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Impact of out-of-hours admission on patient mortality: longitudinal analysis in a tertiary acute hospital. | PSNet

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July 21, 2017 - Study Impact of out-of-hours admission on patient mortality: longitudinal analysis in a tertiary acute hospital. Citation Text: Han L, Sutton M, Clough S, et al. Impact of out-of-hours admission on patient mortality: longitudinal analysis in a tertiary acute hospital. BMJ Qual Saf. 2018;…

Incidence of adverse events related to health care in Spain: results of the Spanish National Study of Adverse Events. | PSNet

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December 01, 2011 - Study Incidence of adverse events related to health care in Spain: results of the Spanish National Study of Adverse Events. Citation Text: Aranaz-Andrés JM, Aibar-Remón C, Vitaller-Murillo J, et al. Incidence of adverse events related to health care in Spain: results of the Spanish Nat…

Residents, responsibility, and error: how residents learn to navigate the intersection. | PSNet

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August 21, 2019 - Study Residents, responsibility, and error: how residents learn to navigate the intersection. Citation Text: Shepherd L, Chilton S, Cristancho SM. Residents, responsibility, and error: how residents learn to navigate the intersection. Acad Med. 2023;98(8):934-940. doi:10.1097/acm.0000000…

Medicines management support to older people: understanding the context of systems failure. | PSNet

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October 04, 2023 - Study Medicines management support to older people: understanding the context of systems failure. Citation Text: Rogers S, Martin G, Rai G. Medicines management support to older people: understanding the context of systems failure. BMJ Open. 2014;4(7):e005302. doi:10.1136/bmjopen-2014-00…

Exploring error in team-based acute care scenarios: an observational study from the United Kingdom. | PSNet

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November 02, 2011 - Study Exploring error in team-based acute care scenarios: an observational study from the United Kingdom. Citation Text: Tallentire VR, Smith SE, Skinner J, et al. Exploring error in team-based acute care scenarios: an observational study from the United kingdom. Acad Med. 2012;87(6):79…

Medical errors and quality of care: from control to commitment. | PSNet

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July 15, 2020 - Commentary Medical errors and quality of care: from control to commitment. Citation Text: Khatri N, Baveja A, Boren SA, et al. Medical Errors and Quality of Care: From Control to Commitment. California Manage Review. 2006;48(3):115-141. doi:10.2307/41166353. Copy Citation Format…

Building a framework for trust: critical event analysis of deaths in surgical care. | PSNet

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June 23, 2009 - Study Building a framework for trust: critical event analysis of deaths in surgical care. Citation Text: Thompson A, Stonebridge PA. Building a framework for trust: critical event analysis of deaths in surgical care. BMJ. 2005;330(7500):1139-42. Copy Citation Format: Goog…

A method for measuring system safety and latent errors associated with pediatric procedural sedation. | PSNet

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April 11, 2011 - Study A method for measuring system safety and latent errors associated with pediatric procedural sedation. Citation Text: Blike G, Christoffersen K, Cravero JP, et al. A method for measuring system safety and latent errors associated with pediatric procedural sedation. Anesth Analg. 2…

Organizational learning: health care leaders need to design structures and processes that enhance collective learning. | PSNet

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November 18, 2020 - Commentary Organizational learning: health care leaders need to design structures and processes that enhance collective learning. Citation Text: Bohmer RM, Edmondson AC. Organizational learning in health care. Health Forum J. 2001;44(2):32-35. Copy Citation Format: Google…

Veterans Health Administration response to the COVID-19 crisis: surveillance to action. | PSNet

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November 17, 2021 - Commentary Veterans Health Administration response to the COVID-19 crisis: surveillance to action. Citation Text: Charles MA, Yackel EE, Mills PD, et al. Veterans Health Administration response to the COVID-19 crisis: surveillance to action. J Patient Saf. 2022;18(7):686-691. doi:10.1097…

Should I report? A qualitative study of barriers to incident reporting among nurses working in nursing homes. | PSNet

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March 31, 2021 - Study Should I report? A qualitative study of barriers to incident reporting among nurses working in nursing homes. Citation Text: Prang IW, Jelsness-Jørgensen L-P. Should I report? A qualitative study of barriers to incident reporting among nurses working in nursing homes. Geriatr Nurs.…

Improving handoffs in the perioperative environment: a conceptual framework of key theories, system factors, methods, and core interventions to ensure success. | PSNet

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November 16, 2022 - Commentary Improving handoffs in the perioperative environment: a conceptual framework of key theories, system factors, methods, and core interventions to ensure success. Citation Text: Starmer AJ, Michael MM, Spector ND, et al. Improving handoffs in the perioperative environment: a conc…

Using co-design to develop a collective leadership intervention for healthcare teams to improve safety culture. | PSNet

psnet.ahrq.gov/issue/using-co-design-develop-collective-leadership-intervention-healthcare-teams-improve-safety

October 02, 2019 - Commentary Emerging Classic Using co-design to develop a collective leadership intervention for healthcare teams to improve safety culture. Citation Text: Ward ME, De Brún A, Beirne D, et al. Using Co-Design to Develop a Collective Leadership Intervention for He…

Encouraging patients to speak up about problems in cancer care. | PSNet

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March 11, 2013 - Study Encouraging patients to speak up about problems in cancer care. Citation Text: Mazor KM, Kamineni A, Roblin DW, et al. Encouraging patients to speak up about problems in cancer care. J Patient Saf. 2021;17(8):e1278-e1284. doi:10.1097/pts.0000000000000510. Copy Citation Format…

A critical review: moral injury in nurses in the aftermath of a patient safety incident. | PSNet

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July 22, 2020 - Review Emerging Classic A critical review: moral injury in nurses in the aftermath of a patient safety incident. Citation Text: Stovall M, Hansen L, van Ryn M. A critical review: moral injury in nurses in the aftermath of a patient safety incident. J Nurs Schola…

Implementing strategies to identify and mitigate adverse safety events: a case study with unplanned extubations. | PSNet

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May 24, 2012 - Study Implementing strategies to identify and mitigate adverse safety events: a case study with unplanned extubations. Citation Text: Hatch D, Rivard M, Bolton J, et al. Implementing Strategies to Identify and Mitigate Adverse Safety Events: A Case Study with Unplanned Extubations. Jt Co…

Physician perspectives on addressing anti-Black racism. | PSNet

psnet.ahrq.gov/issue/physician-perspectives-addressing-anti-black-racism

July 26, 2023 - Study Physician perspectives on addressing anti-Black racism. Citation Text: Brown CE, Marshall AR, Cueva KL, et al. Physician perspectives on addressing anti-Black racism. JAMA Netw Open. 2024;7(1):e2352818. doi:10.1001/jamanetworkopen.2023.52818. Copy Citation Format: DOI…

Understanding diagnostic errors in medicine: a lesson from aviation. | PSNet

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December 30, 2014 - Study Understanding diagnostic errors in medicine: a lesson from aviation. Citation Text: Singh H, Petersen LA, Thomas EJ. Understanding diagnostic errors in medicine: a lesson from aviation. Qual Saf Health Care. 2006;15(3):159-64. Copy Citation Format: Google Scholar Pu…

Opioid dependence and overdose after surgery: rate, risk factors, and reasons. | PSNet

psnet.ahrq.gov/issue/opioid-dependence-and-overdose-after-surgery-rate-risk-factors-and-reasons

August 05, 2020 - Study Opioid dependence and overdose after surgery: rate, risk factors, and reasons. Citation Text: Wylie JA, Kong L, Barth RJ. Opioid dependence and overdose after surgery: rate, risk factors, and reasons. Ann Surg. 2022;276(3):e192-e198. doi:10.1097/sla.0000000000005546. Copy Citatio…

Identifying risk factors for medical injury. | PSNet

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April 12, 2011 - Study Identifying risk factors for medical injury. Citation Text: Guse CE, Yang H, Layde PM. Identifying risk factors for medical injury. Int J Qual Health Care. 2006;18(3):203-10. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…

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