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Patient safety issues from information overload in electronic medical records. | PSNet

psnet.ahrq.gov/issue/patient-safety-issues-information-overload-electronic-medical-records

May 04, 2022 - Review Patient safety issues from information overload in electronic medical records. Citation Text: Nijor S, Rallis G, Lad N, et al. Patient safety issues from information overload in electronic medical records. J Patient Saf. 2022;18(6):e999-e1003. doi:10.1097/pts.0000000000001002. C…

Incidence and severity of medication reconciliation discrepancies in trauma patients. | PSNet

psnet.ahrq.gov/issue/incidence-and-severity-medication-reconciliation-discrepancies-trauma-patients

October 19, 2022 - Study Incidence and severity of medication reconciliation discrepancies in trauma patients. Citation Text: Dunbar EG, Massey AC, Lee YL, et al. Incidence and severity of medication reconciliation discrepancies in trauma patients. Am Surg. 2023;89(7):3272-3274. doi:10.1177/000313482311616…

Are bad outcomes from questionable clinical decisions preventable medical errors? A case of cascade iatrogenesis. | PSNet

psnet.ahrq.gov/issue/are-bad-outcomes-questionable-clinical-decisions-preventable-medical-errors-case-cascade

February 24, 2011 - Study Classic Are bad outcomes from questionable clinical decisions preventable medical errors? A case of cascade iatrogenesis. Citation Text: Hofer TP, Hayward RA. Are bad outcomes from questionable clinical decisions preventable medical errors? A case of cas…

A comprehensive quality assurance program for personnel and procedures in radiation oncology: value of voluntary error reporting and checklists. | PSNet

psnet.ahrq.gov/issue/comprehensive-quality-assurance-program-personnel-and-procedures-radiation-oncology-value

November 18, 2020 - Study A comprehensive quality assurance program for personnel and procedures in radiation oncology: value of voluntary error reporting and checklists. Citation Text: Kalapurakal JA, Zafirovski A, Smith J, et al. A comprehensive quality assurance program for personnel and procedures in …

Improving patient safety by identifying side effects from introducing bar coding in medication administration. | PSNet

psnet.ahrq.gov/issue/improving-patient-safety-identifying-side-effects-introducing-bar-coding-medication

March 11, 2011 - Study Classic Improving patient safety by identifying side effects from introducing bar coding in medication administration. Citation Text: Patterson ES, Cook RI, Render ML. Improving patient safety by identifying side effects from introducing bar coding in me…

Orders on file but no labs drawn: investigation of machine and human errors caused by an interface idiosyncrasy. | PSNet

psnet.ahrq.gov/issue/orders-file-no-labs-drawn-investigation-machine-and-human-errors-caused-interface

April 29, 2018 - Commentary Orders on file but no labs drawn: investigation of machine and human errors caused by an interface idiosyncrasy. Citation Text: Schreiber R, Sittig DF, Ash JS, et al. Orders on file but no labs drawn: investigation of machine and human errors caused by an interface idiosyncras…

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

psnet.ahrq.gov/issue/voluntary-electronic-reporting-medical-errors-and-adverse-events

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…

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

psnet.ahrq.gov/issue/lessons-learnt-incidents-reported-postgraduate-trainees-dutch-general-practice-prospective

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…

Assisting beginners in root cause analysis operations: analysis and recommendations regarding the spread of COVID-19 in nursing facilities for the elderly. | PSNet

psnet.ahrq.gov/issue/assisting-beginners-root-cause-analysis-operations-analysis-and-recommendations-regarding

June 08, 2022 - Commentary Assisting beginners in root cause analysis operations: analysis and recommendations regarding the spread of COVID-19 in nursing facilities for the elderly. Citation Text: Tsuchiya H. Assisting beginners in root cause analysis operations: analysis and recommendations regarding …

Failure mode and effects analysis to reduce risk of heparin use. | PSNet

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July 19, 2023 - Study Failure mode and effects analysis to reduce risk of heparin use. Citation Text: Pino FA, Weidemann DK, Schroeder LL, et al. Failure mode and effects analysis to reduce risk of heparin use. Am J Health Syst Pharm. 2019;76(23):1972-1979. doi:10.1093/ajhp/zxz229. Copy Citation F…

Physician reporting of clinically significant events through a computerized patient sign-out system. | PSNet

psnet.ahrq.gov/issue/physician-reporting-clinically-significant-events-through-computerized-patient-sign-out

January 25, 2023 - Study Physician reporting of clinically significant events through a computerized patient sign-out system. Citation Text: Nabors C, Peterson SJ, Aronow WS, et al. Physician reporting of clinically significant events through a computerized patient sign-out system. J Patient Saf. 2011;7(…

To what extent are adverse events found in patient records reported by patients and healthcare professionals via complaints, claims and incident reports? | PSNet

psnet.ahrq.gov/issue/what-extent-are-adverse-events-found-patient-records-reported-patients-and-healthcare

January 21, 2009 - Study To what extent are adverse events found in patient records reported by patients and healthcare professionals via complaints, claims and incident reports? Citation Text: Christiaans-Dingelhoff I, Smits M, Zwaan L, et al. To what extent are adverse events found in patient records r…

Standards for patient monitoring during general anesthesia at Harvard Medical School. | PSNet

psnet.ahrq.gov/issue/standards-patient-monitoring-during-general-anesthesia-harvard-medical-school

February 10, 2011 - Clinical Guideline Standards for patient monitoring during general anesthesia at Harvard Medical School. Citation Text: Eichhorn JH, Cooper JB, Cullen DJ, et al. Standards for patient monitoring during anesthesia at Harvard Medical School. JAMA. 1986;256(8):1017-20. Copy Citation F…

Patterns of technical error among surgical malpractice claims: an analysis of strategies to prevent injury to surgical patients. | PSNet

psnet.ahrq.gov/issue/patterns-technical-error-among-surgical-malpractice-claims-analysis-strategies-prevent-injury

August 26, 2011 - Study Patterns of technical error among surgical malpractice claims: an analysis of strategies to prevent injury to surgical patients. Citation Text: Regenbogen SE, Greenberg CC, Studdert DM, et al. Patterns of technical error among surgical malpractice claims: an analysis of strategie…

Recruitment of hospitals for a safety climate study: facilitators and barriers. | PSNet

psnet.ahrq.gov/issue/recruitment-hospitals-safety-climate-study-facilitators-and-barriers

June 16, 2011 - Study Recruitment of hospitals for a safety climate study: facilitators and barriers. Citation Text: Rosen AK, Gaba DM, Meterko M, et al. Recruitment of hospitals for a safety climate study: facilitators and barriers. Jt Comm J Qual Patient Saf. 2008;34(5):275-84. Copy Citation For…

An overview of patient safety climate in the VA. | PSNet

psnet.ahrq.gov/issue/overview-patient-safety-climate-va

January 10, 2017 - Study An overview of patient safety climate in the VA. Citation Text: Hartmann CW, Rosen AK, Meterko M, et al. An overview of patient safety climate in the VA. Health Serv Res. 2008;43(4):1263-84. doi:10.1111/j.1475-6773.2008.00839.x. Copy Citation Format: DOI Google Scho…

Human factors analysis of latent safety threats in a pediatric critical care unit. | PSNet

psnet.ahrq.gov/issue/human-factors-analysis-latent-safety-threats-pediatric-critical-care-unit

April 28, 2021 - Study Human factors analysis of latent safety threats in a pediatric critical care unit. Citation Text: Trbovich PL, Tomasi JN, Kolodzey L, et al. Human factors analysis of latent safety threats in a pediatric critical care unit. Pediatr Crit Care Med. 2022;23(3):151-159. doi:10.1097/pcc…

Errors in after-hours phone consultations: a simulation study. | PSNet

psnet.ahrq.gov/issue/errors-after-hours-phone-consultations-simulation-study

March 21, 2017 - Study Errors in after-hours phone consultations: a simulation study. Citation Text: Joffe E, Turley JP, Hwang KO, et al. Errors in after-hours phone consultations: a simulation study. BMJ Qual Saf. 2014;23(5):398-405. doi:10.1136/bmjqs-2013-002243. Copy Citation Format: DOI…

A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional change. | PSNet

psnet.ahrq.gov/issue/case-transfusion-error-trauma-patient-subsequent-root-cause-analysis-leading-institutional

March 30, 2022 - Commentary A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional change. Citation Text: Clifford SP, Mick PB, Derhake BM. A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional ch…

Evaluation of the suitability of root cause analysis frameworks for the investigation of community-acquired pressure ulcers: a systematic review and documentary analysis. | PSNet

psnet.ahrq.gov/issue/evaluation-suitability-root-cause-analysis-frameworks-investigation-community-acquired

June 16, 2021 - Review Evaluation of the suitability of root cause analysis frameworks for the investigation of community-acquired pressure ulcers: a systematic review and documentary analysis. Citation Text: McGraw C, Drennan VM. Evaluation of the suitability of root cause analysis frameworks for the i…

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