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Risk factors for wrong-site surgery: a study of 1,166 reports of informed consent and schedule errors. | PSNet

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January 20, 2021 - Study Risk factors for wrong-site surgery: a study of 1,166 reports of informed consent and schedule errors. Citation Text: Taylor MA, Yonash RA. Risk factors for wrong-site surgery: a study of 1,166 reports of informed consent and schedule errors. Patient Safety. 2024;6(1):1-11. doi:10.…

Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical centers, April-June 2020. | PSNet

psnet.ahrq.gov/issue/seroprevalence-sars-cov-2-among-frontline-health-care-personnel-multistate-hospital-network

October 19, 2022 - Study Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical centers, April-June 2020. Citation Text: Self WH, Tenforde MW, Stubblefield WB, et al. Seroprevalence of SARS-CoV-2 among frontline health care personnel in a mu…

Towards safer healthcare: qualitative insights from a process view of organisational learning from failure. | PSNet

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July 21, 2021 - Study Towards safer healthcare: qualitative insights from a process view of organisational learning from failure. Citation Text: Monazam Tabrizi N, Masri F. Towards safer healthcare: qualitative insights from a process view of organisational learning from failure. BMJ Open. 2021;11(8):e0…

An evidence and consensus-based definition of second victim: a strategic topic in healthcare quality, patient safety, person-centeredness and human resource management. | PSNet

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September 13, 2023 - Commentary An evidence and consensus-based definition of second victim: a strategic topic in healthcare quality, patient safety, person-centeredness and human resource management. Citation Text: Vanhaecht K, Seys D, Russotto S, et al. An evidence and consensus-based definition of second …

How does work environment relate to diagnostic quality? A prospective, mixed methods study in primary care. | PSNet

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September 07, 2022 - Study How does work environment relate to diagnostic quality? A prospective, mixed methods study in primary care. Citation Text: Khazen M, Sullivan EE, Arabadjis S, et al. How does work environment relate to diagnostic quality? A prospective, mixed methods study in primary care. BMJ Open…

Nurses' perceptions and demands regarding COVID-19 care delivery in critical care units and hospital emergency services. | PSNet

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March 09, 2022 - Study Emerging Classic Nurses' perceptions and demands regarding COVID-19 care delivery in critical care units and hospital emergency services. Citation Text: González-Gil MT, González-Blázquez C, Parro-Moreno AI, et al. Nurses’ perceptions and demands regarding…

Parent-reported errors and adverse events in hospitalized children. | PSNet

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June 29, 2009 - Study Classic Parent-reported errors and adverse events in hospitalized children. Citation Text: Khan A, Furtak SL, Melvin P, et al. Parent-reported errors and adverse events in hospitalized children. JAMA Pediatr. 2016;170(4):e154608. doi:10.1001/jamapediatrics…

Surveys on Patient Safety Culture (SOPS) Hospital Survey 2.0: User Database Report. | PSNet

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December 18, 2024 - Book/Report Surveys on Patient Safety Culture (SOPS) Hospital Survey 2.0: User Database Report. Citation Text: Tyler ER, Yalden O, Fan L, et al. Surveys On Patient Safety Culture (Sops) Hospital Survey 2.0: User Database Report. Rockville, MD: Agency for Healthcare Research and Quality; …

Development of an online morbidity, mortality, and near-miss reporting system to identify patterns of adverse events in surgical patients. | PSNet

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August 20, 2018 - Study Development of an online morbidity, mortality, and near-miss reporting system to identify patterns of adverse events in surgical patients. Citation Text: Bilimoria KY, Kmiecik TE, DaRosa DA, et al. Development of an online morbidity, mortality, and near-miss reporting system to ide…

Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety. | PSNet

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November 30, 2011 - Study Classic Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety. Citation Text: Koppel R, Wetterneck TB, Telles JL, et al. Workarounds to barcode medication administration systems: their occurren…

Two decades since To Err Is Human: an assessment of progress and emerging priorities in patient safety. | PSNet

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January 16, 2019 - Commentary Classic Two decades since To Err Is Human: an assessment of progress and emerging priorities in patient safety. Citation Text: Bates DW, Singh H. Two Decades Since To Err Is Human: An Assessment Of Progress And Emerging Priorities In Patient Safety. H…

Improving quality and safety of care using "technovigilance": an ethnographic case study of secondary use of data from an electronic prescribing and decision support system. | PSNet

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March 05, 2014 - Study Improving quality and safety of care using "technovigilance": an ethnographic case study of secondary use of data from an electronic prescribing and decision support system. Citation Text: Dixon-Woods M, Redwood S, Leslie M, et al. Improving quality and safety of care using "techno…

Methodological variations and their effects on reported medication administration error rates. | PSNet

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January 15, 2025 - Review Methodological variations and their effects on reported medication administration error rates. Citation Text: McLeod MC, Barber N, Franklin BD. Methodological variations and their effects on reported medication administration error rates. BMJ Qual Saf. 2013;22(4):278-89. doi:10.…

What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study. | PSNet

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May 19, 2021 - Study What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study. Citation Text: Schnipper JL, Reyes Nieva H, Yoon CS, et al. What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study. BMJ Qual Saf. 2023;32(8):4…

Application of a trigger tool in near real time to inform quality improvement activities: a prospective study in a general medicine ward. | PSNet

psnet.ahrq.gov/issue/application-trigger-tool-near-real-time-inform-quality-improvement-activities-prospective

September 26, 2012 - Study Application of a trigger tool in near real time to inform quality improvement activities: a prospective study in a general medicine ward. Citation Text: Wong BM, Dyal S, Etchells E, et al. Application of a trigger tool in near real time to inform quality improvement activities: a p…

Using a patient internet portal to prevent adverse drug events: a randomized, controlled trial. | PSNet

psnet.ahrq.gov/issue/using-patient-internet-portal-prevent-adverse-drug-events-randomized-controlled-trial

September 15, 2011 - Study Using a patient internet portal to prevent adverse drug events: a randomized, controlled trial. Citation Text: Weingart SN, Carbo AR, Tess A, et al. Using a Patient Internet Portal to Prevent Adverse Drug Events. J Patient Saf. 2013;9(3). doi:10.1097/pts.0b013e31829e4b95. Copy…

'Global Trigger Tool' shows that adverse events in hospitals may be ten times greater than previously measured. | PSNet

psnet.ahrq.gov/issue/global-trigger-tool-shows-adverse-events-hospitals-may-be-ten-times-greater-previously

February 15, 2011 - Study Classic 'Global Trigger Tool' shows that adverse events in hospitals may be ten times greater than previously measured. Citation Text: Classen D, Resar RK, Griffin F, et al. 'Global trigger tool' shows that adverse events in hospitals may be ten times grea…

Patient safety reporting systems: sustained quality improvement using a multidisciplinary team and "Good Catch" awards. | PSNet

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February 12, 2020 - Study Patient safety reporting systems: sustained quality improvement using a multidisciplinary team and "Good Catch" awards. Citation Text: Herzer KR, Mirrer M, Xie Y, et al. Patient Safety Reporting Systems: Sustained Quality Improvement Using a Multidisciplinary Team and “Good Catch” …

Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. | PSNet

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August 15, 2012 - Book/Report Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Citation Text: Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Levit L, Balogh E, Nass S, Ganz PA, eds. Committee on Improving the Quality of Cancer Care: Add…

National hospital ratings systems share few common scores and may generate confusion instead of clarity. | PSNet

psnet.ahrq.gov/issue/national-hospital-ratings-systems-share-few-common-scores-and-may-generate-confusion-instead

October 31, 2014 - Study Classic National hospital ratings systems share few common scores and may generate confusion instead of clarity. Citation Text: Austin M, Jha AK, Romano PS, et al. National hospital ratings systems share few common scores and may generate confusion instead…

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