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Failure to rescue following emergency surgery: a FRAM analysis of the management of the deteriorating patient. | PSNet

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May 19, 2021 - Study Failure to rescue following emergency surgery: a FRAM analysis of the management of the deteriorating patient. Citation Text: Sujan M, Bilbro N, Ross A, et al. Failure to rescue following emergency surgery: A FRAM analysis of the management of the deteriorating patient. Appl Ergon.…

Encouraging employees to speak up to prevent infections: opportunities to leverage quality improvement and care management processes. | PSNet

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January 23, 2017 - Study Encouraging employees to speak up to prevent infections: opportunities to leverage quality improvement and care management processes. Citation Text: Robbins J, McAlearney AS. Encouraging employees to speak up to prevent infections: Opportunities to leverage quality improvement and …

Rural emergency medical services clinicians' perceptions and preferences in receiving clinical feedback from hospitals: a qualitative needs assessment. | PSNet

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June 02, 2021 - Study Rural emergency medical services clinicians' perceptions and preferences in receiving clinical feedback from hospitals: a qualitative needs assessment. Citation Text: Schneider K, Williams M, Mohr NM, et al. Rural emergency medical services clinicians' perceptions and preferences i…

Patient safety outcomes after two years of an enhanced internal medicine residency clinic handoff. | PSNet

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March 21, 2018 - Study Patient safety outcomes after two years of an enhanced internal medicine residency clinic handoff. Citation Text: Pincavage AT, Prochaska M, Dahlstrom M, et al. Patient Safety Outcomes after Two Years of an Enhanced Internal Medicine Residency Clinic Handoff. Am J Med. 2013;127(1).…

Medicare's decision to withhold payment for hospital errors: the devil is in the details. | PSNet

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March 13, 2013 - Commentary Classic Medicare's decision to withhold payment for hospital errors: the devil is in the details. Citation Text: Wachter R, Foster NE, Dudley A. Medicare's decision to withhold payment for hospital errors: the devil is in the det. Jt Comm J Qual Patie…

Patient safety incidents in home hospice care: the experiences of hospice interdisciplinary team members. | PSNet

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February 15, 2011 - Study Patient safety incidents in home hospice care: the experiences of hospice interdisciplinary team members. Citation Text: Smucker DR, Regan S, Elder NC, et al. Patient safety incidents in home hospice care: the experiences of hospice interdisciplinary team members. J Palliat Med. 20…

Lessons learnt from incidents reported by postgraduate trainees in Dutch general practice. A prospective cohort study. | PSNet

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February 23, 2011 - Study Lessons learnt from incidents reported by postgraduate trainees in Dutch general practice. A prospective cohort study. Citation Text: Zwart DLM, Heddema WS, Vermeulen MI, et al. Lessons learnt from incidents reported by postgraduate trainees in Dutch general practice. A prospecti…

Hospital Survey on Patient Safety Culture: 2010 User Comparative Database Report. | PSNet

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November 30, 2016 - Book/Report Hospital Survey on Patient Safety Culture: 2010 User Comparative Database Report. Citation Text: Hospital Survey on Patient Safety Culture: 2010 User Comparative Database Report. Sorra J, Famolaro T, Dyer N, Nelson D, Khanna K. Rockville, MD: Agency for Healthcare Researc…

Linking patient safety culture to quality ratings in the nursing home setting. | PSNet

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June 29, 2022 - Study Linking patient safety culture to quality ratings in the nursing home setting. Citation Text: Yount N, Zebrak KA, Famolaro T, et al. Linking Patient Safety Culture to Quality Ratings in the Nursing Home Setting. J Appl Gerontol. 2021;41(1):73-81. doi:10.1177/0733464820969283. Cop…

Managing diagnostic uncertainty in primary care: a systematic critical review. | PSNet

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February 15, 2017 - Review Managing diagnostic uncertainty in primary care: a systematic critical review. Citation Text: Alam R, Cheraghi-Sohi S, Panagioti M, et al. Managing diagnostic uncertainty in primary care: a systematic critical review. BMC Fam Pract. 2017;18(1):79. doi:10.1186/s12875-017-0650-0. …

Achieving the National Quality Forum's "Never Events": prevention of wrong site, wrong procedure, and wrong patient operations. | PSNet

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September 28, 2010 - Review Achieving the National Quality Forum's "Never Events": prevention of wrong site, wrong procedure, and wrong patient operations. Citation Text: Michaels RK, Makary MA, Dahab Y, et al. Achieving the National Quality Forum's "Never Events": prevention of wrong site, wrong procedure…

Pharmacist medication reviews to improve safety monitoring in primary care patients. | PSNet

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April 24, 2018 - Study Pharmacist medication reviews to improve safety monitoring in primary care patients. Citation Text: Gallimore CE, Sokhal D, Schreiter EZ, et al. Pharmacist medication reviews to improve safety monitoring in primary care patients. Fam Syst Health. 2016;34(2):104-113. doi:10.1037/fsh…

Information technology-based approaches to reducing repeat drug exposure in patients with known drug allergies. | PSNet

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December 21, 2022 - Commentary Information technology-based approaches to reducing repeat drug exposure in patients with known drug allergies. Citation Text: Cresswell K, Sheikh A. Information technology-based approaches to reducing repeat drug exposure in patients with known drug allergies. J Allergy Cli…

Using an enhanced oral chemotherapy computerized provider order entry system to reduce prescribing errors and improve safety. | PSNet

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October 20, 2014 - Study Using an enhanced oral chemotherapy computerized provider order entry system to reduce prescribing errors and improve safety. Citation Text: Collins CM, Elsaid KA. Using an enhanced oral chemotherapy computerized provider order entry system to reduce prescribing errors and improve …

Factors differentiating nursing homes with strong resident safety climate: a qualitative study of leadership and staff perspectives. | PSNet

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August 26, 2020 - Study Factors differentiating nursing homes with strong resident safety climate: a qualitative study of leadership and staff perspectives. Citation Text: Engle RL, Gillespie C, Clark VA, et al. Factors differentiating nursing homes with strong resident safety climate: a qualitative study…

Preventing diagnostic errors in ambulatory care: an electronic notification tool for incomplete radiology tests. | PSNet

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April 22, 2013 - Study Preventing diagnostic errors in ambulatory care: an electronic notification tool for incomplete radiology tests. Citation Text: Weingart SN, Yaghi O, Barnhart L, et al. Preventing diagnostic errors in ambulatory care: an electronic notification tool for incomplete radiology tests. …

Reviewing deaths in British and US hospitals: a study of two scales for assessing preventability. | PSNet

psnet.ahrq.gov/issue/reviewing-deaths-british-and-us-hospitals-study-two-scales-assessing-preventability

April 03, 2019 - Study Reviewing deaths in British and US hospitals: a study of two scales for assessing preventability. Citation Text: Manaseki-Holland S, Lilford RJ, Bishop JRB, et al. Reviewing deaths in British and US hospitals: a study of two scales for assessing preventability. BMJ Qual Saf. 2017;2…

Why and how to approach user experience in safety-critical domains: the example of health care. | PSNet

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May 05, 2021 - Commentary Why and how to approach user experience in safety-critical domains: the example of health care. Citation Text: Grundgeiger T, Hurtienne J, Happel O. Why and how to approach user experience in safety-critical domains: the example of health care. Hum Factors. 2020;63(5):821-832.…

A systems analysis of work-related violence in hospitals: stakeholders, contributory factors, and leverage points. | PSNet

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February 01, 2023 - Study A systems analysis of work-related violence in hospitals: stakeholders, contributory factors, and leverage points. Citation Text: Salmon PM, Coventon L, Read GJM. A systems analysis of work-related violence in hospitals: stakeholders, contributory factors, and leverage points. Safe…

Voluntary electronic reporting of medical errors and adverse events. | PSNet

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March 21, 2017 - Study Voluntary electronic reporting of medical errors and adverse events. Citation Text: Milch CE, Salem D, Pauker SG, et al. Voluntary electronic reporting of medical errors and adverse events. An analysis of 92,547 reports from 26 acute care hospitals. J Gen Intern Med. 2006;21(2):1…

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