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A new, evidence-based estimate of patient harms associated with hospital care. | PSNet

psnet.ahrq.gov/issue/new-evidence-based-estimate-patient-harms-associated-hospital-care

October 19, 2022 - Review A new, evidence-based estimate of patient harms associated with hospital care. Citation Text: James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf. 2013;9(3):122-128. doi:10.1097/PTS.0b013e3182948a69. Copy Citation Format: …

Communication failure in the operating room. | PSNet

psnet.ahrq.gov/issue/communication-failure-operating-room

February 25, 2009 - Study Communication failure in the operating room. Citation Text: Halverson AL, Casey JT, Andersson J, et al. Communication failure in the operating room. Surgery. 2011;149(3):305-310. doi:10.1016/j.surg.2010.07.051. Copy Citation Format: DOI Google Scholar PubMed BibTeX …

A theoretical model of flow disruptions for the anesthesia team during cardiovascular surgery. | PSNet

psnet.ahrq.gov/issue/theoretical-model-flow-disruptions-anesthesia-team-during-cardiovascular-surgery

July 21, 2021 - Study A theoretical model of flow disruptions for the anesthesia team during cardiovascular surgery. Citation Text: Boquet A, Cohen T, Diljohn F, et al. A theoretical model of flow disruptions for the anesthesia team during cardiovascular surgery. J Patient Saf. 2021;17(6):e534-e539. doi…

A novel method for reproducibly measuring the effects of interventions to improve emotional climate, indices of team skills and communication, and threat to patient outcome in a high-volume thoracic surgery center. | PSNet

psnet.ahrq.gov/issue/novel-method-reproducibly-measuring-effects-interventions-improve-emotional-climate-indices

March 16, 2011 - Study A novel method for reproducibly measuring the effects of interventions to improve emotional climate, indices of team skills and communication, and threat to patient outcome in a high-volume thoracic surgery center. Citation Text: Nurok M, Lipsitz S, Satwicz P, et al. A novel me…

Second victims need emotional support after adverse events: even in a just safety culture. | PSNet

psnet.ahrq.gov/issue/second-victims-need-emotional-support-after-adverse-events-even-just-safety-culture

April 12, 2023 - Commentary Second victims need emotional support after adverse events: even in a just safety culture. Citation Text: Schrøder K, Lamont RF, Jørgensen JS, et al. Second victims need emotional support after adverse events: even in a just safety culture. BJOG. 2019;126(4):440-442. doi:10.11…

The effect of external inspections on safety in acute hospitals in the National Health Service in England: a controlled interrupted time-series analysis. | PSNet

psnet.ahrq.gov/issue/effect-external-inspections-safety-acute-hospitals-national-health-service-england-controlled

January 12, 2022 - Study The effect of external inspections on safety in acute hospitals in the National Health Service in England: a controlled interrupted time-series analysis. Citation Text: Castro-Avila A, Bloor K, Thompson C. The effect of external inspections on safety in acute hospitals in the Natio…

Inappropriateness of medication prescriptions to elderly patients in the primary care setting: a systematic review. | PSNet

psnet.ahrq.gov/issue/inappropriateness-medication-prescriptions-elderly-patients-primary-care-setting-systematic

February 14, 2024 - Review Inappropriateness of medication prescriptions to elderly patients in the primary care setting: a systematic review. Citation Text: Opondo D, Eslami S, Visscher S, et al. Inappropriateness of medication prescriptions to elderly patients in the primary care setting: a systematic r…

Investigating US medical students' motivation to respond to lapses in professionalism. | PSNet

psnet.ahrq.gov/issue/investigating-us-medical-students-motivation-respond-lapses-professionalism

January 12, 2022 - Study Investigating US medical students' motivation to respond to lapses in professionalism. Citation Text: van der Vossen MM-, Teherani A, van Mook WNKA, et al. Investigating US medical students' motivation to respond to lapses in professionalism. Med Educ. 2018;52(8):838-850. doi:10.11…

Relationship between complaints and quality of care in New Zealand: a descriptive analysis of complainants and non-complainants following adverse events. | PSNet

psnet.ahrq.gov/issue/relationship-between-complaints-and-quality-care-new-zealand-descriptive-analysis

October 21, 2010 - Study Relationship between complaints and quality of care in New Zealand: a descriptive analysis of complainants and non-complainants following adverse events. Citation Text: Bismark MM, Brennan TA, Paterson RJ, et al. Relationship between complaints and quality of care in New Zealand:…

Laboratory safety monitoring of chronic medications in ambulatory care settings. | PSNet

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January 06, 2017 - Study Laboratory safety monitoring of chronic medications in ambulatory care settings. Citation Text: Hurley JS, Roberts M, Solberg LI, et al. Brief report: Laboratory safety monitoring of chronic medications in ambulatory care settings. J Gen Intern Med. 2005;20(4). doi:10.1111/j.1525…

The effect of prescriber education on medication-related patient harm in the hospital: a systematic review. | PSNet

psnet.ahrq.gov/issue/effect-prescriber-education-medication-related-patient-harm-hospital-systematic-review

January 07, 2015 - Review The effect of prescriber education on medication-related patient harm in the hospital: a systematic review. Citation Text: Bos JM, van den Bemt PMLA, de Smet PAGM, et al. The effect of prescriber education on medication-related patient harm in the hospital: a systematic review. Br…

Human error and the problem of causality in analysis of accidents. | PSNet

psnet.ahrq.gov/issue/human-error-and-problem-causality-analysis-accidents

August 25, 2021 - Commentary Classic Human error and the problem of causality in analysis of accidents. Citation Text: Rasmussen J. Human error and the problem of causality in analysis of accidents. Philos Trans R Soc Lond B Biol Sci. 1990;327(1241):449-462. Copy Citation …

System planning for modern-day Just Culture to mitigate worker distress and second victim response. | PSNet

psnet.ahrq.gov/issue/system-planning-modern-day-just-culture-mitigate-worker-distress-and-second-victim-response

July 19, 2023 - Commentary System planning for modern-day Just Culture to mitigate worker distress and second victim response. Citation Text: Sells JR, Cole I, Dharmasukrit C, et al. System planning for modern-day Just Culture to mitigate worker distress and second victim response. BMJ Lead. 2024;8(2):1…

An acetaminophen icon helps reduce medication decision errors in an experimental setting. | PSNet

psnet.ahrq.gov/issue/acetaminophen-icon-helps-reduce-medication-decision-errors-experimental-setting

January 12, 2022 - Study An acetaminophen icon helps reduce medication decision errors in an experimental setting. Citation Text: Shiffman S, Cotton H, Jessurun C, et al. An acetaminophen icon helps reduce medication decision errors in an experimental setting. J Am Pharm Assoc (2003). 2016;56(5):495-503.e4…

Impact of health information technology interventions to improve medication laboratory monitoring for ambulatory patients: a systematic review. | PSNet

psnet.ahrq.gov/issue/impact-health-information-technology-interventions-improve-medication-laboratory-monitoring

August 11, 2010 - Review Impact of health information technology interventions to improve medication laboratory monitoring for ambulatory patients: a systematic review. Citation Text: Fischer SH, Tjia J, Field T. Impact of health information technology interventions to improve medication laboratory moni…

The association between sepsis and potential medical injury among hospitalized patients. | PSNet

psnet.ahrq.gov/issue/association-between-sepsis-and-potential-medical-injury-among-hospitalized-patients

July 15, 2014 - Study The association between sepsis and potential medical injury among hospitalized patients. Citation Text: Liu V, Turk BJ, Rizk NW, et al. The association between sepsis and potential medical injury among hospitalized patients. Chest. 2012;142(3):606-613. doi:10.1378/chest.11-2556. …

Biasing influence of 'mental shortcuts' on diagnostic decision-making: radiologists can overlook breast cancer in mamograms when prior diagnostic information is available. | PSNet

psnet.ahrq.gov/issue/biasing-influence-mental-shortcuts-diagnostic-decision-making-radiologists-can-overlook

April 07, 2021 - Study Biasing influence of 'mental shortcuts' on diagnostic decision-making: radiologists can overlook breast cancer in mamograms when prior diagnostic information is available. Citation Text: Branch F, Santana I, Hegdé J. Biasing influence of 'mental shortcuts' on diagnostic decision-ma…

Analysing potential harm in Australian general practice: an incident-monitoring study. | PSNet

psnet.ahrq.gov/issue/analysing-potential-harm-australian-general-practice-incident-monitoring-study

July 29, 2020 - Study Classic Analysing potential harm in Australian general practice: an incident-monitoring study. Citation Text: Bhasale AL, Miller GC, Reid SE, et al. Analysing potential harm in Australian general practice: an incident-monitoring study. Med J Aust. 1998;1…

Drug-related morbidity and mortality and the economic impact of pharmaceutical care. | PSNet

psnet.ahrq.gov/issue/drug-related-morbidity-and-mortality-and-economic-impact-pharmaceutical-care

December 23, 2008 - Study Drug-related morbidity and mortality and the economic impact of pharmaceutical care. Citation Text: Johnson JA, Bootman JL. Drug-related morbidity and mortality and the economic impact of pharmaceutical care. Am J Health Syst Pharm. 1997;54(5):554-8. Copy Citation Format: …

A dynamic risk management approach for reducing harm from invasive bedside procedures performed during residency. | PSNet

psnet.ahrq.gov/issue/dynamic-risk-management-approach-reducing-harm-invasive-bedside-procedures-performed-during

April 13, 2022 - Commentary A dynamic risk management approach for reducing harm from invasive bedside procedures performed during residency. Citation Text: Warm E, Ahmad Y, Kinnear B, et al. A dynamic risk management approach for reducing harm from invasive bedside procedures performed during residency.…

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