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Assisting beginners in root cause analysis operations: analysis and recommendations regarding the spread of COVID-19 in nursing facilities for the elderly. | PSNet

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June 08, 2022 - Commentary Assisting beginners in root cause analysis operations: analysis and recommendations regarding the spread of COVID-19 in nursing facilities for the elderly. Citation Text: Tsuchiya H. Assisting beginners in root cause analysis operations: analysis and recommendations regarding …

Outpatient adverse drug events identified by screening electronic health records. | PSNet

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June 08, 2016 - Study Outpatient adverse drug events identified by screening electronic health records. Citation Text: Gandhi TK, Seger AC, Overhage M, et al. Outpatient adverse drug events identified by screening electronic health records. J Patient Saf. 2010;6(2):91-6. doi:10.1097/PTS.0b013e3181dcae06…

A trigger tool to identify adverse events in the intensive care unit. | PSNet

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April 08, 2011 - Study A trigger tool to identify adverse events in the intensive care unit. Citation Text: Resar RK, Rozich JD, Simmonds T, et al. A Trigger Tool to Identify Adverse Events in the Intensive Care Unit. The Joint Commission Journal on Quality and Patient Safety. 2016;32(10). doi:10.1016/s…

Barriers and success factors to the implementation of a multi-site prospective adverse event surveillance system. | PSNet

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November 15, 2017 - Study Barriers and success factors to the implementation of a multi-site prospective adverse event surveillance system. Citation Text: Backman C, Forster AJ, Vanderloo S. Barriers and success factors to the implementation of a multi-site prospective adverse event surveillance system. Int…

Risk managers, physicians, and disclosure of harmful medical errors. | PSNet

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February 15, 2011 - Study Risk managers, physicians, and disclosure of harmful medical errors. Citation Text: Loren DJ, Garbutt J, Dunagan C, et al. Risk managers, physicians, and disclosure of harmful medical errors. Jt Comm J Qual Patient Saf. 2010;36(3):101-8. Copy Citation Format: Google S…

Effects of night surgery on postoperative mortality and morbidity: a multicentre cohort study. | PSNet

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July 19, 2019 - Study Effects of night surgery on postoperative mortality and morbidity: a multicentre cohort study. Citation Text: Althoff FC, Wachtendorf LJ, Rostin P, et al. Effects of night surgery on postoperative mortality and morbidity: a multicentre cohort study. BMJ Qual Saf. 2020;30(8):678-688…

Surfacing safety hazards using standardized operating room briefings and debriefings at a large regional medical center. | PSNet

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January 03, 2017 - Study Surfacing safety hazards using standardized operating room briefings and debriefings at a large regional medical center. Citation Text: Bandari J, Schumacher K, Simon M, et al. Surfacing safety hazards using standardized operating room briefings and debriefings at a large regional …

Identifying barriers to the effective use of clinical reminders: bootstrapping multiple methods. | PSNet

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March 11, 2011 - Study Identifying barriers to the effective use of clinical reminders: bootstrapping multiple methods. Citation Text: Patterson ES, Doebbeling BN, Fung CH, et al. Identifying barriers to the effective use of clinical reminders: bootstrapping multiple methods. J Biomed Inform. 2005;38(3):…

Medication errors involving oral chemotherapy. | PSNet

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January 06, 2017 - Study Medication errors involving oral chemotherapy. Citation Text: Weingart SN, Toro J, Spencer J, et al. Medication errors involving oral chemotherapy. Cancer. 2010;116(10):2455-2464. doi:10.1002/cncr.25027. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X…

Community Pharmacy Survey on Patient Safety Culture: 2019 User Comparative Database Report. | PSNet

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February 20, 2019 - Book/Report Community Pharmacy Survey on Patient Safety Culture: 2019 User Comparative Database Report. Citation Text: Community Pharmacy Survey on Patient Safety Culture: 2019 User Comparative Database Report. Famolaro T, Yount ND, Hare R, et al. Rockville, MD: Agency for Healthcare Res…

Prevalence and predictors of adverse events in older surgical patients: impact of the present on admission indicator. | PSNet

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October 04, 2023 - Study Prevalence and predictors of adverse events in older surgical patients: impact of the present on admission indicator. Citation Text: Kim H, Capezuti E, Kovner C, et al. Prevalence and predictors of adverse events in older surgical patients: impact of the present on admission indi…

Improving medication error reporting in hospice care. | PSNet

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June 22, 2022 - Study Improving medication error reporting in hospice care. Citation Text: Boyer R, McPherson ML, Deshpande G, et al. Improving medication error reporting in hospice care. Am J Hosp Palliat Care. 2009;26(5):361-7. doi:10.1177/1049909109335145. Copy Citation Format: DOI Go…

Incident learning in pursuit of high reliability: implementing a comprehensive, low-threshold reporting program in a large, multisite radiation oncology department. | PSNet

psnet.ahrq.gov/issue/incident-learning-pursuit-high-reliability-implementing-comprehensive-low-threshold-reporting

September 27, 2017 - Study Incident learning in pursuit of high reliability: implementing a comprehensive, low-threshold reporting program in a large, multisite radiation oncology department. Citation Text: Gabriel PE, Volz E, Bergendahl HW, et al. Incident learning in pursuit of high reliability: implementi…

Using participatory design to engage physicians in the development of a provider-level performance dashboard and feedback system. | PSNet

psnet.ahrq.gov/issue/using-participatory-design-engage-physicians-development-provider-level-performance-dashboard

October 28, 2020 - Study Using participatory design to engage physicians in the development of a provider-level performance dashboard and feedback system. Citation Text: Patel S, Pierce L, Jones M, et al. Using participatory design to engage physicians in the development of a provider-level performance da…

Deficiencies in Emergency Department Care for a Patient Who Died by Suicide at the John Cochran Division of the VA St. Louis Health Care System in Missouri. | PSNet

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July 26, 2023 - Book/Report Deficiencies in Emergency Department Care for a Patient Who Died by Suicide at the John Cochran Division of the VA St. Louis Health Care System in Missouri. Citation Text: Deficiencies in Emergency Department Care for a Patient Who Died by Suicide at the John Cochran Division…

Frequency of diagnostic errors in the neonatal intensive care unit: a retrospective cohort study. | PSNet

psnet.ahrq.gov/issue/frequency-diagnostic-errors-neonatal-intensive-care-unit-retrospective-cohort-study

April 13, 2022 - Study Frequency of diagnostic errors in the neonatal intensive care unit: a retrospective cohort study. Citation Text: Shafer GJ, Singh H, Thomas EJ, et al. Frequency of diagnostic errors in the neonatal intensive care unit: a retrospective cohort study. J Perinatol. 2022;42(10):1312-131…

System issues leading to "found-on-floor" incidents: a multi-incident analysis. | PSNet

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August 04, 2021 - Study System issues leading to "found-on-floor" incidents: a multi-incident analysis. Citation Text: Shaw J, Bastawrous M, Burns S, et al. System Issues Leading to “Found-on-Floor” Incidents: A Multi-Incident Analysis. J Patient Saf. 2021;17(1):30-35. doi:10.1097/pts.0000000000000294. …

Remote patient monitoring during COVID-19: an unexpected patient safety benefit. | PSNet

psnet.ahrq.gov/issue/remote-patient-monitoring-during-covid-19-unexpected-patient-safety-benefit

July 20, 2022 - Commentary Remote patient monitoring during COVID-19: an unexpected patient safety benefit. Citation Text: Pronovost PJ, Cole MD, Hughes RM. Remote patient monitoring during COVID-19: an unexpected patient safety benefit. JAMA. 2022;327(12):1125-1126. doi:10.1001/jama.2022.2040. Copy C…

Improving shared situation awareness for high-risk therapies in hospitalized children. | PSNet

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October 20, 2021 - Study Improving shared situation awareness for high-risk therapies in hospitalized children. Citation Text: Sosa T, Mayer B, Chakkalakkal B, et al. Improving shared situation awareness for high-risk therapies in hospitalized children. Hosp Pediatr. 2022;12(1):37-46. doi:10.1542/hpeds.202…

Health professionals' experiences of whistleblowing in maternal and newborn healthcare settings: a scoping review and thematic analysis. | PSNet

psnet.ahrq.gov/issue/health-professionals-experiences-whistleblowing-maternal-and-newborn-healthcare-settings

November 02, 2010 - Review Health professionals' experiences of whistleblowing in maternal and newborn healthcare settings: a scoping review and thematic analysis. Citation Text: Capper T, Ferguson B, Muurlink O. Health professionals' experiences of whistleblowing in maternal and newborn healthcare settings…

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