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Human factor in cardiac surgery: errors and near misses in a high technology medical domain. | PSNet

psnet.ahrq.gov/issue/human-factor-cardiac-surgery-errors-and-near-misses-high-technology-medical-domain

June 09, 2010 - Review Classic Human factor in cardiac surgery: errors and near misses in a high technology medical domain. Citation Text: Carthey J, de Leval MR, Reason JT. The human factor in cardiac surgery: errors and near misses in a high technology medical domain. Ann Tho…

Caring for our own: deploying a systemwide second victim rapid response team. | PSNet

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September 19, 2016 - Study Classic Caring for our own: deploying a systemwide second victim rapid response team. Citation Text: Scott SD, Hirschinger LE, Cox KR, et al. Caring for our own: deploying a systemwide second victim rapid response team. Jt Comm J Qual Saf. 2010;36(5):233-2…

Design and implementation of an analgesia, sedation, and paralysis order set to enhance compliance of pro re nata medication orders with Joint Commission medication management standards in a pediatric ICU. | PSNet

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February 09, 2022 - Study Design and implementation of an analgesia, sedation, and paralysis order set to enhance compliance of pro re nata medication orders with Joint Commission medication management standards in a pediatric ICU. Citation Text: Procaccini D, Rapaport R, Petty BG, et al. Design and Impleme…

The extent and importance of unintended consequences related to computerized provider order entry. | PSNet

psnet.ahrq.gov/issue/extent-and-importance-unintended-consequences-related-computerized-provider-order-entry

May 27, 2011 - Study Classic The extent and importance of unintended consequences related to computerized provider order entry. Citation Text: Ash JS, Sittig DF, Poon EG, et al. The extent and importance of unintended consequences related to computerized provider order entry…

Electronic medical record-based interventions to encourage opioid prescribing best practices in the emergency department. | PSNet

psnet.ahrq.gov/issue/electronic-medical-record-based-interventions-encourage-opioid-prescribing-best-practices

September 01, 2021 - Study Electronic medical record-based interventions to encourage opioid prescribing best practices in the emergency department. Citation Text: Smalley CM, Willner MA, Muir MKR, et al. Electronic medical record-based interventions to encourage opioid prescribing best practices in the emer…

Quasi-experimental evaluation of the effectiveness of a large-scale readmission reduction program. | PSNet

psnet.ahrq.gov/issue/quasi-experimental-evaluation-effectiveness-large-scale-readmission-reduction-program

January 07, 2015 - Study Quasi-experimental evaluation of the effectiveness of a large-scale readmission reduction program. Citation Text: Jenq GY, Doyle MM, Belton BM, et al. Quasi-Experimental Evaluation of the Effectiveness of a Large-Scale Readmission Reduction Program. JAMA Intern Med. 2016;176(5):681…

Improving the specificity of drug-drug interaction alerts: can it be done? | PSNet

psnet.ahrq.gov/issue/improving-specificity-drug-drug-interaction-alerts-can-it-be-done

September 07, 2022 - Study Improving the specificity of drug-drug interaction alerts: can it be done? Citation Text: Reese T, Wright A, Liu S, et al. Improving the specificity of drug-drug interaction alerts: Can it be done? Am J Health Syst Pharm. 2022;79(13):1086-1095. doi:10.1093/ajhp/zxac045. Copy Cita…

Observational evidence of the prevalence and association of polypharmacy and drug administration errors in hospitalized adult patients. | PSNet

psnet.ahrq.gov/issue/observational-evidence-prevalence-and-association-polypharmacy-and-drug-administration-errors

August 11, 2021 - Study Observational evidence of the prevalence and association of polypharmacy and drug administration errors in hospitalized adult patients. Citation Text: Savva G, Papastavrou E, Charalambous A, et al. Observational evidence of the prevalence and association of polypharmacy and drug ad…

Transforming the medication regimen review process using telemedicine to prevent adverse events. | PSNet

psnet.ahrq.gov/issue/transforming-medication-regimen-review-process-using-telemedicine-prevent-adverse-events

November 11, 2015 - Study Transforming the medication regimen review process using telemedicine to prevent adverse events. Citation Text: Kane‐Gill SL, Wong A, Culley CM, et al. Transforming the medication regimen review process using telemedicine to prevent adverse events. J Am Geriatr Soc. 2020;69(2):530-…

Incidence and preventability of adverse drug events among older persons in the ambulatory setting. | PSNet

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March 11, 2011 - Study Classic Incidence and preventability of adverse drug events among older persons in the ambulatory setting. Citation Text: Gurwitz JH, Field T, Harrold LR, et al. Incidence and Preventability of Adverse Drug Events Among Older Persons in the Ambulatory Se…

Moving beyond the weekend effect: how can we best target interventions to improve patient care? | PSNet

psnet.ahrq.gov/issue/moving-beyond-weekend-effect-how-can-we-best-target-interventions-improve-patient-care

September 09, 2015 - Commentary Moving beyond the weekend effect: how can we best target interventions to improve patient care? Citation Text: Marang-van de Mheen PJ, Vincent CA. Moving beyond the weekend effect: how can we best target interventions to improve patient care? BMJ Qual Saf. 2021;30(7):525-528. …

Vital signs: maternity care experiences — United States, April 2023. | PSNet

psnet.ahrq.gov/issue/vital-signs-maternity-care-experiences-united-states-april-2023

July 19, 2023 - Study Vital signs: maternity care experiences — United States, April 2023. Citation Text: Mohamoud YA, Cassidy E, Fuchs E, et al. Vital Signs: Maternity Care Experiences — United States, April 2023. MMWR Morb Mortal Wkly Rep. 2023;72(35):961–967. doi:10.15585/mmwr.mm7235e1. Copy Citati…

The Veterans Affairs root cause analysis system in action. | PSNet

psnet.ahrq.gov/issue/veterans-affairs-root-cause-analysis-system-action

June 22, 2022 - Study Classic The Veterans Affairs root cause analysis system in action. Citation Text: Bagian JP, Gosbee JW, Lee CZ, et al. The Veterans Affairs Root Cause Analysis System in Action. Jt Comm J Qual Improv. 2016;28(10):531-545. doi:10.1016/s1070-3241(02)28057-8.…

Predictors of likelihood of speaking up about safety concerns in labour and delivery. | PSNet

psnet.ahrq.gov/issue/predictors-likelihood-speaking-about-safety-concerns-labour-and-delivery

October 19, 2022 - Study Predictors of likelihood of speaking up about safety concerns in labour and delivery. Citation Text: Lyndon A, Sexton B, Simpson KR, et al. Correction. BMJ Qual Saf. 2011;22(2):791-799. doi:10.1136/bmjqs.2010.050211. Copy Citation Format: DOI Google Scholar BibTeX E…

A cluster randomized trial of interventions to improve work conditions and clinician burnout in primary care: results from the Healthy Work Place (HWP) study. | PSNet

psnet.ahrq.gov/issue/cluster-randomized-trial-interventions-improve-work-conditions-and-clinician-burnout-primary

January 23, 2017 - Study A cluster randomized trial of interventions to improve work conditions and clinician burnout in primary care: results from the Healthy Work Place (HWP) study. Citation Text: Linzer M, Poplau S, Grossman E, et al. A Cluster Randomized Trial of Interventions to Improve Work Condition…

Psychological and psychosomatic symptoms of second victims of adverse events: a systematic review and meta-analysis. | PSNet

psnet.ahrq.gov/issue/psychological-and-psychosomatic-symptoms-second-victims-adverse-events-systematic-review-and

June 23, 2021 - Review Emerging Classic Psychological and psychosomatic symptoms of second victims of adverse events: a systematic review and meta-analysis. Citation Text: Busch IM, Moretti F, Purgato M, et al. Psychological and Psychosomatic Symptoms of Second Victims of Adver…

AHRQ patient safety project reduces bloodstream infections by 40 percent. | PSNet

psnet.ahrq.gov/issue/ahrq-patient-safety-project-reduces-bloodstream-infections-40-percent

January 22, 2020 - Newspaper/Magazine Article AHRQ patient safety project reduces bloodstream infections by 40 percent. Citation Text: AHRQ patient safety project reduces bloodstream infections by 40 percent. Schmidt B. Patient Saf Qual Hcare. September 12, 2012. Copy Citation Save …

A surgical safety checklist to reduce morbidity and mortality in a global population. | PSNet

psnet.ahrq.gov/issue/surgical-safety-checklist-reduce-morbidity-and-mortality-global-population

February 09, 2011 - Study Classic A surgical safety checklist to reduce morbidity and mortality in a global population. Citation Text: Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;3…

Physician burnout, well-being, and work unit safety grades in relationship to reported medical errors. | PSNet

psnet.ahrq.gov/issue/physician-burnout-well-being-and-work-unit-safety-grades-relationship-reported-medical-errors

June 01, 2022 - Study Classic Physician burnout, well-being, and work unit safety grades in relationship to reported medical errors. Citation Text: Tawfik DS, Profit J, Morgenthaler TI, et al. Physician Burnout, Well-being, and Work Unit Safety Grades in Relationship to Reporte…

Lifetime prevalence and correlates of patient-perceived medical errors experienced in the U.S. ambulatory setting: a population-based study. | PSNet

psnet.ahrq.gov/issue/lifetime-prevalence-and-correlates-patient-perceived-medical-errors-experienced-us-ambulatory

June 09, 2021 - Study Lifetime prevalence and correlates of patient-perceived medical errors experienced in the U.S. ambulatory setting: a population-based study. Citation Text: Sundwall DN, Munger MA, Tak CR, et al. Lifetime prevalence and correlates of patient-perceived medical errors experienced in t…

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