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  1. The Theory of Distributed Cognition | Agency for Healthcare Research and Quality

    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/distributed-cognition-er-nurses2.html
    August 01, 2022 - Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department The Theory of Distributed Cognition Previous Page Next Page Table of Contents Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department Introduction The Theory of Dis…

  2. Hospital admissions associated with medication non-adherence: a systematic review of prospective observational studies. | PSNet

    psnet.ahrq.gov/issue/hospital-admissions-associated-medication-non-adherence-systematic-review-prospective
    August 28, 2013 - Review Emerging Classic Hospital admissions associated with medication non-adherence: a systematic review of prospective observational studies. Citation Text: Mongkhon P, Ashcroft DM, Scholfield N, et al. Hospital admissions associated with medication non-adhere…

  3. Using inpatient hospital discharge data to monitor patient safety events. | PSNet

    psnet.ahrq.gov/issue/using-inpatient-hospital-discharge-data-monitor-patient-safety-events
    March 02, 2011 - Study Using inpatient hospital discharge data to monitor patient safety events. Citation Text: Taylor JA, Pandian RS, Mao L, et al. Using inpatient hospital discharge data to monitor patient safety events. J Healthc Risk Manag. 2013;32(4):26-33. doi:10.1002/jhrm.21107. Copy Citation …

  4. Use of professional interpreters for patients with limited English proficiency undergoing surgery. | PSNet

    psnet.ahrq.gov/issue/use-professional-interpreters-patients-limited-english-proficiency-undergoing-surgery
    October 19, 2022 - Study Use of professional interpreters for patients with limited English proficiency undergoing surgery. Citation Text: Cevallos J, Lee C, Bongiovanni T. Use of professional interpreters for patients with limited English proficiency undergoing surgery. JAMA Netw Open. 2024;7(2):e2355014.…

  5. Characteristics associated with requests by pathologists for second opinions on breast biopsies. | PSNet

    psnet.ahrq.gov/issue/characteristics-associated-requests-pathologists-second-opinions-breast-biopsies
    November 03, 2015 - Study Characteristics associated with requests by pathologists for second opinions on breast biopsies. Citation Text: Geller BM, Nelson HD, Weaver DL, et al. Characteristics associated with requests by pathologists for second opinions on breast biopsies. J Clin Pathol. 2017;70(11):947-95…

  6. Measuring perceptions of safety climate in primary care: a cross-sectional study. | PSNet

    psnet.ahrq.gov/issue/measuring-perceptions-safety-climate-primary-care-cross-sectional-study
    January 19, 2011 - Study Measuring perceptions of safety climate in primary care: a cross-sectional study. Citation Text: de Wet C, Johnson P, Mash R, et al. Measuring perceptions of safety climate in primary care: a cross-sectional study. J Eval Clin Pract. 2010;18(1). doi:10.1111/j.1365-2753.2010.01537…

  7. Patient safety strategies in psychiatry and how they construct the notion of preventable harm: a scoping review. | PSNet

    psnet.ahrq.gov/issue/patient-safety-strategies-psychiatry-and-how-they-construct-notion-preventable-harm-scoping
    November 10, 2021 - Review Patient safety strategies in psychiatry and how they construct the notion of preventable harm: a scoping review. Citation Text: Svensson J. Patient safety strategies in psychiatry and how they construct the notion of preventable harm: a scoping review. J Patient Saf. 2022;18(3):24…

  8. Organizational learning in the morbidity and mortality conference. | PSNet

    psnet.ahrq.gov/issue/organizational-learning-morbidity-and-mortality-conference
    June 09, 2015 - Study Organizational learning in the morbidity and mortality conference. Citation Text: Batthish M, Kuper A, Fine C, et al. Organizational learning in the morbidity and mortality conference. J Healthc Qual. 2024;46(2):100-108. doi:10.1097/jhq.0000000000000416. Copy Citation Format:…

  9. We thought we would be perfect: medication errors before and after the initiation of computerized physician order entry. | PSNet

    psnet.ahrq.gov/issue/we-thought-we-would-be-perfect-medication-errors-and-after-initiation-computerized-physician
    September 18, 2019 - Study We thought we would be perfect: medication errors before and after the initiation of computerized physician order entry. Citation Text: Schwartzberg D, Ivanovic S, Patel S, et al. We thought we would be perfect: medication errors before and after the initiation of Computerized Phys…

  10. 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.…

  11. Exploring the human factors of prescribing errors in paediatric intensive care units. | PSNet

    psnet.ahrq.gov/issue/exploring-human-factors-prescribing-errors-paediatric-intensive-care-units
    March 06, 2024 - Study Emerging Classic Exploring the human factors of prescribing errors in paediatric intensive care units. Citation Text: Sutherland A, Ashcroft DM, Phipps D. Exploring the human factors of prescribing errors in paediatric intensive care units. Arch Dis Child.…

  12. ASK ME!-Routine measurement of patient experience with patient safety in ambulatory care: a mixed-mode survey | PSNet

    psnet.ahrq.gov/issue/ask-me-routine-measurement-patient-experience-patient-safety-ambulatory-care-mixed-mode
    April 14, 2021 - Study ASK ME!-Routine measurement of patient experience with patient safety in ambulatory care: a mixed-mode survey Citation Text: Stahl K, Groene O. ASK ME!—Routine measurement of patient experience with patient safety in ambulatory care: A mixed-mode survey. PLoS ONE. 2021;16(12):e0259…

  13. Overlapping surgery in orthopaedics: a review of efficacy, surgical costs, surgical outcomes, and patient safety. | PSNet

    psnet.ahrq.gov/issue/overlapping-surgery-orthopaedics-review-efficacy-surgical-costs-surgical-outcomes-and-patient
    November 03, 2021 - Review Overlapping surgery in orthopaedics: a review of efficacy, surgical costs, surgical outcomes, and patient safety. Citation Text: Ahmed M, Suhrawardy A, Olszewski A, et al. Overlapping surgery in orthopaedics: a review of efficacy, surgical costs, surgical outcomes, and patient saf…

  14. The design of the SAFE or SORRY? study: a cluster randomised trial on the development and testing of an evidence based inpatient safety program for the prevention of adverse events. | PSNet

    psnet.ahrq.gov/issue/design-safe-or-sorry-study-cluster-randomised-trial-development-and-testing-evidence-based
    May 22, 2013 - Study The design of the SAFE or SORRY? study: a cluster randomised trial on the development and testing of an evidence based inpatient safety program for the prevention of adverse events. Citation Text: van Gaal BGI, Schoonhoven L, Hulscher M, et al. The design of the SAFE or SORRY? st…

  15. Do remote community telepharmacies have higher medication error rates than traditional community pharmacies? Evidence from the North Dakota Telepharmacy Project. | PSNet

    psnet.ahrq.gov/issue/do-remote-community-telepharmacies-have-higher-medication-error-rates-traditional-community
    October 17, 2012 - Study Do remote community telepharmacies have higher medication error rates than traditional community pharmacies? Evidence from the North Dakota Telepharmacy Project. Citation Text: Friesner DL, Scott DM, Rathke AM, et al. Do remote community telepharmacies have higher medication erro…

  16. Analysis of paediatric long-term ventilation incidents in the community | PSNet

    psnet.ahrq.gov/issue/analysis-paediatric-long-term-ventilation-incidents-community
    November 06, 2024 - Study Analysis of paediatric long-term ventilation incidents in the community Citation Text: Nawaz RF, Page B, Harrop E, et al. Analysis of paediatric long-term ventilation incidents in the community. Arch Dis Child. 2020;105(5):446-451. doi:10.1136/archdischild-2019-317965. Copy Citat…

  17. Survey of the national drug shortage effect on anesthesia and patient safety: a patient perspective. | PSNet

    psnet.ahrq.gov/issue/survey-national-drug-shortage-effect-anesthesia-and-patient-safety-patient-perspective
    May 23, 2018 - Study Survey of the national drug shortage effect on anesthesia and patient safety: a patient perspective. Citation Text: Hsia IK-H, Dexter F, Logvinov I, et al. Survey of the National Drug Shortage Effect on Anesthesia and Patient Safety: A Patient Perspective. Anesth Analg. 2015;121(2)…

  18. The second victim of unanticipated adverse events. | PSNet

    psnet.ahrq.gov/issue/second-victim-unanticipated-adverse-events
    February 12, 2020 - Commentary The second victim of unanticipated adverse events. Citation Text: Chen S, Skidmore S, Ferrigno BN, et al. The second victim of unanticipated adverse events. J Thorac Cardiovasc Surg. 2023;166(3):890-894. doi:10.1016/j.jtcvs.2022.09.010. Copy Citation Format: DOI …

  19. ASPEN survey of parenteral nutrition access issues: how the system fails the patients. | PSNet

    psnet.ahrq.gov/issue/aspen-survey-parenteral-nutrition-access-issues-how-system-fails-patients
    October 02, 2013 - Study ASPEN survey of parenteral nutrition access issues: how the system fails the patients. Citation Text: Mirtallo JM, Allen P, Book WM, et al. ASPEN survey of parenteral nutrition access issues: how the system fails the patient. Nutr Clin Pract. 2024;39(5):1164-1181. doi:10.1002/ncp.1…

  20. Racial/ethnic disparities in interhospital transfer for conditions with a mortality benefit to transfer among patients with Medicare. | PSNet

    psnet.ahrq.gov/issue/racialethnic-disparities-interhospital-transfer-conditions-mortality-benefit-transfer-among
    April 14, 2021 - Study Racial/ethnic disparities in interhospital transfer for conditions with a mortality benefit to transfer among patients with Medicare. Citation Text: Racial/ethnic disparities in interhospital transfer for conditions with a mortality benefit to transfer among patients with Medicare.…
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