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Randomized controlled evaluation of an insulin pen storage policy. | PSNet

psnet.ahrq.gov/issue/randomized-controlled-evaluation-insulin-pen-storage-policy

January 23, 2017 - Study Randomized controlled evaluation of an insulin pen storage policy. Citation Text: Gibbs HG, McLernon T, Call R, et al. Randomized controlled evaluation of an insulin pen storage policy. Am J Health Syst Pharm. 2017;74(24):2054-2059. doi:10.2146/ajhp160348. Copy Citation Forma…

Reducing potential errors associated with insulin administration: an integrative review. | PSNet

psnet.ahrq.gov/issue/reducing-potential-errors-associated-insulin-administration-integrative-review

March 31, 2021 - Review Reducing potential errors associated with insulin administration: an integrative review. Citation Text: Alqahtani N. Reducing potential errors associated with insulin administration: an integrative review. J Eval Clin Pract. 2022;28(6):1037-1049. doi:10.1111/jep.13668. Copy Cita…

Developing agreement on never events in primary care dentistry: an international eDelphi study. | PSNet

psnet.ahrq.gov/issue/developing-agreement-never-events-primary-care-dentistry-international-edelphi-study

October 05, 2016 - Study Developing agreement on never events in primary care dentistry: an international eDelphi study. Citation Text: Ensaldo-Carrasco E, Carson-Stevens A, Cresswell K, et al. Developing agreement on never events in primary care dentistry: an international eDelphi study. Br Dent J. 2018;2…

Vaccination errors reported to the Vaccine Adverse Event Reporting System (VAERS), United States, 2000–2013. | PSNet

psnet.ahrq.gov/issue/vaccination-errors-reported-vaccine-adverse-event-reporting-system-vaers-united-states-2000

May 18, 2022 - Study Vaccination errors reported to the Vaccine Adverse Event Reporting System (VAERS), United States, 2000–2013. Citation Text: Hibbs BF, Moro PL, Lewis P, et al. Vaccination errors reported to the Vaccine Adverse Event Reporting System, (VAERS) United States, 2000-2013. Vaccine. 2015;…

Assessment of patient medication adherence, medical record accuracy, and medication blood concentrations for prescription and over-the-counter medications. | PSNet

psnet.ahrq.gov/issue/assessment-patient-medication-adherence-medical-record-accuracy-and-medication-blood

April 15, 2019 - Study Assessment of patient medication adherence, medical record accuracy, and medication blood concentrations for prescription and over-the-counter medications. Citation Text: Sutherland JJ, Morrison RD, McNaughton CD, et al. Assessment of Patient Medication Adherence, Medical Record Ac…

Simulation-based clinical systems testing for healthcare spaces: from intake through implementation. | PSNet

psnet.ahrq.gov/issue/simulation-based-clinical-systems-testing-healthcare-spaces-intake-through-implementation

April 10, 2024 - Commentary Emerging Classic Simulation-based clinical systems testing for healthcare spaces: from intake through implementation. Citation Text: Colman N, Doughty C, Arnold J, et al. Simulation-based clinical systems testing for healthcare spaces: from intake thr…

Retrospective review for medication dose errors in pediatric emergency department medication orders that bypassed pharmacist review. | PSNet

psnet.ahrq.gov/issue/retrospective-review-medication-dose-errors-pediatric-emergency-department-medication-orders

January 12, 2022 - Study Retrospective review for medication dose errors in pediatric emergency department medication orders that bypassed pharmacist review. Citation Text: Todd SE, Thompson AJ, Russell WS. Retrospective review for medication dose errors in pediatric emergency department medication orders…

Interventions for reducing wrong-site surgery and invasive procedures. | PSNet

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September 07, 2011 - Review Interventions for reducing wrong-site surgery and invasive procedures. Citation Text: Algie CM, Mahar RK, Wasiak J, et al. Interventions for reducing wrong-site surgery and invasive clinical procedures. Cochrane Database Syst Rev. 2015;3)(3):CD009404. doi:10.1002/14651858.CD009404…

Hospital surveys by the Centers for Medicare and Medicaid Services: an analysis of more than 34,000 deficiencies. | PSNet

psnet.ahrq.gov/issue/hospital-surveys-centers-medicare-and-medicaid-services-analysis-more-34000-deficiencies

May 26, 2021 - Study Hospital surveys by the Centers for Medicare and Medicaid Services: an analysis of more than 34,000 deficiencies. Citation Text: Antognini JF. Hospital surveys by the Centers for Medicare and Medicaid Services: an analysis of more than 34,000 deficiencies. J Patient Saf. 2021;17(4)…

Injury and liability associated with monitored anesthesia care: a closed claims analysis. | PSNet

psnet.ahrq.gov/issue/injury-and-liability-associated-monitored-anesthesia-care-closed-claims-analysis

June 23, 2009 - Study Injury and liability associated with monitored anesthesia care: a closed claims analysis. Citation Text: Bhananker SM, Posner KL, Cheney FW, et al. Injury and liability associated with monitored anesthesia care: a closed claims analysis. Anesthesiology. 2006;104(2):228-234. Cop…

'It's all about patient safety': an ethnographic study of how pharmacy staff construct medicines safety in the context of polypharmacy. | PSNet

psnet.ahrq.gov/issue/its-all-about-patient-safety-ethnographic-study-how-pharmacy-staff-construct-medicines-safety

October 06, 2021 - Study 'It's all about patient safety': an ethnographic study of how pharmacy staff construct medicines safety in the context of polypharmacy. Citation Text: Fudge N, Swinglehurst D. ‘It's all about patient safety’: an ethnographic study of how pharmacy staff construct medicines safety in…

Learning from mistakes is easier said than done: group and organizational influences on the detection and correction of human error. | PSNet

psnet.ahrq.gov/issue/learning-mistakes-easier-said-done-group-and-organizational-influences-detection-and

September 25, 2024 - Study Classic Learning from mistakes is easier said than done: group and organizational influences on the detection and correction of human error. Citation Text: Edmondson AC. Learning from Mistakes is Easier Said Than Done: Group and Organizational Influences o…

The quest to eliminate intrathecal vincristine errors: a 40-year journey. | PSNet

psnet.ahrq.gov/issue/quest-eliminate-intrathecal-vincristine-errors-40-year-journey

September 15, 2010 - Commentary The quest to eliminate intrathecal vincristine errors: a 40-year journey. Citation Text: Noble DJ, Donaldson LJ. The quest to eliminate intrathecal vincristine errors: a 40-year journey. Qual Saf Health Care. 2010;19(4):323-326. doi:10.1136/qshc.2008.030874. Copy Citation …

Performance of a trigger tool for identifying adverse events in oncology. | PSNet

psnet.ahrq.gov/issue/performance-trigger-tool-identifying-adverse-events-oncology

May 23, 2018 - Study Performance of a trigger tool for identifying adverse events in oncology. Citation Text: Lipitz-Snyderman A, Classen D, Pfister D, et al. Performance of a Trigger Tool for Identifying Adverse Events in Oncology. J Oncol Pract. 2017;13(3). doi:10.1200/jop.2016.016634. Copy Citatio…

Using the Assessment of Reasoning Tool to facilitate feedback about diagnostic reasoning. | PSNet

psnet.ahrq.gov/issue/using-assessment-reasoning-tool-facilitate-feedback-about-diagnostic-reasoning

February 23, 2022 - Study Using the Assessment of Reasoning Tool to facilitate feedback about diagnostic reasoning. Citation Text: Cohen AL, Sur M, Falco C, et al. Using the Assessment of Reasoning Tool to facilitate feedback about diagnostic reasoning. Diagnosis (Berl). 2022;9(4):476-484. doi:10.1515/dx-20…

Increasing adoption of computerized provider order entry, and persistent regional disparities, in US emergency departments. | PSNet

psnet.ahrq.gov/issue/increasing-adoption-computerized-provider-order-entry-and-persistent-regional-disparities-us

May 16, 2012 - Study Increasing adoption of computerized provider order entry, and persistent regional disparities, in US emergency departments. Citation Text: Pallin DJ, Sullivan AF, Espinola JA, et al. Increasing adoption of computerized provider order entry, and persistent regional disparities, in…

How dangerous is a day in hospital?: A model of adverse events and length of stay for medical inpatients. | PSNet

psnet.ahrq.gov/issue/how-dangerous-day-hospital-model-adverse-events-and-length-stay-medical-inpatients

February 09, 2012 - Study Classic How dangerous is a day in hospital?: A model of adverse events and length of stay for medical inpatients. Citation Text: Hauck K, Zhao X. How dangerous is a day in hospital? A model of adverse events and length of stay for medical inpatients. Med…

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…

Occupational stress and cognitive failure of nurses and associations with on self-reported adverse events: a national cross-sectional survey. | PSNet

psnet.ahrq.gov/issue/occupational-stress-and-cognitive-failure-nurses-and-associations-self-reported-adverse

June 09, 2021 - Study Emerging Classic Occupational stress and cognitive failure of nurses and associations with on self-reported adverse events: a national cross-sectional survey. Citation Text: Kakemam E, Kalhor R, Khakdel Z, et al. Occupational stress and cognitive failure o…

Cross-Check QA: a quality assurance workflow to prevent missed diagnoses by alerting inadvertent discordance between the radiologist and AI in the interpretation of high acuity CT scans. | PSNet

psnet.ahrq.gov/issue/cross-check-qa-quality-assurance-workflow-prevent-missed-diagnoses-alerting-inadvertent

March 04, 2015 - Study Cross-Check QA: a quality assurance workflow to prevent missed diagnoses by alerting inadvertent discordance between the radiologist and AI in the interpretation of high acuity CT scans. Citation Text: Chekmeyan M, Baccei SJ, Garwood ER. Cross-Check QA: a quality assurance workflow…

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