacheron C-H, Acker A, Autran M, et al. Insurance claims for wrong-side, wrong-organ, wrong-procedure, or wrong-person surgical errors:…

Adding automation and independent dual verification to reduce wrong blood in tube (WBIT) events. | PSNet

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October 21, 2020 - Study Adding automation and independent dual verification to reduce wrong blood in tube (WBIT) events. Citation Text: Passwater M, Huggins YM, Delvo Favre ED, et al. Adding automation and independent dual verification to reduce wrong blood in tube (WBIT) events. Am J Clin Pathol. 2022;15…

Descriptive analysis of patient misidentification from incident report system data in a large academic hospital federation. | PSNet

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August 24, 2022 - Study Descriptive analysis of patient misidentification from incident report system data in a large academic hospital federation. Citation Text: Abraham P, Augey L, Duclos A, et al. Descriptive analysis of patient misidentification from incident report system data in a large academic hos…

Safe but sound: patient safety meets evidence-based medicine. | PSNet

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March 13, 2013 - Commentary Classic Safe but sound: patient safety meets evidence-based medicine. Citation Text: Shojania KG, Duncan BW, McDonald KM, et al. Safe but Sound. JAMA. 2003;288(4):508-513. doi:10.1001/jama.288.4.508. Copy Citation Format: DOI Google Sc…

Unscheduled return visits to the emergency department with ICU admission: a trigger tool for diagnostic error. | PSNet

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December 02, 2020 - Study Unscheduled return visits to the emergency department with ICU admission: a trigger tool for diagnostic error. Citation Text: Aaronson E, Jansson P, Wittbold K, et al. Unscheduled return visits to the emergency department with ICU admission: A trigger tool for diagnostic error. Am …

Vital signs are still vital: instability on discharge and the risk of post-discharge adverse outcomes. | PSNet

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September 23, 2020 - Study Vital signs are still vital: instability on discharge and the risk of post-discharge adverse outcomes. Citation Text: Nguyen OK, Makam AN, Clark C, et al. Vital Signs Are Still Vital: Instability on Discharge and the Risk of Post-Discharge Adverse Outcomes. J Gen Intern Med. 2017;3…

Intravenous infusion administration: a comparative study of practices and errors between the United States and England and their implications for patient safety. | PSNet

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October 18, 2018 - Study Intravenous infusion administration: a comparative study of practices and errors between the United States and England and their implications for patient safety. Citation Text: Blandford A, Dykes PC, Franklin BD, et al. Intravenous Infusion Administration: A Comparative Study of Pr…

Artificial intelligence for identifying the prevention of medication incidents causing serious or moderate harm: an analysis using incident reporters' views. | PSNet

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March 11, 2020 - Study Artificial intelligence for identifying the prevention of medication incidents causing serious or moderate harm: an analysis using incident reporters' views. Citation Text: Härkänen M, Haatainen K, Vehviläinen-Julkunen K, et al. Artificial intelligence for identifying the preventio…

Patient safety perceptions of primary care providers after implementation of an electronic medical record system. | PSNet

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December 21, 2014 - Study Patient safety perceptions of primary care providers after implementation of an electronic medical record system. Citation Text: McGuire MJ, Noronha G, Samal L, et al. Patient safety perceptions of primary care providers after implementation of an electronic medical record system. …

Automated detection of wrong-drug prescribing errors. | PSNet

psnet.ahrq.gov/issue/automated-detection-wrong-drug-prescribing-errors

April 12, 2017 - Study Automated detection of wrong-drug prescribing errors. Citation Text: Lambert BL, Galanter W, Liu KL, et al. Automated detection of wrong-drug prescribing errors. BMJ Qual Saf. 2019;28(11):908-915. doi:10.1136/bmjqs-2019-009420. Copy Citation Format: DOI Google Scholar…

Usability of a human factors-based clinical decision support in the emergency department: lessons learned for design and implementation. | PSNet

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January 08, 2020 - Study Usability of a human factors-based clinical decision support in the emergency department: lessons learned for design and implementation. Citation Text: Salwei ME, Hoonakker PLT, Carayon P, et al. Usability of a human factors-based clinical decision support in the emergency departme…

Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure injuries and medication administration errors: an integrative review. | PSNet

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July 07, 2021 - Review Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure injuries and medication administration errors: an integrative review. Citation Text: Hada A, Coyer F. Shift‐to‐shift nursing handover interventions associated with improved …

Adverse events in long-term care residents transitioning from hospital back to nursing home. | PSNet

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April 28, 2021 - Study Adverse events in long-term care residents transitioning from hospital back to nursing home. Citation Text: Kapoor A, Field T, Handler S, et al. Adverse Events in Long-term Care Residents Transitioning From Hospital Back to Nursing Home. JAMA Intern Med. 2019;179(9):1254-1261. doi:…

Using event reports in real-time to identify and mitigate patient safety concerns during the COVID-19 pandemic. | PSNet

psnet.ahrq.gov/issue/using-event-reports-real-time-identify-and-mitigate-patient-safety-concerns-during-covid-19

March 23, 2022 - Commentary Using event reports in real-time to identify and mitigate patient safety concerns during the COVID-19 pandemic. Citation Text: Kasda EM, Robson C, Saunders J, et al. Using event reports in real-time to identify and mitigate patient safety concerns during the COVID-19 pandemic.…

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