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Root cause analysis of ambulatory adverse drug events that present to the emergency department. | PSNet

psnet.ahrq.gov/issue/root-cause-analysis-ambulatory-adverse-drug-events-present-emergency-department

April 25, 2016 - Study Root cause analysis of ambulatory adverse drug events that present to the emergency department. Citation Text: Gertler SA, Coralic Z, Lopez A, et al. Root Cause Analysis of Ambulatory Adverse Drug Events That Present to the Emergency Department. J Patient Saf. 2014;12(3). doi:10.10…

Improving the quality of written prescriptions in a general hospital: the influence of 10 years of serial audits and targeted interventions. | PSNet

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August 24, 2022 - Study Improving the quality of written prescriptions in a general hospital: the influence of 10 years of serial audits and targeted interventions. Citation Text: Gommans J, McIntosh P, Bee S, et al. Improving the quality of written prescriptions in a general hospital: the influence of …

Safer healthcare at home: detecting, correcting and learning from incidents involving infusion devices. | PSNet

psnet.ahrq.gov/issue/safer-healthcare-home-detecting-correcting-and-learning-incidents-involving-infusion-devices

October 18, 2018 - Study Safer healthcare at home: detecting, correcting and learning from incidents involving infusion devices. Citation Text: Lyons I, Blandford A. Safer healthcare at home: detecting, correcting and learning from incidents involving infusion devices. App Ergon. 2018;67(Feb):104-114. doi:…

Technology induced error and usability: the relationship between usability problems and prescription errors when using a handheld application. | PSNet

psnet.ahrq.gov/issue/technology-induced-error-and-usability-relationship-between-usability-problems-and

June 15, 2022 - Study Technology induced error and usability: the relationship between usability problems and prescription errors when using a handheld application. Citation Text: Kushniruk AW, Triola MM, Borycki EM, et al. Technology induced error and usability: The relationship between usability pro…

Using Six Sigma to reduce medication errors in a home-delivery pharmacy service. | PSNet

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November 18, 2015 - Study Using Six Sigma to reduce medication errors in a home-delivery pharmacy service. Citation Text: Castle L, Franzblau-Isaac E, Paulsen J. Using Six Sigma to reduce medication errors in a home-delivery pharmacy service. Jt Comm J Qual Patient Saf. 2005;31(6):319-24. Copy Citation …

Impact of organizational leadership on physician burnout and satisfaction. | PSNet

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June 28, 2010 - Study Impact of organizational leadership on physician burnout and satisfaction. Citation Text: Shanafelt TD, Gorringe G, Menaker R, et al. Impact of organizational leadership on physician burnout and satisfaction. Mayo Clin Proc. 2015;90(4):432-40. doi:10.1016/j.mayocp.2015.01.012. Co…

Patient safety culture in hospital settings across continents: a systematic review. | PSNet

psnet.ahrq.gov/issue/patient-safety-culture-hospital-settings-across-continents-systematic-review

June 13, 2018 - Review Patient safety culture in hospital settings across continents: a systematic review. Citation Text: Alabdullah H, Karwowski W. Patient safety culture in hospital settings across continents: a systematic review. Appl Sci. 2024;14(18):8496. doi:10.3390/app14188496. Copy Citation …

Latent risk assessment tool for health care leaders. | PSNet

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September 05, 2018 - Commentary Latent risk assessment tool for health care leaders. Citation Text: Paine LA, Holzmueller CG, Elliott R, et al. Latent risk assessment tool for health care leaders. J Healthc Risk Manag. 2018;38(2):36-46. doi:10.1002/jhrm.21316. Copy Citation Format: DOI Google S…

Organisational conditions for safety management practice in homecare and nursing homes, pre-pandemic and in pandemic. | PSNet

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August 03, 2022 - Study Organisational conditions for safety management practice in homecare and nursing homes, pre-pandemic and in pandemic. Citation Text: Dellve L, Skagert K. Organisational conditions for safety management practice in homecare and nursing homes, pre-pandemic and in pandemic. Safety Sci…

Opportunities to mine EHRs for malpractice risk management and patient safety. | PSNet

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October 28, 2020 - Commentary Opportunities to mine EHRs for malpractice risk management and patient safety. Citation Text: Adler-Milstein J, Sarkar U, Wachter RM. Opportunities to mine EHRs for malpractice risk management and patient safety. J Patient Saf Risk Manag. 2022;27(4):160-162. doi:10.1177/251604…

Feedback loop failure modes in medical diagnosis: how biases can emerge and be reinforced. | PSNet

psnet.ahrq.gov/issue/feedback-loop-failure-modes-medical-diagnosis-how-biases-can-emerge-and-be-reinforced

November 01, 2023 - Study Feedback loop failure modes in medical diagnosis: how biases can emerge and be reinforced. Citation Text: Aikens RC, Chen JH, Baiocchi M, et al. Feedback loop failure modes in medical diagnosis: how biases can emerge and be reinforced. Med Decis Making. 2024;44(5):481-496. doi:10.1…

Utilizing pharmacy students in transitions-of-care services. | PSNet

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October 19, 2022 - Commentary Utilizing pharmacy students in transitions-of-care services. Citation Text: L'Hommedieu T, DeCoske M, Lababidi RE, et al. Utilizing pharmacy students in transitions-of-care services. Am J Health Syst Pharm. 2015;72(15):1266-8. doi:10.2146/ajhp140561. Copy Citation Format…

Debriefing to improve interprofessional teamwork in the operating room: a systematic review. | PSNet

psnet.ahrq.gov/issue/debriefing-improve-interprofessional-teamwork-operating-room-systematic-review

January 31, 2024 - Review Debriefing to improve interprofessional teamwork in the operating room: a systematic review. Citation Text: Skegg E, McElroy C, Mudgway M, et al. Debriefing to improve interprofessional teamwork in the operating room: a systematic review. J Nurs Scholarsh. 2023;55(6):1179-1188. do…

Inadequate preoperative team briefings lead to more intraoperative adverse events. | PSNet

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June 07, 2023 - Study Inadequate preoperative team briefings lead to more intraoperative adverse events. Citation Text: Phadnis J, Templeton-Ward O. Inadequate Preoperative Team Briefings Lead to More Intraoperative Adverse Events. J Patient Saf. 2018;14(2):82-86. doi:10.1097/PTS.0000000000000181. Cop…

Tiered daily huddles: the power of teamwork in managing large healthcare organisations. | PSNet

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December 09, 2020 - Commentary Tiered daily huddles: the power of teamwork in managing large healthcare organisations. Citation Text: Mihaljevic T. Tiered daily huddles: the power of teamwork in managing large healthcare organisations. BMJ Qual Saf. 2020;29(12):1050-1052. doi:10.1136/bmjqs-2019-010575. Co…

What practices will most improve safety? Evidence-based medicine meets patient safety. | PSNet

psnet.ahrq.gov/issue/what-practices-will-most-improve-safety-evidence-based-medicine-meets-patient-safety

March 18, 2019 - Commentary Classic What practices will most improve safety? Evidence-based medicine meets patient safety. Citation Text: Leape L, Berwick DM, Bates DW. What practices will most improve safety? Evidence-based medicine meets patient safety. JAMA. 2002;288(4):501-7…

The influence of formulation and medicine delivery system on medication administration errors in care homes for older people. | PSNet

psnet.ahrq.gov/issue/influence-formulation-and-medicine-delivery-system-medication-administration-errors-care

March 23, 2011 - Study The influence of formulation and medicine delivery system on medication administration errors in care homes for older people. Citation Text: Alldred DP, Standage C, Fletcher O, et al. The influence of formulation and medicine delivery system on medication administration errors in…

Improving Diagnosis in Health Care. | PSNet

psnet.ahrq.gov/issue/improving-diagnosis-health-care

September 12, 2018 - Book/Report Classic Improving Diagnosis in Health Care. Citation Text: Improving Diagnosis in Health Care. Committee on Diagnostic Error in Health Care, National Academies of Science, Engineering, and Medicine. Washington, DC: National Academies Press; 2015. ISB…

Causes of use errors in ventilation devices--systematic review. | PSNet

psnet.ahrq.gov/issue/causes-use-errors-ventilation-devices-systematic-review

October 12, 2022 - Review Causes of use errors in ventilation devices--systematic review. Citation Text: Coldewey B, Diruf A, Röhrig R, et al. Causes of use errors in ventilation devices - systematic review. Appl Ergon. 2021;98:103544. doi:10.1016/j.apergo.2021.103544. Copy Citation Format: D…

Lost in translation: medication labeling for immigrant families. | PSNet

psnet.ahrq.gov/issue/lost-translation-medication-labeling-immigrant-families

May 31, 2017 - Commentary Lost in translation: medication labeling for immigrant families. Citation Text: Smith MCJ, Yin S, Sanders LM. Lost in translation: Medication labeling for immigrant families. J Am Pharm Assoc (2003). 2016;56(6):677-679. doi:10.1016/j.japh.2016.07.002. Copy Citation Forma…

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