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

psnet.ahrq.gov/issue/building-framework-trust-critical-event-analysis-deaths-surgical-care

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…

Anesthesia Risk Alert program: a proactive safety initiative. | PSNet

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September 02, 2015 - Study Anesthesia Risk Alert program: a proactive safety initiative. Citation Text: Lee B, Marhalik-Helms J, Penzi L. Anesthesia Risk Alert program: a proactive safety initiative. Jt Comm J Qual Patient Saf. 2023;49(9):441-449. doi:10.1016/j.jcjq.2023.06.005. Copy Citation Format: …

Imperfect practice makes perfect: error management training improves transfer of learning. | PSNet

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May 19, 2019 - Study Imperfect practice makes perfect: error management training improves transfer of learning. Citation Text: Dyre L, Tabor A, Ringsted C, et al. Imperfect practice makes perfect: error management training improves transfer of learning. Med Educ. 2017;51(2):196-206. doi:10.1111/medu.13…

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

psnet.ahrq.gov/issue/method-measuring-system-safety-and-latent-errors-associated-pediatric-procedural-sedation

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…

Medication errors: a prospective cohort study of hand-written and computerised physician order entry in the intensive care unit. | PSNet

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March 06, 2013 - Study Medication errors: a prospective cohort study of hand-written and computerised physician order entry in the intensive care unit. Citation Text: Shulman R, Singer M, Goldstone J, et al. Medication errors: a prospective cohort study of hand-written and computerised physician order …

Effectiveness of interventions to improve adverse drug reaction reporting by healthcare professionals over the last decade: A systematic review | PSNet

psnet.ahrq.gov/issue/effectiveness-interventions-improve-adverse-drug-reaction-reporting-healthcare-professionals

August 28, 2024 - Review Effectiveness of interventions to improve adverse drug reaction reporting by healthcare professionals over the last decade: A systematic review Citation Text: Li R, Zaidi STR, Chen T, et al. Effectiveness of interventions to improve adverse drug reaction reporting by healthcare pr…

A radiation oncology-specific automated trigger indicator tool for high-risk near-miss safety events. | PSNet

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October 14, 2020 - Study A radiation oncology-specific automated trigger indicator tool for high-risk near-miss safety events. Citation Text: Hartvigson PE, Gensheimer MF, Spady PK, et al. A Radiation Oncology–Specific Automated Trigger Indicator Tool for High-Risk, Near-Miss Safety Events. Pract Radiat On…

Measuring and improving diagnostic safety in primary care: addressing the “twin” pandemics of diagnostic error and clinician burnout. | PSNet

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September 07, 2022 - Commentary Measuring and improving diagnostic safety in primary care: addressing the “twin” pandemics of diagnostic error and clinician burnout. Citation Text: Olson APJ, Linzer M, Schiff GD. Measuring and Improving Diagnostic Safety in Primary Care: Addressing the “Twin” Pandemics of Di…

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…

Detection rates of mild cognitive impairment in primary care for the United States Medicare population. | PSNet

psnet.ahrq.gov/issue/detection-rates-mild-cognitive-impairment-primary-care-united-states-medicare-population

February 16, 2022 - Study Detection rates of mild cognitive impairment in primary care for the United States Medicare population. Citation Text: Liu Y, Jun H, Becker A, et al. Detection rates of mild cognitive impairment in primary care for the United States Medicare population. J Prev Alz Dis. 2024;11:7–12…

Preventable hospital admissions related to medication (HARM): cost analysis of the HARM study. | PSNet

psnet.ahrq.gov/issue/preventable-hospital-admissions-related-medication-harm-cost-analysis-harm-study

April 27, 2022 - Study Preventable hospital admissions related to medication (HARM): cost analysis of the HARM study. Citation Text: Leendertse AJ, van den Bemt PMLA, Poolman JB, et al. Preventable hospital admissions related to medication (HARM): cost analysis of the HARM study. Value Health. 2011;14(1)…

Association of anesthesiologist staffing ratio with surgical patient morbidity and mortality. | PSNet

psnet.ahrq.gov/issue/association-anesthesiologist-staffing-ratio-surgical-patient-morbidity-and-mortality

July 06, 2022 - Study Association of anesthesiologist staffing ratio with surgical patient morbidity and mortality. Citation Text: Burns ML, Saager L, Cassidy RB, et al. Association of anesthesiologist staffing ratio with surgical patient morbidity and mortality. JAMA Surg. 2022;157(9):807-815. doi:10.1…

Effects of interorganisational information technology networks on patient safety: a realist synthesis. | PSNet

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December 02, 2020 - Review Effects of interorganisational information technology networks on patient safety: a realist synthesis. Citation Text: Keen J, Abdulwahid MA, King N, et al. Effects of interorganisational information technology networks on patient safety: a realist synthesis. BMJ Open. 2020;10(10):…

Barriers to incident-reporting behavior among nursing staff: a study based on the theory of planned behavior. | PSNet

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February 27, 2019 - Study Barriers to incident-reporting behavior among nursing staff: a study based on the theory of planned behavior. Citation Text: Lee Y-H, Yang C-C, Chen T-T. Barriers to incident-reporting behavior among nursing staff: A study based on the theory of planned behavior. J Manag Organ. 201…

Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions. | PSNet

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September 23, 2020 - Commentary Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions. Citation Text: Morris AH, Stagg B, Lanspa M, et al. Enabling a learning healthcare system with automated computer protocols that produce replicab…

Comparison and interpretation of urinalysis performed by a nephrologist versus a hospital-based clinical laboratory. | PSNet

psnet.ahrq.gov/issue/comparison-and-interpretation-urinalysis-performed-nephrologist-versus-hospital-based

March 14, 2016 - Study Comparison and interpretation of urinalysis performed by a nephrologist versus a hospital-based clinical laboratory. Citation Text: Tsai JJ, Yeun JY, Kumar VA, et al. Comparison and interpretation of urinalysis performed by a nephrologist versus a hospital-based clinical laborato…

Show me the money, I'll show you my complications: impacts of incentivized incident self-reporting among surgeons. | PSNet

psnet.ahrq.gov/issue/show-me-money-ill-show-you-my-complications-impacts-incentivized-incident-self-reporting

March 09, 2022 - Study Show me the money, I'll show you my complications: impacts of incentivized incident self-reporting among surgeons. Citation Text: Cook-Richardson S, Addo A, Kim P, et al. Show me the money, I'll show you my complications: impacts of incentivized incident self-reporting among surgeo…

Improving self-reported empathy and communication skills through harm in healthcare response training. | PSNet

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March 09, 2022 - Study Improving self-reported empathy and communication skills through harm in healthcare response training. Citation Text: Samuels A, Broome ME, McDonald TB, et al. Improving self-reported empathy and communication skills through harm in healthcare response training. J Patient Saf Risk …

Hastened death due to disease burden and distress that has not received timely, quality palliative care is a medical error. | PSNet

psnet.ahrq.gov/issue/hastened-death-due-disease-burden-and-distress-has-not-received-timely-quality-palliative

October 31, 2023 - Commentary Hastened death due to disease burden and distress that has not received timely, quality palliative care is a medical error. Citation Text: Gallagher R, Passmore MJ, Baldwin C. Hastened death due to disease burden and distress that has not received timely, quality palliative ca…

Eliminating explicit and implicit biases in health care: evidence and research needs. | PSNet

psnet.ahrq.gov/issue/eliminating-explicit-and-implicit-biases-health-care-evidence-and-research-needs

May 11, 2016 - Review Eliminating explicit and implicit biases in health care: evidence and research needs. Citation Text: Vela MB, Erondu AI, Smith NA, et al. Eliminating explicit and implicit biases in health care: evidence and research needs. Annu Rev Public Health. 2022;43(1):477-501. doi:10.1146/…

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