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Laboratory test ordering and results management systems: a qualitative study of safety risks identified by administrators in general practice. | PSNet

psnet.ahrq.gov/issue/laboratory-test-ordering-and-results-management-systems-qualitative-study-safety-risks

March 16, 2016 - Study Laboratory test ordering and results management systems: a qualitative study of safety risks identified by administrators in general practice. Citation Text: Bowie P, Halley L, McKay J. Laboratory test ordering and results management systems: a qualitative study of safety risks id…

Reducing ambulatory central line-associated bloodstream infections: a family-centered approach. | PSNet

psnet.ahrq.gov/issue/reducing-ambulatory-central-line-associated-bloodstream-infections-family-centered-approach

February 15, 2023 - Study Reducing ambulatory central line-associated bloodstream infections: a family-centered approach. Citation Text: Wong CI, Ilowite M, Yan A, et al. Reducing ambulatory central line‐associated bloodstream infections: a family‐centered approach. Pediatr Blood Cancer. 2024;71(8):e31064. …

Evaluation of a Web-based education program on reducing medication dosing error: a multicenter, randomized controlled trial. | PSNet

psnet.ahrq.gov/issue/evaluation-web-based-education-program-reducing-medication-dosing-error-multicenter

May 18, 2022 - Study Evaluation of a Web-based education program on reducing medication dosing error: a multicenter, randomized controlled trial. Citation Text: Frush K, Hohenhaus S, Luo X, et al. Evaluation of a Web-based education program on reducing medication dosing error: a multicenter, randomiz…

Women with large vessel occlusion acute ischemic stroke are less likely to be routed to comprehensive stroke centers. | PSNet

psnet.ahrq.gov/issue/women-large-vessel-occlusion-acute-ischemic-stroke-are-less-likely-be-routed-comprehensive

October 12, 2022 - Study Women with large vessel occlusion acute ischemic stroke are less likely to be routed to comprehensive stroke centers. Citation Text: Tariq MB, Ali I, Salazar‐Marioni S, et al. Women with large vessel occlusion acute ischemic stroke are less likely to be routed to comprehensive stro…

Barriers to implementing a reporting and learning patient safety system: pediatric chiropractic perspective. | PSNet

psnet.ahrq.gov/issue/barriers-implementing-reporting-and-learning-patient-safety-system-pediatric-chiropractic

October 19, 2016 - Study Barriers to implementing a reporting and learning patient safety system: pediatric chiropractic perspective. Citation Text: Pohlman KA, Carroll L, Hartling L, et al. Barriers to Implementing a Reporting and Learning Patient Safety System: Pediatric Chiropractic Perspective. J Evid …

Underdiagnosis of dementia: an observational study of patterns in diagnosis and awareness in US older adults. | PSNet

psnet.ahrq.gov/issue/underdiagnosis-dementia-observational-study-patterns-diagnosis-and-awareness-us-older-adults

October 14, 2016 - Study Classic Underdiagnosis of dementia: an observational study of patterns in diagnosis and awareness in US older adults. Citation Text: Amjad H, Roth DL, Sheehan OC, et al. Underdiagnosis of Dementia: an Observational Study of Patterns in Diagnosis and Awaren…

Addressing mistreatment of providers by patients and family members as a patient safety event. | PSNet

psnet.ahrq.gov/issue/addressing-mistreatment-providers-patients-and-family-members-patient-safety-event

March 30, 2022 - Study Addressing mistreatment of providers by patients and family members as a patient safety event. Citation Text: Hatfield M, Ciaburri R, Shaikh H, et al. Addressing mistreatment of providers by patients and family members as a patient safety event. Hosp Pediatr. 2022;12(2):181-190. do…

Modifying head nurse messages during daily conversations as leverage for safety climate improvement: a randomised field experiment. | PSNet

psnet.ahrq.gov/issue/modifying-head-nurse-messages-during-daily-conversations-leverage-safety-climate-improvement

August 26, 2011 - Study Modifying head nurse messages during daily conversations as leverage for safety climate improvement: a randomised field experiment. Citation Text: Zohar D, Werber YT, Marom R, et al. Modifying head nurse messages during daily conversations as leverage for safety climate improvement…

Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. | PSNet

psnet.ahrq.gov/issue/introduction-medical-emergency-team-met-system-cluster-randomised-controlled-trial

January 18, 2011 - Study Classic Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. Citation Text: Hillman K, Chen J, Cretikos M, et al. Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. L…

Structuring patient and family involvement in medical error event disclosure and analysis. | PSNet

psnet.ahrq.gov/issue/structuring-patient-and-family-involvement-medical-error-event-disclosure-and-analysis

September 01, 2018 - Study Structuring patient and family involvement in medical error event disclosure and analysis. Citation Text: Etchegaray J, Ottosen M, Burress L, et al. Structuring patient and family involvement in medical error event disclosure and analysis. Health Aff (Millwood). 2014;33(1):46-52. d…

Effects of racial bias in pulse oximetry on children and how to address algorithmic bias in clinical medicine. | PSNet

psnet.ahrq.gov/issue/effects-racial-bias-pulse-oximetry-children-and-how-address-algorithmic-bias-clinical

May 08, 2017 - Commentary Effects of racial bias in pulse oximetry on children and how to address algorithmic bias in clinical medicine. Citation Text: Gray KD, Subramaniam HL, Huang ES. Effects of racial bias in pulse oximetry on children and how to address algorithmic bias in clinical medicine. JAMA …

Use of an emergency manual during an intraoperative cardiac arrest by an interprofessional team: a positive-exemplar case study of a new patient safety tool. | PSNet

psnet.ahrq.gov/issue/use-emergency-manual-during-intraoperative-cardiac-arrest-interprofessional-team-positive

April 03, 2019 - Study Use of an emergency manual during an intraoperative cardiac arrest by an interprofessional team: a positive-exemplar case study of a new patient safety tool. Citation Text: Merrell SB, Gaba DM, Agarwala A, et al. Use of an Emergency Manual During an Intraoperative Cardiac Arrest by…

Outpatient adverse drug events identified by screening electronic health records. | PSNet

psnet.ahrq.gov/issue/outpatient-adverse-drug-events-identified-screening-electronic-health-records

June 08, 2016 - Study Outpatient adverse drug events identified by screening electronic health records. Citation Text: Gandhi TK, Seger AC, Overhage M, et al. Outpatient adverse drug events identified by screening electronic health records. J Patient Saf. 2010;6(2):91-6. doi:10.1097/PTS.0b013e3181dcae06…

Implementation of an emergency department sign-out checklist improves transfer of information at shift change. | PSNet

psnet.ahrq.gov/issue/implementation-emergency-department-sign-out-checklist-improves-transfer-information-shift

October 30, 2019 - Study Implementation of an emergency department sign-out checklist improves transfer of information at shift change. Citation Text: Dubosh NM, Carney D, Fisher J, et al. Implementation of an emergency department sign-out checklist improves transfer of information at shift change. J Emerg…

Why an open disclosure procedure is and is not followed after an avoidable adverse event. | PSNet

psnet.ahrq.gov/issue/why-open-disclosure-procedure-and-not-followed-after-avoidable-adverse-event

August 11, 2021 - Study Why an open disclosure procedure is and is not followed after an avoidable adverse event. Citation Text: Carrillo I, Mira JJ, Guilabert M, et al. Why an open disclosure procedure is and is not followed after an avoidable adverse event. J Patient Saf. 2021;17(6):e529-e533. doi:10.10…

Exploring the intersection of structural racism and ageism in healthcare. | PSNet

psnet.ahrq.gov/issue/exploring-intersection-structural-racism-and-ageism-healthcare

January 18, 2023 - Commentary Exploring the intersection of structural racism and ageism in healthcare. Citation Text: Farrell TW, Hung WW, Unroe KT, et al. Exploring the intersection of structural racism and ageism in healthcare. J Am Geriatr Soc. 2022;70(12):3366-3377. doi:10.1111/jgs.18105. Copy Citat…

The perfect storm: exam of a medical error and factors contributing to its possible escalation. | PSNet

psnet.ahrq.gov/issue/perfect-storm-exam-medical-error-and-factors-contributing-its-possible-escalation

October 20, 2021 - Commentary The perfect storm: exam of a medical error and factors contributing to its possible escalation. Citation Text: Walters GK. The perfect storm: exam of a medical error and factors contributing to its possible escalation. J Patient Saf. 2021;17(4):e264-e267. doi:10.1097/pts.00000…

Errors upstream and downstream to the Universal Protocol associated with wrong surgery events in the Veterans Health Administration. | PSNet

psnet.ahrq.gov/issue/errors-upstream-and-downstream-universal-protocol-associated-wrong-surgery-events-veterans

November 21, 2012 - Study Errors upstream and downstream to the Universal Protocol associated with wrong surgery events in the Veterans Health Administration. Citation Text: Paull DE, Mazzia L, Neily J, et al. Errors upstream and downstream to the Universal Protocol associated with wrong surgery events in t…

Completion of recommended tests and referrals in telehealth vs in-person visits. | PSNet

psnet.ahrq.gov/issue/completion-recommended-tests-and-referrals-telehealth-vs-person-visits

January 31, 2024 - Study Completion of recommended tests and referrals in telehealth vs in-person visits. Citation Text: Zhong A, Amat MJ, Anderson TS, et al. Completion of recommended tests and referrals in telehealth vs in-person visits. JAMA Netw Open. 2023;6(11):e2343417. doi:10.1001/jamanetworkopen.20…

Unintended consequences of online consultations: a qualitative study in UK primary care. | PSNet

psnet.ahrq.gov/issue/unintended-consequences-online-consultations-qualitative-study-uk-primary-care

November 16, 2022 - Study Unintended consequences of online consultations: a qualitative study in UK primary care. Citation Text: Turner A, Morris R, Rakhra D, et al. Unintended consequences of online consultations: a qualitative study in UK primary care. Br J Gen Pract. 2021;72(715):e128-e137. doi:10.3399/…

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