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How to perform a root cause analysis for workup and future prevention of medical errors: a review. | PSNet

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August 03, 2017 - Review How to perform a root cause analysis for workup and future prevention of medical errors: a review. Citation Text: Charles R, Hood B, DeRosier JM, et al. How to perform a root cause analysis for workup and future prevention of medical errors: a review. Patient Saf Surg. 2016;10:20.…

Standardized competencies for parenteral nutrition prescribing: The American Society for Parenteral and Enteral Nutrition Model. | PSNet

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February 17, 2015 - Commentary Standardized competencies for parenteral nutrition prescribing: The American Society for Parenteral and Enteral Nutrition Model. Citation Text: Guenter P, Boullata JI, Ayers P, et al. Standardized Competencies for Parenteral Nutrition Prescribing: The American Society for Pare…

Racial, ethnic, and socioeconomic disparities in estimates of AHRQ patient safety indicators. | PSNet

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April 03, 2005 - Study Racial, ethnic, and socioeconomic disparities in estimates of AHRQ patient safety indicators. Citation Text: Coffey RM, Andrews RM, Moy E. Racial, ethnic, and socioeconomic disparities in estimates of AHRQ patient safety indicators. Med Care. 2005;43(3 Suppl):I48-I57. Copy Cita…

Tragedy into policy: a quantitative study of nurses' attitudes toward patient advocacy activities. | PSNet

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June 01, 2011 - Study Tragedy into policy: a quantitative study of nurses' attitudes toward patient advocacy activities. Citation Text: Black LM. Tragedy into policy: a quantitative study of nurses' attitudes toward patient advocacy activities. Am J Nurs. 2011;111(6):26-37. doi:10.1097/01.NAJ.0000398537…

Surgeons' disclosures of clinical adverse events. | PSNet

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August 18, 2021 - Study Surgeons' disclosures of clinical adverse events. Citation Text: Elwy R, Itani KMF, Bokhour BG, et al. Surgeons' Disclosures of Clinical Adverse Events. JAMA Surg. 2016;151(11):1015-1021. doi:10.1001/jamasurg.2016.1787. Copy Citation Format: DOI Google Scholar PubMed …

An integrative review of the current evidence on the relationship between hand hygiene interventions and the incidence of health care-associated infections. | PSNet

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February 22, 2023 - Review An integrative review of the current evidence on the relationship between hand hygiene interventions and the incidence of health care-associated infections. Citation Text: Backman C, Zoutman DE, Marck PB. An integrative review of the current evidence on the relationship between h…

Can we make postoperative patient handovers safer? A systematic review of the literature. | PSNet

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June 10, 2015 - Review Can we make postoperative patient handovers safer? A systematic review of the literature. Citation Text: Segall N, Bonifacio AS, Schroeder RA, et al. Can we make postoperative patient handovers safer? A systematic review of the literature. Anesth Analg. 2012;115(1):102-15. doi:1…

Reducing Avoidable Readmissions Effectively campaign: a statewide collaborative. | PSNet

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January 31, 2018 - Award Recipient Reducing Avoidable Readmissions Effectively campaign: a statewide collaborative. Citation Text: McCoy KA, Bear-Pfaffendorf K, Foreman JK, et al. Reducing Avoidable Hospital Readmissions Effectively: A Statewide Campaign. Joint Comm J Qual Patient Saf. 2016;40(5):198-204,…

Five years after 'To Err is Human': what have we learned? | PSNet

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March 18, 2019 - Commentary Classic Five years after 'To Err is Human': what have we learned? Citation Text: Leape L, Berwick DM. Five years after To Err Is Human: what have we learned? JAMA. 2005;293(19):2384-90. Copy Citation Format: Google Scholar PubMed BibTe…

Severe hypertension in pregnancy: progress made and future directions for patient safety, quality improvement, and implementation of a patient safety bundle. | PSNet

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October 23, 2024 - Commentary Severe hypertension in pregnancy: progress made and future directions for patient safety, quality improvement, and implementation of a patient safety bundle. Citation Text: Prior A, Taylor I, Gibson KS, et al. Severe hypertension in pregnancy: progress made and future directio…

What is safety leadership? A systematic review of definitions. | PSNet

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October 26, 2022 - Review What is safety leadership? A systematic review of definitions. Citation Text: Adra I, Giga S, Hardy C, et al. What is safety leadership? A systematic review of definitions. J Safety Res. 2024;90:181-191. doi:10.1016/j.jsr.2024.04.001. Copy Citation Format: DOI Google…

Large language models for preventing medication direction errors in online pharmacies. | PSNet

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February 27, 2019 - Study Large language models for preventing medication direction errors in online pharmacies. Citation Text: Pais C, Liu J, Voigt R, et al. Large language models for preventing medication direction errors in online pharmacies. Nat Med. 2024;30(6):1574-1582. doi:10.1038/s41591-024-02933-8.…

Crowdsourcing a diagnosis? Exploring the accuracy of the size and type of group diagnosis: an experimental study. | PSNet

psnet.ahrq.gov/issue/crowdsourcing-diagnosis-exploring-accuracy-size-and-type-group-diagnosis-experimental-study

October 27, 2021 - Study Crowdsourcing a diagnosis? Exploring the accuracy of the size and type of group diagnosis: an experimental study. Citation Text: Sherbino J, Sibbald M, Norman GR, et al. Crowdsourcing a diagnosis? Exploring the accuracy of the size and type of group diagnosis: an experimental study…

Surgical never events and contributing human factors. | PSNet

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August 20, 2018 - Study Classic Surgical never events and contributing human factors. Citation Text: Thiels CA, Lal TM, Nienow JM, et al. Surgical never events and contributing human factors. Surgery. 2015;158(2):515-21. doi:10.1016/j.surg.2015.03.053. Copy Citation Format:…

A high-reliability organization mindset. | PSNet

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April 01, 2020 - Commentary A high-reliability organization mindset. Citation Text: Merchant NB, O’Neal J, Dealino-Perez C, et al. A high-reliability organization mindset. Am J Med Qual. 2022;37(6):504-510. doi:10.1097/jmq.0000000000000086. Copy Citation Format: DOI Google Scholar BibTeX En…

Cognitive and implicit biases in nurses' judgment and decision-making: a scoping review. | PSNet

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October 20, 2021 - Review Cognitive and implicit biases in nurses' judgment and decision-making: a scoping review. Citation Text: Thirsk LM, Panchuk JT, Stahlke S, et al. Cognitive and implicit biases in nurses' judgment and decision-making: a scoping review. Int J Nurs Stud. 2022;133:104284. doi:10.1016/j…

Developing health care organizations that pursue learning and exploration of diagnostic excellence: an action plan. | PSNet

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October 28, 2020 - Commentary Developing health care organizations that pursue learning and exploration of diagnostic excellence: an action plan. Citation Text: Singh H, Upadhyay DK, Torretti D. Developing Health Care Organizations That Pursue Learning and Exploration of Diagnostic Excellence: An Action Pl…

Reducing Risk and Promoting Patient Safety for NIH Intramural Clinical Research—Final Report. | PSNet

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November 18, 2020 - Book/Report Reducing Risk and Promoting Patient Safety for NIH Intramural Clinical Research—Final Report. Citation Text: Reducing Risk and Promoting Patient Safety for NIH Intramural Clinical Research—Final Report. The Clinical Center Working Group Report to the Advisory Committee to the…

Redesign of health care systems to reduce diagnostic errors: leveraging human experience and artificial intelligence. | PSNet

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December 04, 2016 - Commentary Redesign of health care systems to reduce diagnostic errors: leveraging human experience and artificial intelligence. Citation Text: Abid MH. Redesign of health care systems to reduce diagnostic errors: leveraging human experience and artificial intelligence. J Clin Outcomes M…

Medication errors involving nursing students: a systematic review. | PSNet

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March 09, 2022 - Review Medication errors involving nursing students: a systematic review. Citation Text: Asensi-Vicente J, Jiménez-Ruiz I, Vizcaya-Moreno F. Medication Errors Involving Nursing Students: A Systematic Review. Nurse Educ. 2018;43(5):E1-E5. doi:10.1097/NNE.0000000000000481. Copy Citation …

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