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Medical record review of deaths, unexpected intensive care unit admissions and clinician referrals: detection of adverse events and insight into the system. | PSNet

psnet.ahrq.gov/issue/medical-record-review-deaths-unexpected-intensive-care-unit-admissions-and-clinician

October 12, 2022 - Study Medical record review of deaths, unexpected intensive care unit admissions and clinician referrals: detection of adverse events and insight into the system. Citation Text: Dunn KL, Reddy P, Moulden A, et al. Medical record review of deaths, unexpected intensive care unit admissio…

"Every error counts": a web-based incident reporting and learning system for general practice. | PSNet

psnet.ahrq.gov/issue/every-error-counts-web-based-incident-reporting-and-learning-system-general-practice

January 08, 2014 - Study "Every error counts": a web-based incident reporting and learning system for general practice. Citation Text: Hoffmann B, Beyer M, Rohe J, et al. "Every error counts": a web-based incident reporting and learning system for general practice. Qual Saf Health Care. 2008;17(4):307-12…

Reporting of perioperative adverse events by pediatric anesthesiologists at a tertiary children's hospital: targeted interventions to increase the rate of reporting. | PSNet

psnet.ahrq.gov/issue/reporting-perioperative-adverse-events-pediatric-anesthesiologists-tertiary-childrens

April 24, 2018 - Study Reporting of perioperative adverse events by pediatric anesthesiologists at a tertiary children's hospital: targeted interventions to increase the rate of reporting. Citation Text: Williams GD, Muffly MK, Mendoza JM, et al. Reporting of Perioperative Adverse Events by Pediatric Ane…

Role of communicating diagnostic uncertainty in the safety-netting process: insights from a vignette study. | PSNet

psnet.ahrq.gov/issue/role-communicating-diagnostic-uncertainty-safety-netting-process-insights-vignette-study

February 20, 2019 - Study Role of communicating diagnostic uncertainty in the safety-netting process: insights from a vignette study. Citation Text: Cox C, Hatfield T, Fritz Z. Role of communicating diagnostic uncertainty in the safety-netting process: insights from a vignette study. BMJ Qual Saf. 2024;33(1…

The heart of darkness: the impact of perceived mistakes on physicians. | PSNet

psnet.ahrq.gov/issue/heart-darkness-impact-perceived-mistakes-physicians

April 24, 2018 - Study Classic The heart of darkness: the impact of perceived mistakes on physicians. Citation Text: Christensen JF, Levinson W, Dunn PM. The heart of darkness: the impact of perceived mistakes on physicians. J Gen Intern Med. 1992;7(4):424-31. Copy Citation …

Use of nondisclosure agreements in medical malpractice settlements by a large academic health care system. | PSNet

psnet.ahrq.gov/issue/use-nondisclosure-agreements-medical-malpractice-settlements-large-academic-health-care

December 19, 2018 - Study Use of nondisclosure agreements in medical malpractice settlements by a large academic health care system. Citation Text: Sage WM, Jablonski JS, Thomas EJ. Use of Nondisclosure Agreements in Medical Malpractice Settlements by a Large Academic Health Care System. JAMA Intern Med. 20…

Unintended discontinuation of medication following hospitalisation: a retrospective cohort study. | PSNet

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September 05, 2018 - Study Unintended discontinuation of medication following hospitalisation: a retrospective cohort study. Citation Text: Redmond P, McDowell R, Grimes TC, et al. Unintended discontinuation of medication following hospitalisation: a retrospective cohort study. BMJ Open. 2019;9(6):e024747. d…

Discrepancies in written versus calculated durations in opioid prescriptions: pre-post study. | PSNet

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October 19, 2022 - Study Discrepancies in written versus calculated durations in opioid prescriptions: pre-post study. Citation Text: Slovis BH, Kairys J, Babula B, et al. Discrepancies in written versus calculated durations in opioid prescriptions: pre-post study. JMIR Med Inform. 2020;8(3). doi:10.2196/1…

Minimizing Opioid Prescribing in Surgery (MOPiS) initiative: an analysis of implementation barriers. | PSNet

psnet.ahrq.gov/issue/minimizing-opioid-prescribing-surgery-mopis-initiative-analysis-implementation-barriers

September 09, 2020 - Study Minimizing Opioid Prescribing in Surgery (MOPiS) initiative: an analysis of implementation barriers. Citation Text: Coughlin JM, Shallcross ML, Schäfer WLA, et al. Minimizing Opioid Prescribing in Surgery (MOPiS) Initiative: An Analysis of Implementation Barriers. J Surg Res. 2019;…

A review of healthcare failure mode and effects analysis (HFMEA) in radiotherapy. | PSNet

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June 13, 2011 - Review A review of healthcare failure mode and effects analysis (HFMEA) in radiotherapy. Citation Text: Giardina M, Cantone MC, Tomarchio E, et al. A Review of Healthcare Failure Mode and Effects Analysis (HFMEA) in Radiotherapy. Health Phys. 2016;111(4):317-26. doi:10.1097/HP.0000000000…

Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization. | PSNet

psnet.ahrq.gov/issue/excess-length-stay-charges-and-mortality-attributable-medical-injuries-during-hospitalization

February 27, 2009 - Study Classic Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization. Citation Text: Zhan C, Miller MR. Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization. JAMA. …

Information-gathering patterns associated with higher rates of diagnostic error. | PSNet

psnet.ahrq.gov/issue/information-gathering-patterns-associated-higher-rates-diagnostic-error

June 27, 2018 - Study Information-gathering patterns associated with higher rates of diagnostic error. Citation Text: Delzell JE, Chumley H, Webb R, et al. Information-gathering patterns associated with higher rates of diagnostic error. Adv Health Sci Educ Theory Pract. 2009;14(5):697-711. doi:10.1007…

Hospital inpatient falls across clinical departments. | PSNet

psnet.ahrq.gov/issue/hospital-inpatient-falls-across-clinical-departments

September 15, 2021 - Study Hospital inpatient falls across clinical departments. Citation Text: Mikos M, Banas T, Czerw A, et al. Hospital inpatient falls across clinical departments. Int J Environ Res Public Health. 2021;18(15):8167. doi:10.3390/ijerph18158167. Copy Citation Format: DOI Google…

A randomised controlled trial of the effect of continuous electronic physiological monitoring on the adverse event rate in high risk medical and surgical patients. | PSNet

psnet.ahrq.gov/issue/randomised-controlled-trial-effect-continuous-electronic-physiological-monitoring-adverse

August 04, 2021 - Study A randomised controlled trial of the effect of continuous electronic physiological monitoring on the adverse event rate in high risk medical and surgical patients. Citation Text: Watkinson PJ, Barber VS, Price JD, et al. A randomised controlled trial of the effect of continuous e…

Characteristics of morbidity and mortality conferences associated with the implementation of patient safety improvement initiatives, an observational study. | PSNet

psnet.ahrq.gov/issue/characteristics-morbidity-and-mortality-conferences-associated-implementation-patient-safety

March 18, 2020 - Study Characteristics of morbidity and mortality conferences associated with the implementation of patient safety improvement initiatives, an observational study. Citation Text: François P, Prate F, Vidal-Trecan G, et al. Characteristics of morbidity and mortality conferences associated …

A survey of pharmacists' perception of the work environment and patient safety in community pharmacies during the COVID-19 pandemic. | PSNet

psnet.ahrq.gov/issue/survey-pharmacists-perception-work-environment-and-patient-safety-community-pharmacies-during

June 23, 2009 - Study A survey of pharmacists' perception of the work environment and patient safety in community pharmacies during the COVID-19 pandemic. Citation Text: Ljungberg Persson C, Nordén Hägg A, Södergård B. A survey of pharmacists' perception of the work environment and patient safety in com…

Drug dosing error with drops – severe clinical course of codeine intoxication in twins. | PSNet

psnet.ahrq.gov/issue/drug-dosing-error-drops-severe-clinical-course-codeine-intoxication-twins

September 29, 2021 - Study Drug dosing error with drops – severe clinical course of codeine intoxication in twins. Citation Text: Hermanns-Clausen M, Weinmann W, Auwärter V, et al. Drug dosing error with drops: severe clinical course of codeine intoxication in twins. Eur J Pediatr. 2009;168(7):819-24. doi:…

Risk factors for patient-reported medical errors in eleven countries. | PSNet

psnet.ahrq.gov/issue/risk-factors-patient-reported-medical-errors-eleven-countries

December 04, 2024 - Study Risk factors for patient-reported medical errors in eleven countries. Citation Text: Schwappach DLB. Risk factors for patient-reported medical errors in eleven countries. Health Expect. 2014;17(3):321-31. doi:10.1111/j.1369-7625.2011.00755.x. Copy Citation Format: DOI…

High nursing staff turnover in nursing homes offers important quality information. | PSNet

psnet.ahrq.gov/issue/high-nursing-staff-turnover-nursing-homes-offers-important-quality-information

September 16, 2020 - Study Classic High nursing staff turnover in nursing homes offers important quality information. Citation Text: Gandhi A, Yu H, Grabowski DC. High nursing staff turnover in nursing homes offers important quality information. Health Aff (Millwood). 2021;40(3):384…

Exploring the causes of COPD misdiagnosis in primary care: a mixed methods study. | PSNet

psnet.ahrq.gov/issue/exploring-causes-copd-misdiagnosis-primary-care-mixed-methods-study

September 23, 2020 - Study Exploring the causes of COPD misdiagnosis in primary care: a mixed methods study. Citation Text: Patel K, Smith DJ, Huntley CC, et al. Exploring the causes of COPD misdiagnosis in primary care: a mixed methods study. PLoS ONE. 2024;19(3):e0298432. doi:10.1371/journal.pone.0298432. …

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