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Human error, not communication and systems, underlies surgical complications. | PSNet

psnet.ahrq.gov/issue/human-error-not-communication-and-systems-underlies-surgical-complications

November 18, 2020 - Study Human error, not communication and systems, underlies surgical complications. Citation Text: Fabri PJ, Zayas-Castro JL. Human error, not communication and systems, underlies surgical complications. Surgery. 2008;144(4):557-63; discussion 563-5. doi:10.1016/j.surg.2008.06.011. C…

More than just crushing: a prospective pre-post intervention study to reduce drug preparation errors in patients with feeding tubes. | PSNet

psnet.ahrq.gov/issue/more-just-crushing-prospective-pre-post-intervention-study-reduce-drug-preparation-errors

November 02, 2010 - Study More than just crushing: a prospective pre-post intervention study to reduce drug preparation errors in patients with feeding tubes. Citation Text: Lohmann K, Gartner D, Kurze R, et al. More than just crushing: a prospective pre-post intervention study to reduce drug preparation er…

Quantitative analysis of the content of EMS handoff of critically ill and injured patients to the emergency department. | PSNet

psnet.ahrq.gov/issue/quantitative-analysis-content-ems-handoff-critically-ill-and-injured-patients-emergency

August 04, 2021 - Study Quantitative analysis of the content of EMS handoff of critically ill and injured patients to the emergency department. Citation Text: Goldberg SA, Porat A, Strother CG, et al. Quantitative Analysis of the Content of EMS Handoff of Critically Ill and Injured Patients to the Emergen…

Accidents and incidents related to intravenous drug administration: a pre-post study following implementation of smart pumps in a teaching hospital. | PSNet

psnet.ahrq.gov/issue/accidents-and-incidents-related-intravenous-drug-administration-pre-post-study-following

September 24, 2016 - Study Accidents and incidents related to intravenous drug administration: a pre-post study following implementation of smart pumps in a teaching hospital. Citation Text: Guérin A, Tourel J, Delage E, et al. Accidents and Incidents Related to Intravenous Drug Administration: A Pre-Post St…

The role of dynamic trade-offs in creating safety—a qualitative study of handover across care boundaries in emergency care. | PSNet

psnet.ahrq.gov/issue/role-dynamic-trade-offs-creating-safety-qualitative-study-handover-across-care-boundaries

January 21, 2015 - Study The role of dynamic trade-offs in creating safety—a qualitative study of handover across care boundaries in emergency care. Citation Text: Sujan M, Spurgeon P, Cooke M. The role of dynamic trade-offs in creating safety—A qualitative study of handover across care boundaries in emerg…

Improving the governance of patient safety in emergency care: a systematic review of interventions. | PSNet

psnet.ahrq.gov/issue/improving-governance-patient-safety-emergency-care-systematic-review-interventions

March 06, 2013 - Review Improving the governance of patient safety in emergency care: a systematic review of interventions. Citation Text: Hesselink G, Berben S, Beune T, et al. Improving the governance of patient safety in emergency care: a systematic review of interventions. BMJ Open. 2016;6(1):e009837…

Improving organizational climate for quality and quality of care: does membership in a collaborative help? | PSNet

psnet.ahrq.gov/issue/improving-organizational-climate-quality-and-quality-care-does-membership-collaborative-help

December 14, 2016 - Study Improving organizational climate for quality and quality of care: does membership in a collaborative help? Citation Text: Nembhard IM, Northrup V, Shaller D, et al. Improving organizational climate for quality and quality of care: does membership in a collaborative help? Med Car…

The impact of health information management professionals on patient safety: a systematic review. | PSNet

psnet.ahrq.gov/issue/impact-health-information-management-professionals-patient-safety-systematic-review

August 25, 2021 - Review The impact of health information management professionals on patient safety: a systematic review. Citation Text: Kemp T, Butler‐Henderson K, Allen P, et al. The impact of health information management professionals on patient safety: a systematic review. Health Info Libr J. 2021;3…

Estimating breast cancer overdiagnosis after screening mammography among older women in the United States. | PSNet

psnet.ahrq.gov/issue/estimating-breast-cancer-overdiagnosis-after-screening-mammography-among-older-women-united

October 19, 2022 - Study Estimating breast cancer overdiagnosis after screening mammography among older women in the United States. Citation Text: Richman IB, Long JB, Soulos PR, et al. Estimating breast cancer overdiagnosis after screening mammography among older women in the United States. Ann Intern Med…

Development of a trigger tool to identify adverse events and harm in emergency medical services. | PSNet

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August 07, 2024 - Study Development of a trigger tool to identify adverse events and harm in emergency medical services. Citation Text: Howard IL, Bowen JM, Shaikh LAHA, et al. Development of a trigger tool to identify adverse events and harm in Emergency Medical Services. Emerg Med J. 2017;34(6):391-397.…

Action on patient safety can reduce health inequalities. | PSNet

psnet.ahrq.gov/issue/action-patient-safety-can-reduce-health-inequalities

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…

Extent of diagnostic agreement among medical referrals. | PSNet

psnet.ahrq.gov/issue/extent-diagnostic-agreement-among-medical-referrals

October 31, 2011 - Study Extent of diagnostic agreement among medical referrals. Citation Text: Van Such M, Lohr R, Beckman T, et al. Extent of diagnostic agreement among medical referrals. J Eval Clin Pract. 2017;23(4):870-874. doi:10.1111/jep.12747. Copy Citation Format: DOI Google Scholar …

Embracing errors in simulation-based training: the effect of error training on retention and transfer of central venous catheter skills. | PSNet

psnet.ahrq.gov/issue/embracing-errors-simulation-based-training-effect-error-training-retention-and-transfer

May 23, 2013 - Study Embracing errors in simulation-based training: the effect of error training on retention and transfer of central venous catheter skills. Citation Text: Gardner AK, Abdelfattah K, Wiersch J, et al. Embracing Errors in Simulation-Based Training: The Effect of Error Training on Retent…

Addressing ambulatory safety and malpractice: the Massachusetts PROMISES project. | PSNet

psnet.ahrq.gov/issue/addressing-ambulatory-safety-and-malpractice-massachusetts-promises-project

August 14, 2017 - Commentary Addressing ambulatory safety and malpractice: the Massachusetts PROMISES project. Citation Text: Schiff G, Nieva HR, Griswold P, et al. Addressing Ambulatory Safety and Malpractice: The Massachusetts PROMISES Project. Health Serv Res. 2016;51 Suppl 3:2634-2641. doi:10.1111/147…

Preoperative site marking: are we adhering to good surgical practice? | PSNet

psnet.ahrq.gov/issue/preoperative-site-marking-are-we-adhering-good-surgical-practice

August 02, 2017 - Study Preoperative site marking: are we adhering to good surgical practice? Citation Text: Bathla S, Chadwick M, Nevins EJ, et al. Preoperative Site Marking. J Patient Saf. 2021;17(6):e503-e508. doi:10.1097/pts.0000000000000398. Copy Citation Format: DOI Google Scholar BibT…

Simulation-based assessment identifies longitudinal changes in cognitive skills in an anesthesiology residency training program. | PSNet

psnet.ahrq.gov/issue/simulation-based-assessment-identifies-longitudinal-changes-cognitive-skills-anesthesiology

August 11, 2021 - Study Simulation-based assessment identifies longitudinal changes in cognitive skills in an anesthesiology residency training program. Citation Text: Sidi A, Gravenstein N, Vasilopoulos T, et al. Simulation-based assessment identifies longitudinal changes in cognitive skills in an anesth…

Patient harm events and associated cost outcomes reported to a patient safety organization. | PSNet

psnet.ahrq.gov/issue/patient-harm-events-and-associated-cost-outcomes-reported-patient-safety-organization

July 18, 2017 - Study Patient harm events and associated cost outcomes reported to a patient safety organization. Citation Text: Miller S, Stockwell DC. Patient harm events and associated cost outcomes reported to a patient safety organization. J Patient Saf. 2024;20(7):e92-e96. doi:10.1097/pts.00000000…

Using a patient safety/quality improvement model to assess telehealth for psychiatry and behavioral health services among special populations during COVID-19 and beyond. | PSNet

psnet.ahrq.gov/issue/using-patient-safetyquality-improvement-model-assess-telehealth-psychiatry-and-behavioral

September 27, 2023 - Commentary Using a patient safety/quality improvement model to assess telehealth for psychiatry and behavioral health services among special populations during COVID-19 and beyond. Citation Text: Using a patient safety/quality improvement model to assess telehealth for psychiatry and beh…

Using risk stratification to reduce medical errors in cervical cancer prevention. | PSNet

psnet.ahrq.gov/issue/using-risk-stratification-reduce-medical-errors-cervical-cancer-prevention

September 05, 2012 - Commentary Using risk stratification to reduce medical errors in cervical cancer prevention. Citation Text: Perkins RB, Cain JM, Feldman S. Using Risk Stratification to Reduce Medical Errors in Cervical Cancer Prevention. JAMA Intern Med. 2017;177(10):1411-1412. doi:10.1001/jamainternmed…

Adolescents identifying errors and omissions in their electronic health records: a national survey. | PSNet

psnet.ahrq.gov/issue/adolescents-identifying-errors-and-omissions-their-electronic-health-records-national-survey

December 08, 2021 - Study Adolescents identifying errors and omissions in their electronic health records: a national survey. Citation Text: Hagström J, Blease CR, Kharko A, et al. Adolescents identifying errors and omissions in their electronic health records: a national survey. Stud Health Technol Inform.…

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