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Implementing root cause analysis and action: integrating human factors to create strong interventions and reduce risk of patient harm. | PSNet

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December 23, 2020 - Study Implementing root cause analysis and action: integrating human factors to create strong interventions and reduce risk of patient harm. Citation Text: Wolf L, Gorman K, Clark J, et al. Implementing root cause analysis and action: integrating human factors to create strong interventi…

Prevalence and characteristics of physicians prone to malpractice claims. | PSNet

psnet.ahrq.gov/issue/prevalence-and-characteristics-physicians-prone-malpractice-claims

April 03, 2019 - Study Classic Prevalence and characteristics of physicians prone to malpractice claims. Citation Text: Studdert DM, Bismark M, Mello MM, et al. Prevalence and Characteristics of Physicians Prone to Malpractice Claims. New Engl J Med. 2016;374(4):354-362. doi:10.…

Using radiofrequency technology to prevent retained sponges and improve patient outcomes. | PSNet

psnet.ahrq.gov/issue/using-radiofrequency-technology-prevent-retained-sponges-and-improve-patient-outcomes

November 25, 2020 - Study Using radiofrequency technology to prevent retained sponges and improve patient outcomes. Citation Text: Primiano M, Sparks D, Murphy J, et al. Using radiofrequency technology to prevent retained sponges and improve patient outcomes. AORN J. 2020;112(4):345-352. doi:10.1002/aorn.13…

Eliminating central line-associated bloodstream infections: a national patient safety imperative. | PSNet

psnet.ahrq.gov/issue/eliminating-central-line-associated-bloodstream-infections-national-patient-safety-imperative

March 21, 2012 - Study Eliminating central line-associated bloodstream infections: a national patient safety imperative. Citation Text: Berenholtz SM, Lubomski LH, Weeks K, et al. Eliminating central line-associated bloodstream infections: a national patient safety imperative. Infect Control Hosp Epidem…

The extent and importance of unintended consequences related to computerized provider order entry. | PSNet

psnet.ahrq.gov/issue/extent-and-importance-unintended-consequences-related-computerized-provider-order-entry

May 27, 2011 - Study Classic The extent and importance of unintended consequences related to computerized provider order entry. Citation Text: Ash JS, Sittig DF, Poon EG, et al. The extent and importance of unintended consequences related to computerized provider order entry…

Identifying trigger concepts to screen emergency department visits for diagnostic errors. | PSNet

psnet.ahrq.gov/issue/identifying-trigger-concepts-screen-emergency-department-visits-diagnostic-errors

March 12, 2025 - Study Identifying trigger concepts to screen emergency department visits for diagnostic errors. Citation Text: Mahajan P, Pai C-W, Cosby KS, et al. Identifying trigger concepts to screen emergency department visits for diagnostic errors. Diagnosis (Berl). 2021;8(3):340-346. doi:10.1515/d…

Posttraumatic growth and second victim distress resulting from medical mishaps among physicians and nurses. | PSNet

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January 12, 2022 - Study Posttraumatic growth and second victim distress resulting from medical mishaps among physicians and nurses. Citation Text: Pado K, Fraus K, Mulhem E, et al. Posttraumatic growth and second victim distress resulting from medical mishaps among physicians and nurses. J Clin Psychol Me…

Operating room to intensive care unit handoffs and the risks of patient harm. | PSNet

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October 05, 2022 - Study Operating room to intensive care unit handoffs and the risks of patient harm. Citation Text: McElroy LM, Collins KM, Koller FL, et al. Operating room to intensive care unit handoffs and the risks of patient harm. Surgery. 2015;158(3):588-594. doi:10.1016/j.surg.2015.03.061. Copy …

Stroke hospitalization after misdiagnosis of "benign dizziness" is lower in specialty care than general practice: a population-based cohort analysis of missed stroke using SPADE methods. | PSNet

psnet.ahrq.gov/issue/stroke-hospitalization-after-misdiagnosis-benign-dizziness-lower-specialty-care-general

May 12, 2021 - Study Stroke hospitalization after misdiagnosis of "benign dizziness" is lower in specialty care than general practice: a population-based cohort analysis of missed stroke using SPADE methods. Citation Text: Chang T-P, Bery AK, Wang Z, et al. Stroke hospitalization after misdiagnosis of …

Breakdowns in the initial patient-provider encounter are a frequent source of diagnostic error among ischemic stroke cases included in a large medical malpractice claims database. | PSNet

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January 23, 2019 - Review Breakdowns in the initial patient-provider encounter are a frequent source of diagnostic error among ischemic stroke cases included in a large medical malpractice claims database. Citation Text: Liberman AL, Skillings J, Greenberg P, et al. Breakdowns in the initial patient-provid…

An evidence and consensus-based definition of second victim: a strategic topic in healthcare quality, patient safety, person-centeredness and human resource management. | PSNet

psnet.ahrq.gov/issue/evidence-and-consensus-based-definition-second-victim-strategic-topic-healthcare-quality

September 13, 2023 - Commentary An evidence and consensus-based definition of second victim: a strategic topic in healthcare quality, patient safety, person-centeredness and human resource management. Citation Text: Vanhaecht K, Seys D, Russotto S, et al. An evidence and consensus-based definition of second …

Evaluation of medication errors at the transition of care from an ICU to non-ICU location. | PSNet

psnet.ahrq.gov/issue/evaluation-medication-errors-transition-care-icu-non-icu-location

September 23, 2020 - Study Emerging Classic Evaluation of medication errors at the transition of care from an ICU to non-ICU location. Citation Text: Tully AP, Hammond DA, Li C, et al. Evaluation of Medication Errors at the Transition of Care From an ICU to Non-ICU Location. Crit Ca…

Effectiveness of pharmacist intervention to reduce medication errors and health-care resources utilization after transitions of care: a meta-analysis of randomized controlled trials. | PSNet

psnet.ahrq.gov/issue/effectiveness-pharmacist-intervention-reduce-medication-errors-and-health-care-resources

August 04, 2021 - Review Effectiveness of pharmacist intervention to reduce medication errors and health-care resources utilization after transitions of care: a meta-analysis of randomized controlled trials. Citation Text: De Oliveira GS, Castro-Alves LJ, Kendall MC, et al. Effectiveness of Pharmacist Int…

Effect of an emergency department process improvement package on suicide prevention: the ED-SAFE 2 cluster randomized clinical trial. | PSNet

psnet.ahrq.gov/issue/effect-emergency-department-process-improvement-package-suicide-prevention-ed-safe-2-cluster

March 09, 2022 - Study Effect of an emergency department process improvement package on suicide prevention: the ED-SAFE 2 cluster randomized clinical trial. Citation Text: Boudreaux ED, Larkin C, Vallejo Sefair A, et al. Effect of an emergency department process improvement package on suicide prevention:…

Impact of multidisciplinary team huddles on patient safety: a systematic review and proposed taxonomy. | PSNet

psnet.ahrq.gov/issue/impact-multidisciplinary-team-huddles-patient-safety-systematic-review-and-proposed-taxonomy

November 10, 2015 - Review Emerging Classic Impact of multidisciplinary team huddles on patient safety: a systematic review and proposed taxonomy. Citation Text: Franklin BJ, Gandhi TK, Bates DW, et al. Impact of multidisciplinary team huddles on patient safety: a systematic review…

Analysis of suicides reported as adverse events in psychiatry resulted in nine quality improvement initiatives. | PSNet

psnet.ahrq.gov/issue/analysis-suicides-reported-adverse-events-psychiatry-resulted-nine-quality-improvement

October 21, 2020 - Study Analysis of suicides reported as adverse events in psychiatry resulted in nine quality improvement initiatives. Citation Text: Mackenhauer J, Winsløv J-H, Holmskov J, et al. Analysis of suicides reported as adverse events in psychiatry resulted in nine quality improvement initiativ…

Adverse events during intrahospital transport of critically ill patients: a systematic review and meta-analysis. | PSNet

psnet.ahrq.gov/issue/adverse-events-during-intrahospital-transport-critically-ill-patients-systematic-review-and

March 02, 2022 - Study Adverse events during intrahospital transport of critically ill patients: a systematic review and meta-analysis. Citation Text: Murata M, Nakagawa N, Kawasaki T, et al. Adverse events during intrahospital transport of critically ill patients: A systematic review and meta-analysis. …

Post-operative mortality, missed care and nurse staffing in nine countries: a cross-sectional study. | PSNet

psnet.ahrq.gov/issue/post-operative-mortality-missed-care-and-nurse-staffing-nine-countries-cross-sectional-study

December 12, 2014 - June 22, 2022 Factors associated with missed nursing care and nurse-assessed quality

The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research. | PSNet

psnet.ahrq.gov/issue/safety-attitudes-questionnaire-psychometric-properties-benchmarking-data-and-emerging

June 16, 2011 - nursing homes: variance of six patient safety climate factor scores across nursing homes and wards—assessed

Why patient summaries in electronic health records do not provide the cognitive support necessary for nurses' handoffs on medical and surgical units: insights from interviews and observations. | PSNet

psnet.ahrq.gov/issue/why-patient-summaries-electronic-health-records-do-not-provide-cognitive-support-necessary

January 18, 2013 - January 18, 2013 The effect of hospital electronic health record adoption on nurse-assessed

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