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When there's no one to whom an error can be disclosed, how should an error be handled? | PSNet

psnet.ahrq.gov/issue/when-theres-no-one-whom-error-can-be-disclosed-how-should-error-be-handled

March 19, 2018 - Commentary When there's no one to whom an error can be disclosed, how should an error be handled? Citation Text: Chiu RG. When There's No One to Whom an Error Can Be Disclosed, How Should an Error Be Handled? AMA J Ethics. 2019;21(7):E553-558. doi:10.1001/amajethics.2019.553. Copy Cita…

Cognitive processes involved in blame and blame-like judgments and in forgiveness and forgiveness-like judgments. | PSNet

psnet.ahrq.gov/issue/cognitive-processes-involved-blame-and-blame-judgments-and-forgiveness-and-forgiveness

August 23, 2017 - Study Cognitive processes involved in blame and blame-like judgments and in forgiveness and forgiveness-like judgments. Citation Text: Mullet E, Rivière S, Sastre MTM. Cognitive processes involved in blame and blame-like judgments and in forgiveness and forgiveness-like judgments. Am J…

Drs Bramhall and Bawa-Garba and the rightful domain of the criminal law. | PSNet

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November 13, 2024 - Commentary Drs Bramhall and Bawa-Garba and the rightful domain of the criminal law. Citation Text: Ost S. Drs Bramhall and Bawa-Garba and the rightful domain of the criminal law. J Med Ethics. 2019;45(3):151-155. doi:10.1136/medethics-2018-105135. Copy Citation Format: DOI …

Evidence and efficacy: time to think beyond the traditional randomised controlled trial in patient safety studies. | PSNet

psnet.ahrq.gov/issue/evidence-and-efficacy-time-think-beyond-traditional-randomised-controlled-trial-patient

January 24, 2024 - Commentary Evidence and efficacy: time to think beyond the traditional randomised controlled trial in patient safety studies. Citation Text: Webster CS. Evidence and efficacy: time to think beyond the traditional randomised controlled trial in patient safety studies. Br J Anaesth. 2019;1…

An objective study of the impact of the electronic medical record on outcomes in trauma patients. | PSNet

psnet.ahrq.gov/issue/objective-study-impact-electronic-medical-record-outcomes-trauma-patients

October 13, 2018 - Study An objective study of the impact of the electronic medical record on outcomes in trauma patients. Citation Text: Schenarts PJ, Goettler CE, White MA, et al. An objective study of the impact of the electronic medical record on outcomes in trauma patients. Am Surg. 2012;78(11):1249…

Quality improvement: Universal Protocol use in office-based gastrointestinal procedure units. | PSNet

psnet.ahrq.gov/issue/quality-improvement-universal-protocol-use-office-based-gastrointestinal-procedure-units

November 16, 2022 - Commentary Quality improvement: Universal Protocol use in office-based gastrointestinal procedure units. Citation Text: Hardee LK. Quality improvement: universal protocol use in office-based gastrointestinal procedure units. Gastroenterol Nurs. 2012;35(6):380-2. doi:10.1097/SGA.0b013e3…

Quali-quantitative analysis: a new model for evaluation of unusual cases in hospital performance? | PSNet

psnet.ahrq.gov/issue/quali-quantitative-analysis-new-model-evaluation-unusual-cases-hospital-performance

October 25, 2018 - Review Quali-quantitative analysis: a new model for evaluation of unusual cases in hospital performance? Citation Text: Bell E. Quali-quantitative analysis: a new model for evaluation of unusual cases in hospital performance? Aust Health Rev. 2007;31 Suppl 1:S86-97. Copy Citation …

Knowledge-based errors in anesthesia: a paired, controlled trial of learning and retention. | PSNet

psnet.ahrq.gov/issue/knowledge-based-errors-anesthesia-paired-controlled-trial-learning-and-retention

December 06, 2023 - Study Knowledge-based errors in anesthesia: a paired, controlled trial of learning and retention. Citation Text: Goldhaber-Fiebert SN, Goldhaber-Fiebert JD, Rosow CE. Knowledge-based errors in anesthesia: a paired, controlled trial of learning and retention. Can J Anaesth. 2009;56(1):3…

From good intentions to successful implementation: the case of patient safety in Canada. | PSNet

psnet.ahrq.gov/issue/good-intentions-successful-implementation-case-patient-safety-canada

February 24, 2011 - Commentary From good intentions to successful implementation: the case of patient safety in Canada. Citation Text: Thomas PG. From good intentions to successful implementation: the case of patient safety in Canada. Canadian Public Administration/Administration publique du Canada. 2008;…

Nursing student medication errors involving tubing and catheters: a descriptive study. | PSNet

psnet.ahrq.gov/issue/nursing-student-medication-errors-involving-tubing-and-catheters-descriptive-study

July 14, 2010 - Study Nursing student medication errors involving tubing and catheters: a descriptive study. Citation Text: Wolf ZR, Hicks RW, Altmiller G, et al. Nursing student medication errors involving tubing and catheters: A descriptive study. Nurse Educ Today. 2009;29(6). doi:10.1016/j.nedt.200…

Structural iatrogenesis—a 43-year-old man with "opioid misuse." | PSNet

psnet.ahrq.gov/issue/structural-iatrogenesis-43-year-old-man-opioid-misuse

September 04, 2016 - Commentary Structural iatrogenesis—a 43-year-old man with "opioid misuse." Citation Text: Stonington S, Coffa D. Structural Iatrogenesis - A 43-Year-Old Man with "Opioid Misuse". N Engl J Med. 2019;380(8):701-704. doi:10.1056/NEJMp1811473. Copy Citation Format: DOI Google S…

Perceived disability-based discrimination in health care for children with medical complexity. | PSNet

psnet.ahrq.gov/issue/perceived-disability-based-discrimination-health-care-children-medical-complexity

November 16, 2022 - Study Perceived disability-based discrimination in health care for children with medical complexity. Citation Text: Ames SG, Delaney RK, Houtrow AJ, et al. Perceived disability-based discrimination in health care for children with medical complexity. Pediatrics. 2023;152(1):e2022060975. …

A 2-year study of patient safety competency assessment in 29 clinical laboratories. | PSNet

psnet.ahrq.gov/issue/2-year-study-patient-safety-competency-assessment-29-clinical-laboratories

December 14, 2016 - Study A 2-year study of patient safety competency assessment in 29 clinical laboratories. Citation Text: Reed RC, Kim S, Farquharson K, et al. A 2-Year Study of Patient Safety Competency Assessment in 29 Clinical Laboratories. Am J Clin Pathol. 2008;129(6). doi:10.1309/bm8jje1auca408tq…

Creating a just culture: the Ottawa Hospital's experience. | PSNet

psnet.ahrq.gov/issue/creating-just-culture-ottawa-hospitals-experience

July 10, 2024 - Commentary Creating a just culture: the Ottawa Hospital's experience. Citation Text: Forster AJ, Hamilton S, Hayes T, et al. Creating a Just Culture: The Ottawa Hospital's experience. Healthc Manage Forum. 2019;32(5):266-271. doi:10.1177/0840470419853303. Copy Citation Format: …

Potentially fatal errors with GDH-PQQ [glucose dehydrogenase pyrroloquinoline quinone] glucose monitoring technology. | PSNet

psnet.ahrq.gov/issue/potentially-fatal-errors-gdh-pqq-glucose-dehydrogenase-pyrroloquinoline-quinone-glucose

June 22, 2011 - Press Release/Announcement Potentially fatal errors with GDH-PQQ [glucose dehydrogenase pyrroloquinoline quinone] glucose monitoring technology. Citation Text: Potentially fatal errors with GDH-PQQ [glucose dehydrogenase pyrroloquinoline quinone] glucose monitoring technology. MedWat…

Mary Lanning Memorial Hospital: communication is key. | PSNet

psnet.ahrq.gov/issue/mary-lanning-memorial-hospital-communication-key

July 16, 2015 - Award Recipient Mary Lanning Memorial Hospital: communication is key. Citation Text: Lindblad B, Chilcott J, Rolls L. Mary Lanning Memorial Hospital: communication is key. Joint Commission journal on quality and safety. 2004;30(10):551-8. Copy Citation Format: Google Schola…

Relationship of incorrect dosing of fibrinolytic therapy and clinical outcomes. | PSNet

psnet.ahrq.gov/issue/relationship-incorrect-dosing-fibrinolytic-therapy-and-clinical-outcomes

November 10, 2015 - Study Relationship of incorrect dosing of fibrinolytic therapy and clinical outcomes. Citation Text: Mehta RH. Relationship of Incorrect Dosing of Fibrinolytic Therapy and Clinical Outcomes. JAMA. 2005;293(14). doi:10.1001/jama.293.14.1746. Copy Citation Format: DOI Googl…

Using a change model to reduce the risk of surgical site infection. | PSNet

psnet.ahrq.gov/issue/using-change-model-reduce-risk-surgical-site-infection

June 06, 2018 - Commentary Using a change model to reduce the risk of surgical site infection. Citation Text: Burden M. Using a change model to reduce the risk of surgical site infection. Br J Nurs. 2016;25(17):949-955. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndN…

Revisiting old slides—how worthwhile is it? | PSNet

psnet.ahrq.gov/issue/revisiting-old-slides-how-worthwhile-it

October 05, 2022 - Study Revisiting old slides—how worthwhile is it? Citation Text: Agarwal S, Wadhwa N. Revisiting old slides--how worthwhile is it? Pathol Res Pract. 2010;206(6):368-71. doi:10.1016/j.prp.2010.01.006. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML En…

What is the value and impact of quality and safety teams? A scoping review. | PSNet

psnet.ahrq.gov/issue/what-value-and-impact-quality-and-safety-teams-scoping-review

December 06, 2017 - Review What is the value and impact of quality and safety teams? A scoping review. Citation Text: White DE, Straus SE, Stelfox T, et al. What is the value and impact of quality and safety teams? A scoping review. Implement Sci. 2011;6:97. doi:10.1186/1748-5908-6-97. Copy Citation …

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