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We will not compete on safety: how children's hospitals have come together to hasten harm reduction. | PSNet

psnet.ahrq.gov/issue/we-will-not-compete-safety-how-childrens-hospitals-have-come-together-hasten-harm-reduction

August 10, 2022 - Study We will not compete on safety: how children's hospitals have come together to hasten harm reduction. Citation Text: Lyren A, Coffey M, Shepherd M, et al. We Will Not Compete on Safety: How Children's Hospitals Have Come Together to Hasten Harm Reduction. Jt Comm J Qual Patient Saf.…

Medication errors involving patient-controlled analgesia. | PSNet

psnet.ahrq.gov/issue/medication-errors-involving-patient-controlled-analgesia

May 24, 2015 - Study Medication errors involving patient-controlled analgesia. Citation Text: Hicks RW, Sikirica V, Nelson W, et al. Medication errors involving patient-controlled analgesia. Am J Health Syst Pharm. 2008;65(5):429-40. doi:10.2146/ajhp070194. Copy Citation Format: DOI G…

A proactive risk avoidance system using failure mode and effects analysis for "same-name" physician orders. | PSNet

psnet.ahrq.gov/issue/proactive-risk-avoidance-system-using-failure-mode-and-effects-analysis-same-name-physician

February 23, 2022 - Commentary A proactive risk avoidance system using failure mode and effects analysis for "same-name" physician orders. Citation Text: Tarpey K, Schaaf E, Lakhani U, et al. A proactive risk avoidance system using failure mode and effects analysis for "same-name" physician orders. Jt Comm …

Errors, omissions, and outliers in hourly vital signs measurements in intensive care. | PSNet

psnet.ahrq.gov/issue/errors-omissions-and-outliers-hourly-vital-signs-measurements-intensive-care

June 20, 2011 - Study Errors, omissions, and outliers in hourly vital signs measurements in intensive care. Citation Text: Maslove DM, Dubin JA, Shrivats A, et al. Errors, Omissions, and Outliers in Hourly Vital Signs Measurements in Intensive Care. Crit Care Med. 2016;44(11):e1021-e1030. Copy Citatio…

Intensive care unit nurses' perceptions of safety after a highly specific safety intervention. | PSNet

psnet.ahrq.gov/issue/intensive-care-unit-nurses-perceptions-safety-after-highly-specific-safety-intervention

June 16, 2011 - Study Intensive care unit nurses' perceptions of safety after a highly specific safety intervention. Citation Text: Elder NC, Brungs SM, Nagy M, et al. Intensive care unit nurses' perceptions of safety after a highly specific safety intervention. Qual Saf Health Care. 2008;17(1):25-3…

Increasing compliance with the World Health Organization surgical safety checklist—a regional health system's experience. | PSNet

psnet.ahrq.gov/issue/increasing-compliance-world-health-organization-surgical-safety-checklist-regional-health

September 12, 2018 - Study Increasing compliance with the World Health Organization surgical safety checklist—a regional health system's experience. Citation Text: Gitelis ME, Kaczynski A, Shear T, et al. Increasing compliance with the World Health Organization Surgical Safety Checklist-A regional health sys…

The causes of their death appear (unto our shame perpetual): why root cause analysis is not the best model for error investigation in mental health services. | PSNet

psnet.ahrq.gov/issue/causes-their-death-appear-unto-our-shame-perpetual-why-root-cause-analysis-not-best-model

September 27, 2016 - Study The causes of their death appear (unto our shame perpetual): why root cause analysis is not the best model for error investigation in mental health services. Citation Text: Vrklevski LP, McKechnie L, OʼConnor N. The Causes of Their Death Appear (Unto Our Shame Perpetual): Why Root …

Escalation of care in surgery: a systematic risk assessment to prevent avoidable harm in hospitalized patients. | PSNet

psnet.ahrq.gov/issue/escalation-care-surgery-systematic-risk-assessment-prevent-avoidable-harm-hospitalized

December 17, 2014 - Study Escalation of care in surgery: a systematic risk assessment to prevent avoidable harm in hospitalized patients. Citation Text: Johnston MJ, Arora S, Anderson O, et al. Escalation of care in surgery: a systematic risk assessment to prevent avoidable harm in hospitalized patients. An…

Trends in survival after in-hospital cardiac arrest during nights and weekends. | PSNet

psnet.ahrq.gov/issue/trends-survival-after-hospital-cardiac-arrest-during-nights-and-weekends

February 17, 2011 - Study Emerging Classic Trends in survival after in-hospital cardiac arrest during nights and weekends. Citation Text: Ofoma UR, Basnet S, Berger A, et al. Trends in Survival After In-Hospital Cardiac Arrest During Nights and Weekends. J Am Coll Cardiol. 2018;71(…

He thought the "lady in the door" was the "lady in the window": a qualitative study of patient identification practices. | PSNet

psnet.ahrq.gov/issue/he-thought-lady-door-was-lady-window-qualitative-study-patient-identification-practices

June 14, 2017 - Study He thought the "lady in the door" was the "lady in the window": a qualitative study of patient identification practices. Citation Text: Phipps E, Turkel M, Mackenzie ER, et al. He thought the "lady in the door" was the "lady in the window": a qualitative study of patient identifica…

Automated surveillance for adverse drug events at a community hospital and an academic medical center. | PSNet

psnet.ahrq.gov/issue/automated-surveillance-adverse-drug-events-community-hospital-and-academic-medical-center

September 23, 2020 - Study Automated surveillance for adverse drug events at a community hospital and an academic medical center. Citation Text: Kilbridge PM, Campbell UC, Cozart HB, et al. Automated surveillance for adverse drug events at a community hospital and an academic medical center. J Am Med Infor…

Identifying and characterizing preventable adverse drug events for prioritizing pharmacist intervention in hospitals. | PSNet

psnet.ahrq.gov/issue/identifying-and-characterizing-preventable-adverse-drug-events-prioritizing-pharmacist

July 15, 2010 - Study Identifying and characterizing preventable adverse drug events for prioritizing pharmacist intervention in hospitals. Citation Text: Jeon N, Staley B, Johns T, et al. Identifying and characterizing preventable adverse drug events for prioritizing pharmacist intervention in hospital…

Impact of a reengineered electronic error-reporting system on medication event reporting and care process improvements at an urban medical center. | PSNet

psnet.ahrq.gov/issue/impact-reengineered-electronic-error-reporting-system-medication-event-reporting-and-care

December 29, 2014 - Study Impact of a reengineered electronic error-reporting system on medication event reporting and care process improvements at an urban medical center. Citation Text: McKaig D, Collins C, Elsaid KA. Impact of a reengineered electronic error-reporting system on medication event reporting…

Empowerment failure: how shortcomings in physician communication unwittingly undermine patient autonomy. | PSNet

psnet.ahrq.gov/issue/empowerment-failure-how-shortcomings-physician-communication-unwittingly-undermine-patient

January 17, 2019 - Study Empowerment failure: how shortcomings in physician communication unwittingly undermine patient autonomy. Citation Text: Ubel PA, Scherr KA, Fagerlin A. Empowerment Failure: How Shortcomings in Physician Communication Unwittingly Undermine Patient Autonomy. Am J Bioeth. 2017;17(11):…

Professionalising patient safety? Findings from a mixed-methods formative evaluation of the patient safety specialist role in the English National Health Service. | PSNet

psnet.ahrq.gov/issue/professionalising-patient-safety-findings-mixed-methods-formative-evaluation-patient-safety

August 28, 2024 - Study Professionalising patient safety? Findings from a mixed-methods formative evaluation of the patient safety specialist role in the English National Health Service. Citation Text: Martin G, Pralat R, Waring J, et al. Professionalising patient safety? Findings from a mixed-methods for…

Systematic root cause analysis of adverse drug events in a tertiary referral hospital. | PSNet

psnet.ahrq.gov/issue/systematic-root-cause-analysis-adverse-drug-events-tertiary-referral-hospital

November 16, 2022 - Study Classic Systematic root cause analysis of adverse drug events in a tertiary referral hospital. Citation Text: Rex JH, Turnbull JE, Allen SJ, et al. Systematic Root Cause Analysis of Adverse Drug Events in a Tertiary Referral Hospital. Jt Comm J Qual Improv…

Controversy and quality improvement: lingering questions about ethics, oversight, and patient safety research. | PSNet

psnet.ahrq.gov/issue/controversy-and-quality-improvement-lingering-questions-about-ethics-oversight-and-patient

January 15, 2014 - Commentary Controversy and quality improvement: lingering questions about ethics, oversight, and patient safety research. Citation Text: Kass N, Pronovost P, Sugarman J, et al. Controversy and quality improvement: lingering questions about ethics, oversight, and patient safety research. …

Pharmacists’ perceptions of error reporting systems. | PSNet

psnet.ahrq.gov/issue/pharmacists-perceptions-error-reporting-systems

November 09, 2016 - Study Pharmacists’ perceptions of error reporting systems. Citation Text: Hartt CM, Weigand H, MacDonald AJ, et al. Pharmacists’ perceptions of error reporting systems. J Patient Saf Risk Manag. 2024;29(6):268-273. doi:10.1177/25160435241288287. Copy Citation Format: DOI Go…

Delayed workup of rectal bleeding in adult primary care: examining process-of-care failures. | PSNet

psnet.ahrq.gov/issue/delayed-workup-rectal-bleeding-adult-primary-care-examining-process-care-failures

April 24, 2018 - Study Delayed workup of rectal bleeding in adult primary care: examining process-of-care failures. Citation Text: Weingart SN, Stoffel EM, Chung DC, et al. Delayed Workup of Rectal Bleeding in Adult Primary Care: Examining Process-of-Care Failures. The Joint Commission Journal on Quality…

Implementation and impact of a rapid response team in a children's hospital. | PSNet

psnet.ahrq.gov/issue/implementation-and-impact-rapid-response-team-childrens-hospital

April 24, 2018 - Study Implementation and impact of a rapid response team in a children's hospital. Citation Text: Zenker P, Schlesinger A, Hauck M, et al. Implementation and impact of a rapid response team in a children's hospital. Jt Comm J Qual Patient Saf. 2007;33(7):418-425. Copy Citation Fo…

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