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The nature and causes of unintended events reported at 10 internal medicine departments. | PSNet

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August 17, 2016 - Study The nature and causes of unintended events reported at 10 internal medicine departments. Citation Text: Lubberding S, Zwaan L, Timmermans D, et al. The nature and causes of unintended events reported at 10 internal medicine departments. J Patient Saf. 2011;7(4):224-31. doi:10.109…

The relationship between computerized physician order entry and pediatric adverse drug events: a nested matched case-control study. | PSNet

psnet.ahrq.gov/issue/relationship-between-computerized-physician-order-entry-and-pediatric-adverse-drug-events

July 13, 2009 - Study The relationship between computerized physician order entry and pediatric adverse drug events: a nested matched case-control study. Citation Text: Yu F, Salas M, Kim Y-I, et al. The relationship between computerized physician order entry and pediatric adverse drug events: a nested…

A systematic review of the prevalence and types of adverse events in interfacility critical care transfers by paramedics. | PSNet

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November 25, 2020 - Review A systematic review of the prevalence and types of adverse events in interfacility critical care transfers by paramedics. Citation Text: Alabdali A, Fisher JD, Trivedy C, et al. A Systematic Review of the Prevalence and Types of Adverse Events in Interfacility Critical Care Transf…

Making patients safer: nurses' responses to patient safety alerts. | PSNet

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April 13, 2011 - Study Making patients safer: nurses' responses to patient safety alerts. Citation Text: Lankshear A, Lowson K, Harden J, et al. Making patients safer: nurses’ responses to patient safety alerts. J Adv Nurs. 2008;63(6). doi:10.1111/j.1365-2648.2008.04741.x. Copy Citation Format: …

Serious adverse events in pediatric procedural sedation before and after the implementation of a pre-sedation checklist. | PSNet

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February 12, 2020 - Study Serious adverse events in pediatric procedural sedation before and after the implementation of a pre-sedation checklist. Citation Text: Librov S, Shavit I. Serious adverse events in pediatric procedural sedation before and after the implementation of a pre-sedation checklist. J Pai…

Evaluation of near-miss wrong-patient events in radiology reports. | PSNet

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June 13, 2015 - Study Evaluation of near-miss wrong-patient events in radiology reports. Citation Text: Sadigh G, Loehfelm T, Applegate KE, et al. JOURNAL CLUB: Evaluation of Near-Miss Wrong-Patient Events in Radiology Reports. AJR Am J Roentgenol. 2015;205(2):337-43. doi:10.2214/AJR.14.13339. Copy Ci…

Debunking the myth that the majority of medical errors are attributed to communication. | PSNet

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February 14, 2024 - Journal Article Debunking the myth that the majority of medical errors are attributed to communication. Citation Text: Clapper TC, Ching K. Debunking the myth that the majority of medical errors are attributed to communication. Med Educ. 2020;54(1):74-81. doi:10.1111/medu.13821. Copy C…

What is driving hospitals' patient-safety efforts? | PSNet

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February 10, 2015 - Commentary What is driving hospitals' patient-safety efforts? Citation Text: Devers KJ, Pham HH, Liu G. What is driving hospitals' patient-safety efforts? Health Aff (Millwood). 2004;23(2):103-15. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7…

A lethal hidden curriculum—death of a medical student from opioid use disorder. | PSNet

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October 19, 2022 - Commentary A lethal hidden curriculum—death of a medical student from opioid use disorder. Citation Text: Lucey CR, Jones L, Eastburn A. A Lethal Hidden Curriculum - Death of a Medical Student from Opioid Use Disorder. N Engl J Med. 2019;381(9):793-795. doi:10.1056/NEJMp1901537. Copy C…

Effect of distractions on operative performance and ability to multitask—a case for deliberate practice. | PSNet

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September 15, 2010 - Study Effect of distractions on operative performance and ability to multitask—a case for deliberate practice. Citation Text: Ahmed A, Ahmad M, Stewart M, et al. Effect of distractions on operative performance and ability to multitask--a case for deliberate practice. Laryngoscope. 2015;1…

Clinical decision support as a prevention tool for medication errors in the operating room: a retrospective cross-sectional study. | PSNet

psnet.ahrq.gov/issue/clinical-decision-support-prevention-tool-medication-errors-operating-room-retrospective

July 05, 2023 - Study Clinical decision support as a prevention tool for medication errors in the operating room: a retrospective cross-sectional study. Citation Text: Amici LD, van Pelt M, Mylott L, et al. Clinical decision support as a prevention tool for medication errors in the operating room: a ret…

Risk-adjusted cumulative sum for early detection of hospitals with excess perioperative mortality. | PSNet

psnet.ahrq.gov/issue/risk-adjusted-cumulative-sum-early-detection-hospitals-excess-perioperative-mortality

August 14, 2019 - Study Risk-adjusted cumulative sum for early detection of hospitals with excess perioperative mortality. Citation Text: Chen VW, Chidi AP, Dong Y, et al. Risk-adjusted cumulative sum for early detection of hospitals with excess perioperative mortality. JAMA Surg. 2023;158(11):1176. doi:1…

Incivility and clinical performance, teamwork, and emotions: a randomized controlled trial. | PSNet

psnet.ahrq.gov/issue/incivility-and-clinical-performance-teamwork-and-emotions-randomized-controlled-trial

May 22, 2013 - Study Incivility and clinical performance, teamwork, and emotions: a randomized controlled trial. Citation Text: Johnson SL, Haerling KA, Yuwen W, et al. Incivility and Clinical Performance, Teamwork, and Emotions: A Randomized Controlled Trial. J Nurs Care Qual. 2020;35(1):70-76. doi:10…

Who pays for medical errors? An analysis of adverse event costs, the medical liability system, and incentives for patient safety improvement. | PSNet

psnet.ahrq.gov/issue/who-pays-medical-errors-analysis-adverse-event-costs-medical-liability-system-and-incentives

April 13, 2011 - Study Classic Who pays for medical errors? An analysis of adverse event costs, the medical liability system, and incentives for patient safety improvement. Citation Text: Mello MM, Studdert DM, Thomas EJ, et al. Who Pays for Medical Errors? An Analysis of Advers…

The development of the concept of return-on-investment from large-scale quality improvement programmes in healthcare: an integrative systematic literature review. | PSNet

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October 27, 2021 - Review The development of the concept of return-on-investment from large-scale quality improvement programmes in healthcare: an integrative systematic literature review. Citation Text: Thusini S’thembile, Milenova M, Nahabedian N, et al. The development of the concept of return-on-invest…

Learning to overcome hierarchical pressures to achieve safer patient care: an interprofessional simulation for nursing, medical, and physician assistant students. | PSNet

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November 18, 2016 - Commentary Learning to overcome hierarchical pressures to achieve safer patient care: an interprofessional simulation for nursing, medical, and physician assistant students. Citation Text: Reeves SA, Denault D, Huntington JT, et al. Learning to Overcome Hierarchical Pressures to Achieve …

Pain states, the opioid epidemic, and the role of radiologists. | PSNet

psnet.ahrq.gov/issue/pain-states-opioid-epidemic-and-role-radiologists

September 01, 2013 - Review Pain states, the opioid epidemic, and the role of radiologists. Citation Text: Jones MR, Kaye AD, Manchikanti L, et al. Pain States, the Opioid Epidemic, and the Role of Radiologists. Curr Pain Headache Rep. 2018;22(3):20. doi:10.1007/s11916-018-0672-x. Copy Citation Format:…

Fostering a just culture in healthcare organizations: experiences in practice. | PSNet

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August 10, 2022 - Study Fostering a just culture in healthcare organizations: experiences in practice. Citation Text: van Baarle E, Hartman L, Rooijakkers S, et al. Fostering a just culture in healthcare organizations: experiences in practice. BMC Health Serv Res. 2022;22(1):1035. doi:10.1186/s12913-022-0…

Health literacy and systemic racism—using clear communication to reduce health care inequities. | PSNet

psnet.ahrq.gov/issue/health-literacy-and-systemic-racism-using-clear-communication-reduce-health-care-inequities

July 19, 2023 - Commentary Health literacy and systemic racism—using clear communication to reduce health care inequities. Citation Text: Coleman C, Birk S, DeVoe J. Health literacy and systemic racism—using clear communication to reduce health care inequities. JAMA Intern Med. 2023;183(8):753-754. doi:…

Finding diagnostic errors in children admitted to the PICU. | PSNet

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May 21, 2016 - Study Finding diagnostic errors in children admitted to the PICU. Citation Text: Davalos MC, Samuels K, Meyer AND, et al. Finding diagnostic errors in children admitted to the PICU. Pediatr Crit Care Med. 2017;18(3):265-271. doi:10.1097/PCC.0000000000001059. Copy Citation Format: …

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