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

psnet.ahrq.gov/issue/operating-room-intensive-care-unit-handoffs-and-risks-patient-harm

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

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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

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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

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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

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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

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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. …

Hospital readmission and parent perceptions of their child's hospital discharge. | PSNet

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July 03, 2016 - Study Hospital readmission and parent perceptions of their child's hospital discharge. Citation Text: Berry JG, Ziniel SI, Freeman L, et al. Hospital readmission and parent perceptions of their child's hospital discharge. Int J Qual Health Care. 2013;25(5):573-81. doi:10.1093/intqhc/mzt0…

Duplicate medication order errors: safety gaps and recommendations for improvement. | PSNet

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March 22, 2023 - Study Duplicate medication order errors: safety gaps and recommendations for improvement. Citation Text: Bocknek L, Kim T, Spaar P, et al. Duplicate medication order errors: safety gaps and recommendations for improvement. Patient Safety. 2022;4(3):39-47. doi:10.33940/data/2022.9.6. Co…

Improving communication and teamwork during labor: a feasibility, acceptability, and safety study. | PSNet

psnet.ahrq.gov/issue/improving-communication-and-teamwork-during-labor-feasibility-acceptability-and-safety-study

July 20, 2022 - Study Improving communication and teamwork during labor: a feasibility, acceptability, and safety study. Citation Text: Weiseth A, Plough A, Aggarwal R, et al. Improving communication and teamwork during labor: A feasibility, acceptability, and safety study. Birth. 2022;49(4):637-647. do…

Using statistical text classification to identify health information technology incidents. | PSNet

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February 14, 2024 - Study Using statistical text classification to identify health information technology incidents. Citation Text: Chai KEK, Anthony S, Coiera E, et al. Using statistical text classification to identify health information technology incidents. J Am Med Inform Assoc. 2013;20(5):980-5. doi:10…

The impact of the COVID-19 pandemic on Emergency Department visits and patient safety in the United States. | PSNet

psnet.ahrq.gov/issue/impact-covid-19-pandemic-emergency-department-visits-and-patient-safety-united-states

July 14, 2021 - Study The impact of the COVID-19 pandemic on Emergency Department visits and patient safety in the United States. Citation Text: Boserup B, McKenney M, Elkbuli A. The impact of the COVID-19 pandemic on emergency department visits and patient safety in the United States. Am J Emerg Med. 2…

When safety event reporting is seen as punitive: "I've been PSN-ed!" | PSNet

psnet.ahrq.gov/issue/when-safety-event-reporting-seen-punitive-ive-been-psn-ed

September 02, 2020 - Study When safety event reporting is seen as punitive: "I've been PSN-ed!" Citation Text: Feeser VR, Jackson AK, Savage NM, et al. When safety event reporting is seen as punitive: "I've been PSN-ed!". Ann Emerg Med. 2021;77(4):449-458. doi:10.1016/j.annemergmed.2020.06.048. Copy Citati…

A novel study of situational awareness among out-of-hospital providers during an online clinical simulation. | PSNet

psnet.ahrq.gov/issue/novel-study-situational-awareness-among-out-hospital-providers-during-online-clinical

June 08, 2022 - Study A novel study of situational awareness among out-of-hospital providers during an online clinical simulation. Citation Text: Hunter J, Porter M, Williams B. A novel study of situational awareness among out-of-hospital providers during an online clinical simulation. Australas Emerg C…

Unplanned early hospital readmission among critical care survivors: a mixed methods study of patients and carers. | PSNet

psnet.ahrq.gov/issue/unplanned-early-hospital-readmission-among-critical-care-survivors-mixed-methods-study

September 23, 2020 - Study Unplanned early hospital readmission among critical care survivors: a mixed methods study of patients and carers. Citation Text: Donaghy E, Salisbury L, Lone NI, et al. Unplanned early hospital readmission among critical care survivors: a mixed methods study of patients and carers.…

Primary care teams' reported actions to improve medication safety: a qualitative study with insights in high reliability organising. | PSNet

psnet.ahrq.gov/issue/primary-care-teams-reported-actions-improve-medication-safety-qualitative-study-insights-high

July 06, 2022 - Study Primary care teams' reported actions to improve medication safety: a qualitative study with insights in high reliability organising. Citation Text: Young RA, Gurses AP, Fulda KG, et al. Primary care teams’ reported actions to improve medication safety: a qualitative study with insi…

Cognitive tests predict real-world errors: the relationship between drug name confusion rates in laboratory-based memory and perception tests and corresponding error rates in large pharmacy chains. | PSNet

psnet.ahrq.gov/issue/cognitive-tests-predict-real-world-errors-relationship-between-drug-name-confusion-rates

April 12, 2017 - Study Cognitive tests predict real-world errors: the relationship between drug name confusion rates in laboratory-based memory and perception tests and corresponding error rates in large pharmacy chains. Citation Text: Schroeder SR, Salomon MM, Galanter W, et al. Cognitive tests predict …

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