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

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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…

How to avoid catastrophic events on the ward. | PSNet

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February 03, 2011 - Review How to avoid catastrophic events on the ward. Citation Text: Bein B, Seewald S, Gräsner J-T. How to avoid catastrophic events on the ward. Best Pract Res Clin Anaesthesiol. 2016;30(2):237-45. doi:10.1016/j.bpa.2016.04.003. Copy Citation Format: DOI Google Scholar Pub…

Safety culture assessment in community pharmacy: development, face validity, and feasibility of the Manchester Patient Safety Assessment Framework. | PSNet

psnet.ahrq.gov/issue/safety-culture-assessment-community-pharmacy-development-face-validity-and-feasibility

June 09, 2011 - Study Safety culture assessment in community pharmacy: development, face validity, and feasibility of the Manchester Patient Safety Assessment Framework. Citation Text: Ashcroft DM, Morecroft C, Parker D, et al. Safety culture assessment in community pharmacy: development, face validit…

What happens when healthcare innovations collide? | PSNet

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December 06, 2017 - Commentary What happens when healthcare innovations collide? Citation Text: Pendharkar SR, Woiceshyn J, da Silveira GJC, et al. What happens when healthcare innovations collide? BMJ Qual Saf. 2016;25(1):9-13. doi:10.1136/bmjqs-2015-004441. Copy Citation Format: DOI Google S…

The design of the SAFE or SORRY? study: a cluster randomised trial on the development and testing of an evidence based inpatient safety program for the prevention of adverse events. | PSNet

psnet.ahrq.gov/issue/design-safe-or-sorry-study-cluster-randomised-trial-development-and-testing-evidence-based

May 22, 2013 - Study The design of the SAFE or SORRY? study: a cluster randomised trial on the development and testing of an evidence based inpatient safety program for the prevention of adverse events. Citation Text: van Gaal BGI, Schoonhoven L, Hulscher M, et al. The design of the SAFE or SORRY? st…

Establishing psychological safety in clinical supervision: multi-professional perspectives. | PSNet

psnet.ahrq.gov/issue/establishing-psychological-safety-clinical-supervision-multi-professional-perspectives

October 13, 2021 - Commentary Establishing psychological safety in clinical supervision: multi-professional perspectives. Citation Text: Lee EH, Pitts S, Pignataro S, et al. Establishing psychological safety in clinical supervision: multi‐professional perspectives. Clin Teach. 2022;19(2):71-78. doi:10.1111…

Making the transition to nursing bedside shift reports. | PSNet

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September 29, 2017 - Study Making the transition to nursing bedside shift reports. Citation Text: Wakefield DS, Ragan R, Brandt J, et al. Making the transition to nursing bedside shift reports. Jt Comm J Qual Patient Saf. 2012;38(6):243-53. Copy Citation Format: Google Scholar PubMed BibTeX End…

The Top Six: standardized safety practices in U.S. Army Medical Department treatment facilities worldwide. | PSNet

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March 18, 2020 - Study The Top Six: standardized safety practices in U.S. Army Medical Department treatment facilities worldwide. Citation Text: Hartstein B, Munante M, Toor PA. The Top Six: Standardized safety practices in U.S. Army Medical Department treatment facilities worldwide. NEJM Catal Innov Car…

Clinical alerts to decrease high-risk medication use in older adults. | PSNet

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September 02, 2015 - Commentary Clinical alerts to decrease high-risk medication use in older adults. Citation Text: Lord-Adem W, Brandt NJ. Clinical Alerts to Decrease High-Risk Medication Use in Older Adults. J Gerontol Nurs. 2017;43(7):7-12. doi:10.3928/00989134-20170614-04. Copy Citation Format: …

The business case for quality: case studies and an analysis. | PSNet

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February 23, 2019 - Study Classic The business case for quality: case studies and an analysis. Citation Text: Leatherman S, Berwick DM, Iles D, et al. The business case for quality: case studies and an analysis. Health Aff (Millwood). 2003;22(2):17-30. Copy Citation Format: …

A multidisciplinary approach to reduce central line-associated bloodstream infections. | PSNet

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November 16, 2022 - Study A multidisciplinary approach to reduce central line-associated bloodstream infections. Citation Text: McMullan C, Propper G, Schuhmacher C, et al. A multidisciplinary approach to reduce central line-associated bloodstream infections. Jt Comm J Qual Patient Saf. 2013;39(2):61-69. …

Leading causes of anesthesia-related liability claims in ambulatory surgery centers. | PSNet

psnet.ahrq.gov/issue/leading-causes-anesthesia-related-liability-claims-ambulatory-surgery-centers

December 16, 2020 - Study Leading causes of anesthesia-related liability claims in ambulatory surgery centers. Citation Text: Ranum D, Beverly A, Shapiro FE, et al. Leading causes of anesthesia-related liability claims in ambulatory surgery centers. J Patient Saf. 2021;17(7):513-521. doi:10.1097/pts.0000000…

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

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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…

'Why is there another person's name on my infusion bag?' Patient safety in chemotherapy care—a review of the literature. | PSNet

psnet.ahrq.gov/issue/why-there-another-persons-name-my-infusion-bag-patient-safety-chemotherapy-care-review

May 01, 2024 - Review 'Why is there another person's name on my infusion bag?' Patient safety in chemotherapy care—a review of the literature. Citation Text: Kullberg A, Larsen J, Sharp L. 'Why is there another person's name on my infusion bag?' Patient safety in chemotherapy care - a review of the l…

Predicting computerized physician order entry system adoption in US hospitals: can the federal mandate be met? | PSNet

psnet.ahrq.gov/issue/predicting-computerized-physician-order-entry-system-adoption-us-hospitals-can-federal

October 06, 2011 - Study Predicting computerized physician order entry system adoption in US hospitals: can the federal mandate be met? Citation Text: Ford EW, McAlearney AS, Phillips MT, et al. Predicting computerized physician order entry system adoption in US hospitals: Can the federal mandate be met?…

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…

The unintended consequences of computerized provider order entry: findings from a mixed methods exploration. | PSNet

psnet.ahrq.gov/issue/unintended-consequences-computerized-provider-order-entry-findings-mixed-methods-exploration

May 27, 2011 - Study The unintended consequences of computerized provider order entry: findings from a mixed methods exploration. Citation Text: Ash JS, Sittig DF, Dykstra RH, et al. The unintended consequences of computerized provider order entry: Findings from a mixed methods exploration. Int J Med…

Accidental deaths, saved lives, and improved quality. | PSNet

psnet.ahrq.gov/issue/accidental-deaths-saved-lives-and-improved-quality

February 04, 2015 - Commentary Classic Accidental deaths, saved lives, and improved quality. Citation Text: Brennan TA, Gawande AA, Thomas EJ, et al. Accidental Deaths, Saved Lives, and Improved Quality. New England Journal of Medicine. 2005;353(13). doi:10.1056/nejmsb051157. C…

Unintended medication discrepancies at the time of hospital admission. | PSNet

psnet.ahrq.gov/issue/unintended-medication-discrepancies-time-hospital-admission

March 18, 2015 - Study Classic Unintended medication discrepancies at the time of hospital admission. Citation Text: Cornish PL, Knowles SR, Marchesano R, et al. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med. 2005;165(4):424-9. Copy Cit…

Between demarcation and discretion: the medical-administrative boundary as a locus of safety in high-volume organisational routines. | PSNet

psnet.ahrq.gov/issue/between-demarcation-and-discretion-medical-administrative-boundary-locus-safety-high-volume

June 14, 2017 - Study Between demarcation and discretion: the medical-administrative boundary as a locus of safety in high-volume organisational routines. Citation Text: Grant S, Guthrie B. Between demarcation and discretion: The medical-administrative boundary as a locus of safety in high-volume organi…

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