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Improving safety in the operating room: medication icon labels increase visibility and discrimination. | PSNet

psnet.ahrq.gov/issue/improving-safety-operating-room-medication-icon-labels-increase-visibility-and-discrimination

April 03, 2019 - Study Improving safety in the operating room: medication icon labels increase visibility and discrimination. Citation Text: Lusk C, Catchpole K, Neyens DM, et al. Improving safety in the operating room: medication icon labels increase visibility and discrimination. Appl Ergon. 2022;104:1…

Cultural transformation after implementation of crew resource management: is it really possible? | PSNet

psnet.ahrq.gov/issue/cultural-transformation-after-implementation-crew-resource-management-it-really-possible

November 16, 2022 - Study Cultural transformation after implementation of crew resource management: is it really possible? Citation Text: Hefner JL, Hilligoss B, Knupp A, et al. Cultural Transformation After Implementation of Crew Resource Management: Is It Really Possible? Am J Med Qual. 2017;32(4):384-390…

Electronic surveillance and pharmacist intervention for vulnerable older inpatients on high-risk medication regimens. | PSNet

psnet.ahrq.gov/issue/electronic-surveillance-and-pharmacist-intervention-vulnerable-older-inpatients-high-risk

March 21, 2017 - Study Electronic surveillance and pharmacist intervention for vulnerable older inpatients on high-risk medication regimens. Citation Text: Peterson JF, Kripalani S, Danciu I, et al. Electronic surveillance and pharmacist intervention for vulnerable older inpatients on high-risk medicatio…

Unit-based care teams and the frequency and quality of physician–nurse communications. | PSNet

psnet.ahrq.gov/issue/unit-based-care-teams-and-frequency-and-quality-physician-nurse-communications

November 16, 2022 - Study Unit-based care teams and the frequency and quality of physician–nurse communications. Citation Text: Gordon M, Melvin P, Graham DA, et al. Unit-based care teams and the frequency and quality of physician-nurse communications. Arch Pediatr Adolesc Med. 2011;165(5):424-8. doi:10.100…

The challenge of risk prevention in home healthcare-an interview study with nurses in municipal care. | PSNet

psnet.ahrq.gov/issue/challenge-risk-prevention-home-healthcare-interview-study-nurses-municipal-care

August 21, 2024 - Study The challenge of risk prevention in home healthcare-an interview study with nurses in municipal care. Citation Text: Lekman J, Lindén E, Ekstedt M. The challenge of risk prevention in home healthcare—an interview study with nurses in municipal care. Scand J Caring Sci. 2023;37(4):1…

The impact of prolonged continuous wakefulness on resident clinical performance in the intensive care unit: a patient simulator study. | PSNet

psnet.ahrq.gov/issue/impact-prolonged-continuous-wakefulness-resident-clinical-performance-intensive-care-unit

November 21, 2016 - Study The impact of prolonged continuous wakefulness on resident clinical performance in the intensive care unit: a patient simulator study. Citation Text: Sharpe R, Koval V, Ronco JJ, et al. The impact of prolonged continuous wakefulness on resident clinical performance in the intensi…

Should all duty hours be the same? Results of a national survey of surgical trainees. | PSNet

psnet.ahrq.gov/issue/should-all-duty-hours-be-same-results-national-survey-surgical-trainees

October 19, 2022 - Study Should all duty hours be the same? Results of a national survey of surgical trainees. Citation Text: Moalem J, Salzman P, Ruan DT, et al. Should All Duty Hours Be the Same? Results of a National Survey of Surgical Trainees. J Am Coll Surg. 2009;209(1). doi:10.1016/j.jamcollsurg.2…

Patient involvement in patient safety: how willing are patients to participate? | PSNet

psnet.ahrq.gov/issue/patient-involvement-patient-safety-how-willing-are-patients-participate

September 05, 2013 - Study Classic Patient involvement in patient safety: how willing are patients to participate? Citation Text: Davis R, Sevdalis N, Vincent C. Patient involvement in patient safety: How willing are patients to participate? BMJ Qual Saf. 2011;20(1):108-114. doi:…

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

psnet.ahrq.gov/issue/case-transfusion-error-trauma-patient-subsequent-root-cause-analysis-leading-institutional

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…

Safety perceptions of health care leaders in 2 Canadian academic acute care centers. | PSNet

psnet.ahrq.gov/issue/safety-perceptions-health-care-leaders-2-canadian-academic-acute-care-centers

March 14, 2022 - Study Safety perceptions of health care leaders in 2 Canadian academic acute care centers. Citation Text: Goldstein DH, Nyce JM, Van Den Kerkhof EG. Safety Perceptions of Health Care Leaders in 2 Canadian Academic Acute Care Centers. J Patient Saf. 2017;13(2):62-68. doi:10.1097/PTS.00000…

VA Health Care: Actions Needed to Assess Decrease in Root Cause Analyses of Adverse Events. | PSNet

psnet.ahrq.gov/issue/va-health-care-actions-needed-assess-decrease-root-cause-analyses-adverse-events

November 22, 2017 - Book/Report VA Health Care: Actions Needed to Assess Decrease in Root Cause Analyses of Adverse Events. Citation Text: VA Health Care: Actions Needed to Assess Decrease in Root Cause Analyses of Adverse Events. Washington, DC: United States Government Accountability Office; July 29, 2015…

Policy and practice in the use of root cause analysis to investigate clinical adverse events: mind the gap. | PSNet

psnet.ahrq.gov/issue/policy-and-practice-use-root-cause-analysis-investigate-clinical-adverse-events-mind-gap

December 09, 2020 - Study Policy and practice in the use of root cause analysis to investigate clinical adverse events: mind the gap. Citation Text: Nicolini D, Waring J, Mengis J. Policy and practice in the use of root cause analysis to investigate clinical adverse events: mind the gap. Soc Sci Med. 2011…

How accurately do older adult emergency department patients recall their medications? | PSNet

psnet.ahrq.gov/issue/how-accurately-do-older-adult-emergency-department-patients-recall-their-medications

September 02, 2020 - Study How accurately do older adult emergency department patients recall their medications? Citation Text: Goldberg EM, Marks SJ, Merchant RC, et al. How accurately do older adult emergency department patients recall their medications? Acad Emerg Med. 2021;28(2):248-252. doi:10.1111/acem…

Association between hospital penalty status under the Hospital Readmission Reduction Program and readmission rates for target and nontarget conditions. | PSNet

psnet.ahrq.gov/issue/association-between-hospital-penalty-status-under-hospital-readmission-reduction-program-and

August 15, 2018 - Study Association between hospital penalty status under the Hospital Readmission Reduction Program and readmission rates for target and nontarget conditions. Citation Text: Desai NR, Ross JS, Kwon JY, et al. Association Between Hospital Penalty Status Under the Hospital Readmission Reduc…

Risks in the implementation and use of smart pumps in a pediatric intensive care unit: application of the failure mode and effects analysis. | PSNet

psnet.ahrq.gov/issue/risks-implementation-and-use-smart-pumps-pediatric-intensive-care-unit-application-failure

March 09, 2022 - Study Risks in the implementation and use of smart pumps in a pediatric intensive care unit: application of the failure mode and effects analysis. Citation Text: Manrique-Rodríguez S, Sánchez-Galindo AC, López-Herce J, et al. Risks in the implementation and use of smart pumps in a pediat…

Organizational response to known medical errors: does peer review protection impede improvement? | PSNet

psnet.ahrq.gov/issue/organizational-response-known-medical-errors-does-peer-review-protection-impede-improvement

April 24, 2018 - Commentary Organizational response to known medical errors: does peer review protection impede improvement? Citation Text: Wenner WJ, Choi SW. Organizational Response to Known Medical Errors: Does Peer Review Protection Impede Improvement? Am J Med Qual. 2018;33(5):552-553. doi:10.1177/1…

Avoiding handover fumbles: a controlled trial of a structured handover tool versus traditional handover methods. | PSNet

psnet.ahrq.gov/issue/avoiding-handover-fumbles-controlled-trial-structured-handover-tool-versus-traditional

January 19, 2022 - Study Avoiding handover fumbles: a controlled trial of a structured handover tool versus traditional handover methods. Citation Text: Payne CE, Stein JM, Leong T, et al. Avoiding handover fumbles: a controlled trial of a structured handover tool versus traditional handover methods. BMJ…

Repeat medication errors in nursing homes: contributing factors and their association with patient harm. | PSNet

psnet.ahrq.gov/issue/repeat-medication-errors-nursing-homes-contributing-factors-and-their-association-patient

August 07, 2013 - Study Repeat medication errors in nursing homes: contributing factors and their association with patient harm. Citation Text: Crespin DJ, Modi A, Wei D, et al. Repeat medication errors in nursing homes: Contributing factors and their association with patient harm. Am J Geriatr Pharmaco…

Confidential clinician-reported surveillance of adverse events among medical inpatients. | PSNet

psnet.ahrq.gov/issue/confidential-clinician-reported-surveillance-adverse-events-among-medical-inpatients

June 29, 2011 - Study Classic Confidential clinician-reported surveillance of adverse events among medical inpatients. Citation Text: Weingart SN, Ship AN, Aronson MD. Confidential clinician-reported surveillance of adverse events among medical inpatients. J Gen Intern Med. 2…

A 38-year-old woman with fetal loss and hysterectomy. | PSNet

psnet.ahrq.gov/issue/38-year-old-woman-fetal-loss-and-hysterectomy

January 12, 2011 - Commentary Classic A 38-year-old woman with fetal loss and hysterectomy. Citation Text: Sachs BP. A 38-Year-Old Woman With Fetal Loss and Hysterectomy. JAMA. 2005;294(7):833-840. doi:10.1001/jama.294.7.833. Copy Citation Format: DOI Google Schola…

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