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Deficiencies in Emergent and Outpatient Care of a Patient with Alcohol Use Disorder at the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana. | PSNet

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July 13, 2022 - Book/Report Deficiencies in Emergent and Outpatient Care of a Patient with Alcohol Use Disorder at the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana. Citation Text: Deficiencies in Emergent and Outpatient Care of a Patient with Alcohol Use Disorder at the Richard L. Rou…

Health professionals' experiences of whistleblowing in maternal and newborn healthcare settings: a scoping review and thematic analysis. | PSNet

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November 02, 2010 - Review Health professionals' experiences of whistleblowing in maternal and newborn healthcare settings: a scoping review and thematic analysis. Citation Text: Capper T, Ferguson B, Muurlink O. Health professionals' experiences of whistleblowing in maternal and newborn healthcare settings…

Influence of surgeon behavior on trainee willingness to speak up: a randomized controlled trial. | PSNet

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February 22, 2019 - Study Influence of surgeon behavior on trainee willingness to speak up: a randomized controlled trial. Citation Text: Salazar MJB, Minkoff H, Bayya J, et al. Influence of surgeon behavior on trainee willingness to speak up: a randomized controlled trial. J Am Coll Surg. 2014;219(5):1001-…

Medication errors in the homes of children with chronic conditions. | PSNet

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April 27, 2010 - Study Medication errors in the homes of children with chronic conditions. Citation Text: Walsh KE, Mazor KM, Stille CJ, et al. Medication errors in the homes of children with chronic conditions. Arch Dis Child. 2011;96(6):581-6. doi:10.1136/adc.2010.204479. Copy Citation Format: …

Deficiencies in the Community Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures. | PSNet

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November 29, 2023 - Book/Report Deficiencies in the Community Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures. Citation Text: Deficiencies in the Community Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administra…

For children admitted to hospital, what interventions improve medication safety on ward rounds? | PSNet

psnet.ahrq.gov/issue/children-admitted-hospital-what-interventions-improve-medication-safety-ward-rounds

July 29, 2020 - Review For children admitted to hospital, what interventions improve medication safety on ward rounds? Citation Text: King C, Dudley J, Mee A, et al. For children admitted to hospital, what interventions improve medication safety on ward rounds? A systematic review. Arch Dis Child. 2023;…

Elimination of central-venous-catheter-related bloodstream infections from the intensive care unit. | PSNet

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January 11, 2017 - Study Elimination of central-venous-catheter-related bloodstream infections from the intensive care unit. Citation Text: Longmate AG, Ellis KS, Boyle L, et al. Elimination of central-venous-catheter-related bloodstream infections from the intensive care unit. BMJ Qual Saf. 2011;20(2):1…

Action on patient safety can reduce health inequalities. | PSNet

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February 05, 2020 - Commentary Action on patient safety can reduce health inequalities. Citation Text: Wade C, Malhotra AM, McGuire P, et al. Action on patient safety can reduce health inequalities. BMJ. 2022;376:e067090. doi:10.1136/bmj-2021-067090. Copy Citation Format: DOI Google Scholar Bi…

What defines a high-performing health system: a systematic review. | PSNet

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August 17, 2022 - Review What defines a high-performing health system: a systematic review. Citation Text: Ahluwalia SC, Damberg CL, Silverman M, et al. What Defines a High-Performing Health Care Delivery System: A Systematic Review. Jt Comm J Qual Patient Saf. 2017;43(9):450-459. doi:10.1016/j.jcjq.2017.…

Machine learning models outperform manual result review for the identification of wrong blood in tube errors in complete blood count results. | PSNet

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May 13, 2020 - Study Machine learning models outperform manual result review for the identification of wrong blood in tube errors in complete blood count results. Citation Text: Farrell C‐JL, Giannoutsos J. Machine learning models outperform manual result review for the identification of wrong blood in…

Types of diagnostic errors reported by paediatric emergency providers in a global paediatric emergency care research network. | PSNet

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December 16, 2020 - Study Types of diagnostic errors reported by paediatric emergency providers in a global paediatric emergency care research network. Citation Text: Mahajan P, Grubenhoff JA, Cranford J, et al. Types of diagnostic errors reported by paediatric emergency providers in a global paediatric eme…

Physician perspectives on addressing anti-Black racism. | PSNet

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July 26, 2023 - Study Physician perspectives on addressing anti-Black racism. Citation Text: Brown CE, Marshall AR, Cueva KL, et al. Physician perspectives on addressing anti-Black racism. JAMA Netw Open. 2024;7(1):e2352818. doi:10.1001/jamanetworkopen.2023.52818. Copy Citation Format: DOI…

Evaluation of Quality, Safety, and Value in Veterans Health Administration Facilities, FY 2020. | PSNet

psnet.ahrq.gov/issue/evaluation-quality-safety-and-value-veterans-health-administration-facilities-fy-2020

September 10, 2014 - Book/Report Evaluation of Quality, Safety, and Value in Veterans Health Administration Facilities, FY 2020. Citation Text: Evaluation of Quality, Safety, and Value in Veterans Health Administration Facilities, FY 2020. Washington, DC: Veterans Affairs Office of Inspector General; August …

Unexpected Death of a Patient During Treatment With Multiple Medications, Tomah VA Medical Center, Tomah, Wisconsin. | PSNet

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October 12, 2022 - Government Resource Unexpected Death of a Patient During Treatment With Multiple Medications, Tomah VA Medical Center, Tomah, Wisconsin. Citation Text: Unexpected Death of a Patient During Treatment With Multiple Medications, Tomah VA Medical Center, Tomah, Wisconsin. Washington, DC: VA …

The relationship between safety culture and voluntary event reporting in a large regional ambulatory care group. | PSNet

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November 26, 2014 - Study The relationship between safety culture and voluntary event reporting in a large regional ambulatory care group. Citation Text: Miller N, Bhowmik S, Ezinwa M, et al. The Relationship Between Safety Culture and Voluntary Event Reporting in a Large Regional Ambulatory Care Group. J P…

Strengthening open disclosure after incidents in maternity care: a realist synthesis of international research evidence. | PSNet

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September 18, 2024 - Review Strengthening open disclosure after incidents in maternity care: a realist synthesis of international research evidence. Citation Text: Adams M, Hartley J, Sanford N, et al. Strengthening open disclosure after incidents in maternity care: a realist synthesis of international resea…

Failures in Care Coordination and Reviewing a Patient's Death at the VA Salt Lake City Healthcare System in Utah. | PSNet

psnet.ahrq.gov/issue/failures-care-coordination-and-reviewing-patients-death-va-salt-lake-city-healthcare-system

April 19, 2023 - Book/Report Failures in Care Coordination and Reviewing a Patient's Death at the VA Salt Lake City Healthcare System in Utah. Citation Text: Failures in Care Coordination and Reviewing a Patient's Death at the VA Salt Lake City Healthcare System in Utah. Washington, DC: Department of Vet…

Assessing the excess costs of the in-hospital adverse events covered by the AHRQ's Patient Safety Indicators in Switzerland. | PSNet

psnet.ahrq.gov/issue/assessing-excess-costs-hospital-adverse-events-covered-ahrqs-patient-safety-indicators

January 10, 2024 - Study Assessing the excess costs of the in-hospital adverse events covered by the AHRQ's Patient Safety Indicators in Switzerland. Citation Text: Giese A, Khanam R, Nghiem S, et al. Assessing the excess costs of the in-hospital adverse events covered by the AHRQ’s Patient Safety Indicato…

When the lights go down in the delivery room: lessons from a ransomware attack. | PSNet

psnet.ahrq.gov/issue/when-lights-go-down-delivery-room-lessons-ransomware-attack

September 02, 2020 - Commentary When the lights go down in the delivery room: lessons from a ransomware attack. Citation Text: Gabbay‐Benziv R, Ben‐Natan M, Roguin A, et al. When the lights go down in the delivery room: lessons from a ransomware attack. Int J Gynaecol Obstet. 2023;162(2):562-568. doi:10.1002…

Electronic Health Record Modernization Caused Pharmacy-Related Patient Safety Issues Nationally and at the VA Central Ohio Healthcare System in Columbus. | PSNet

psnet.ahrq.gov/issue/electronic-health-record-modernization-caused-pharmacy-related-patient-safety-issues

January 31, 2024 - Book/Report Electronic Health Record Modernization Caused Pharmacy-Related Patient Safety Issues Nationally and at the VA Central Ohio Healthcare System in Columbus. Citation Text: Electronic Health Record Modernization Caused Pharmacy-Related Patient Safety Issues Nationally and at the …

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