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Root cause analyses of reported adverse events occurring during gastrointestinal scope and tube placement procedures in the Veterans Health Association. | PSNet

psnet.ahrq.gov/issue/root-cause-analyses-reported-adverse-events-occurring-during-gastrointestinal-scope-and-tube

November 17, 2021 - Study Root cause analyses of reported adverse events occurring during gastrointestinal scope and tube placement procedures in the Veterans Health Association. Citation Text: Soncrant C, Mills PD, Neily J, et al. Root cause analyses of reported adverse events occurring during gastrointest…

Suicide and suicide attempts on hospital grounds and clinic areas. | PSNet

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October 29, 2017 - Study Suicide and suicide attempts on hospital grounds and clinic areas. Citation Text: Mills PD, Watts BV, Hemphill RR. Suicide and suicide attempts on hospital grounds and clinic areas. J Patient Saf. 2021;17(5):e423-e428. doi:10.1097/pts.0000000000000356. Copy Citation Format: …

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…

Establishing a global learning community for incident-reporting systems. | PSNet

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May 24, 2012 - Commentary Establishing a global learning community for incident-reporting systems. Citation Text: Pham JC, Gianci S, Battles J, et al. Establishing a global learning community for incident-reporting systems. Qual Saf Health Care. 2010;19(5):446-51. doi:10.1136/qshc.2009.037739. Copy…

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…

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

psnet.ahrq.gov/issue/system-issues-leading-found-floor-incidents-multi-incident-analysis

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

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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…

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…

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…

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

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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…

The challenges and opportunities for shared decision making highlighted by COVID-19. | PSNet

psnet.ahrq.gov/issue/challenges-and-opportunities-shared-decision-making-highlighted-covid-19

June 15, 2022 - Commentary The challenges and opportunities for shared decision making highlighted by COVID-19. Citation Text: Abrams EM, Shaker M, Oppenheimer J, et al. The challenges and opportunities for shared decision making highlighted by COVID-19. J Allergy Clin Immunol Pract. 2020;8(8):2474-2480…

Effectiveness of acute care remote triage systems: a systematic review. | PSNet

psnet.ahrq.gov/issue/effectiveness-acute-care-remote-triage-systems-systematic-review

March 14, 2022 - Review Emerging Classic Effectiveness of acute care remote triage systems: a systematic review. Citation Text: Boggan JC, Shoup JP, Whited JD, et al. Effectiveness of acute care remote triage systems: a systematic review. J Gen Intern Med. 2020;35(7):2136-2145.…

"Time is of the essence": relationship between hospital staff perceptions of time, safety attitudes and staff wellbeing. | PSNet

psnet.ahrq.gov/issue/time-essence-relationship-between-hospital-staff-perceptions-time-safety-attitudes-and-staff

September 01, 2021 - Study "Time is of the essence": relationship between hospital staff perceptions of time, safety attitudes and staff wellbeing. Citation Text: Ellis LA, Tran Y, Pomare C, et al. “Time is of the essence”: relationship between hospital staff perceptions of time, safety attitudes and staff …

Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care units. | PSNet

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March 31, 2021 - Study Classic Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care units. Citation Text: Cullen DJ, Sweitzer BJ, Bates DW, et al. Preventable adverse drug events in hospitalized patients. Crit Care Me…

Perceptions of U.S. and U.K. incident reporting systems: a scoping review. | PSNet

psnet.ahrq.gov/issue/perceptions-us-and-uk-incident-reporting-systems-scoping-review

January 19, 2022 - Review Perceptions of U.S. and U.K. incident reporting systems: a scoping review. Citation Text: Gampetro PJ, Nickum A, Schultz CM. Perceptions of U.S. and U.K. incident reporting systems: a scoping review. J Patient Saf. 2024;20(5):360-365. doi:10.1097/pts.0000000000001231. Copy Citat…

Primary care providers' opening of time-sensitive alerts sent to commercial electronic health record InBaskets. | PSNet

psnet.ahrq.gov/issue/primary-care-providers-opening-time-sensitive-alerts-sent-commercial-electronic-health-record

March 17, 2021 - Study Primary care providers' opening of time-sensitive alerts sent to commercial electronic health record InBaskets. Citation Text: Cutrona SL, Fouayzi H, Burns L, et al. Primary Care Providers' Opening of Time-Sensitive Alerts Sent to Commercial Electronic Health Record InBaskets. J Ge…

Duty hours, quality of care, and patient safety: general surgery resident perceptions. | PSNet

psnet.ahrq.gov/issue/duty-hours-quality-care-and-patient-safety-general-surgery-resident-perceptions

July 02, 2014 - Study Duty hours, quality of care, and patient safety: general surgery resident perceptions. Citation Text: Borman KR, Jones AT, Shea JA. Duty hours, quality of care, and patient safety: general surgery resident perceptions. J Am Coll Surg. 2012;215(1):70-7; discussion 77-9. doi:10.101…

Redesigning rounds: towards a more purposeful approach to inpatient teaching and learning. | PSNet

psnet.ahrq.gov/issue/redesigning-rounds-towards-more-purposeful-approach-inpatient-teaching-and-learning

February 02, 2022 - Commentary Redesigning rounds: towards a more purposeful approach to inpatient teaching and learning. Citation Text: Reilly JB, Bennett N, Fosnocht K, et al. Redesigning rounds: towards a more purposeful approach to inpatient teaching and learning. Acad Med. 2015;90(4):450-3. doi:10.1097…

How hospital leaders contribute to patient safety through the development of trust. | PSNet

psnet.ahrq.gov/issue/how-hospital-leaders-contribute-patient-safety-through-development-trust

January 22, 2014 - Study How hospital leaders contribute to patient safety through the development of trust. Citation Text: Auer C, Schwendimann R, Koch R, et al. How hospital leaders contribute to patient safety through the development of trust. J Nurs Adm. 2014;44(1):23-9. doi:10.1097/NNA.00000000000000…

Analysis of critical incident reports using natural language processing. | PSNet

psnet.ahrq.gov/issue/analysis-critical-incident-reports-using-natural-language-processing

June 14, 2023 - Study Analysis of critical incident reports using natural language processing. Citation Text: Denecke K, Paula H. Analysis of critical incident reports using natural language processing. Stud Health Technol Inform. 2024;313:1-6. doi:10.3233/shti240002. Copy Citation Format: …

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