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Introduction of a mobile adverse event reporting system is associated with participation in adverse event reporting. | PSNet

psnet.ahrq.gov/issue/introduction-mobile-adverse-event-reporting-system-associated-participation-adverse-event

July 03, 2016 - Study Introduction of a mobile adverse event reporting system is associated with participation in adverse event reporting. Citation Text: Rubin DS, Pesyna C, Jakubczyk S, et al. Introduction of a Mobile Adverse Event Reporting System Is Associated With Participation in Adverse Event Repo…

ASPEN survey of parenteral nutrition access issues: how the system fails the patients. | PSNet

psnet.ahrq.gov/issue/aspen-survey-parenteral-nutrition-access-issues-how-system-fails-patients

October 02, 2013 - Study ASPEN survey of parenteral nutrition access issues: how the system fails the patients. Citation Text: Mirtallo JM, Allen P, Book WM, et al. ASPEN survey of parenteral nutrition access issues: how the system fails the patient. Nutr Clin Pract. 2024;39(5):1164-1181. doi:10.1002/ncp.1…

Handoffs causing patient harm: a survey of medical and surgical house staff. | PSNet

psnet.ahrq.gov/issue/handoffs-causing-patient-harm-survey-medical-and-surgical-house-staff

July 10, 2008 - Study Handoffs causing patient harm: a survey of medical and surgical house staff. Citation Text: Kitch BT, Cooper JB, Zapol WM, et al. Handoffs causing patient harm: a survey of medical and surgical house staff. Jt Comm J Qual Patient Saf. 2008;34(10):563-70. Copy Citation Format:…

Assessing the impact of an electronic chemotherapy order verification checklist on pharmacist reported errors in oncology infusion centers of a health-system. | PSNet

psnet.ahrq.gov/issue/assessing-impact-electronic-chemotherapy-order-verification-checklist-pharmacist-reported

January 22, 2016 - Study Assessing the impact of an electronic chemotherapy order verification checklist on pharmacist reported errors in oncology infusion centers of a health-system. Citation Text: Wat SK (S), Wesolowski B, Cierniak K, et al. Assessing the impact of an electronic chemotherapy order verifi…

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

psnet.ahrq.gov/issue/imperfect-practice-makes-perfect-error-management-training-improves-transfer-learning

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…

Mobile in situ obstetric emergency simulation and teamwork training to improve maternal–fetal safety in hospitals. | PSNet

psnet.ahrq.gov/issue/mobile-situ-obstetric-emergency-simulation-and-teamwork-training-improve-maternal-fetal

July 09, 2008 - Study Mobile in situ obstetric emergency simulation and teamwork training to improve maternal–fetal safety in hospitals. Citation Text: Guise J-M, Lowe NK, Deering S, et al. Mobile in situ obstetric emergency simulation and teamwork training to improve maternal-fetal safety in hospitals.…

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…

Resolving malpractice claims after tort reform: experience in a self-insured Texas public academic health system. | PSNet

psnet.ahrq.gov/issue/resolving-malpractice-claims-after-tort-reform-experience-self-insured-texas-public-academic

December 19, 2018 - Study Resolving malpractice claims after tort reform: experience in a self-insured Texas public academic health system. Citation Text: Sage WM, Harding MC, Thomas EJ. Resolving Malpractice Claims after Tort Reform: Experience in a Self-Insured Texas Public Academic Health System. Health …

Influences of physical layout and space on patient safety and communication in ambulatory oncology practices: a multisite, mixed method investigation. | PSNet

psnet.ahrq.gov/issue/influences-physical-layout-and-space-patient-safety-and-communication-ambulatory-oncology

August 25, 2021 - Study Influences of physical layout and space on patient safety and communication in ambulatory oncology practices: a multisite, mixed method investigation. Citation Text: Fauer AJ. Influences of physical layout and space on patient safety and communication in ambulatory oncology practic…

Unit-based care teams and the frequency and quality of physician–nurse communications. | PSNet

psnet.ahrq.gov/issue/unit-based-care-teams-and-frequency-and-quality-physician-nurse-communications

November 16, 2022 - Study Unit-based care teams and the frequency and quality of physician–nurse communications. Citation Text: Gordon M, Melvin P, Graham DA, et al. Unit-based care teams and the frequency and quality of physician-nurse communications. Arch Pediatr Adolesc Med. 2011;165(5):424-8. doi:10.100…

The RCA ReCAst: a root cause analysis simulation for the interprofessional clinical learning environment. | PSNet

psnet.ahrq.gov/issue/rca-recast-root-cause-analysis-simulation-interprofessional-clinical-learning-environment

May 18, 2022 - Study The RCA ReCAst: a root cause analysis simulation for the interprofessional clinical learning environment. Citation Text: Ziemba JB, Berns JS, Huzinec JG, et al. The RCA ReCAst: a root cause analysis simulation for the interprofessional clinical learning environment. Acad Med. 2021;…

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

psnet.ahrq.gov/issue/achieving-national-quality-forums-never-events-prevention-wrong-site-wrong-procedure-and

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…

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…

Analysis of unintended events in hospitals: inter-rater reliability of constructing causal trees and classifying root causes. | PSNet

psnet.ahrq.gov/issue/analysis-unintended-events-hospitals-inter-rater-reliability-constructing-causal-trees-and

April 30, 2014 - Study Analysis of unintended events in hospitals: inter-rater reliability of constructing causal trees and classifying root causes. Citation Text: Smits M, Janssen J, de Vet R, et al. Analysis of unintended events in hospitals: inter-rater reliability of constructing causal trees and c…

Electronic alerts to prevent venous thromboembolism among hospitalized patients. | PSNet

psnet.ahrq.gov/issue/electronic-alerts-prevent-venous-thromboembolism-among-hospitalized-patients

October 19, 2022 - Study Classic Electronic alerts to prevent venous thromboembolism among hospitalized patients. Citation Text: Kucher N, Koo S, Quiroz R, et al. Electronic alerts to prevent venous thromboembolism among hospitalized patients. N Engl J Med. 2005;352(10):969-77. …

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

psnet.ahrq.gov/issue/patient-safety-outcomes-after-two-years-enhanced-internal-medicine-residency-clinic-handoff

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).…

Can mindfulness in health care professionals improve patient care? An integrative review and proposed model. | PSNet

psnet.ahrq.gov/issue/can-mindfulness-health-care-professionals-improve-patient-care-integrative-review-and

September 21, 2022 - Review Emerging Classic Can mindfulness in health care professionals improve patient care? An integrative review and proposed model. Citation Text: Braun SE, Kinser PA, Rybarczyk B. Can mindfulness in health care professionals improve patient care? An integrativ…

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…

ESPEN guideline on hospital nutrition. | PSNet

psnet.ahrq.gov/issue/espen-guideline-hospital-nutrition

February 17, 2015 - Organizational Policy/Guidelines ESPEN guideline on hospital nutrition. Citation Text: Thibault R, Abbasoglu O, Ioannou E, et al. ESPEN guideline on hospital nutrition. Clin Nutr. 2021;40(12):5684-5709. doi:10.1016/j.clnu.2021.09.039. Copy Citation Format: DOI Google Schola…

Laboratory testing in general practice: a patient safety blind spot. | PSNet

psnet.ahrq.gov/issue/laboratory-testing-general-practice-patient-safety-blind-spot

July 29, 2015 - Commentary Laboratory testing in general practice: a patient safety blind spot. Citation Text: Elder NC. Laboratory testing in general practice: a patient safety blind spot. BMJ Qual Saf. 2015;24(11):667-70. doi:10.1136/bmjqs-2015-004644. Copy Citation Format: DOI Google Sc…

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