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psnet.ahrq.gov/issue/perfect-storm-averted-flawed-systems-dropped-ball-and-cognitive-biases-delay-critical
November 30, 2022 - Commentary
A perfect storm averted: flawed systems, a dropped ball, and cognitive biases delay a critical diagnosis.
Citation Text:
Roberts TJ, Sellars MC, Sands JM, et al. A perfect storm averted: flawed systems, a dropped ball, and cognitive biases delay a critical diagnosis. JCO Oncol…
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psnet.ahrq.gov/issue/missed-breast-cancer-effects-subconscious-bias-and-lesion-characteristics
February 02, 2022 - Commentary
Missed breast cancer: effects of subconscious bias and lesion characteristics.
Citation Text:
Lamb LR, Mohallem Fonseca M, Verma R, et al. Missed breast cancer: effects of subconscious bias and lesion characteristics. RadioGraphics. 2020;40(4):941-960. doi:10.1148/rg.202019009…
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psnet.ahrq.gov/issue/integrative-review-patient-safety-studies-care-and-safety-patients-communication-disabilities
April 10, 2019 - Review
An integrative review of patient safety in studies on the care and safety of patients with communication disabilities in hospital.
Citation Text:
Hemsley B, Georgiou A, Hill S, et al. An integrative review of patient safety in studies on the care and safety of patients with commun…
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psnet.ahrq.gov/issue/problem-preventable-deaths
July 24, 2024 - Commentary
The problem with preventable deaths.
Citation Text:
Hogan H. The problem with preventable deaths. BMJ Qual Saf. 2016;25(5):320-3. doi:10.1136/bmjqs-2015-004983.
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psnet.ahrq.gov/issue/user-satisfaction-computerized-order-entry-system-and-its-effect-workplace-level-stress
August 27, 2017 - Study
User satisfaction with computerized order entry system and its effect on workplace level of stress.
Citation Text:
Ghahramani N, Lendel I, Haque R, et al. User satisfaction with computerized order entry system and its effect on workplace level of stress. J Med Syst. 2009;33(3):19…
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psnet.ahrq.gov/issue/health-care-huddles-managing-complexity-achieve-high-reliability
November 17, 2015 - Study
Health care huddles: managing complexity to achieve high reliability.
Citation Text:
Provost SM, Lanham H, Leykum LK, et al. Health care huddles: managing complexity to achieve high reliability. Health Care Manage Rev. 2015;40(1):2-12. doi:10.1097/HMR.0000000000000009.
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psnet.ahrq.gov/issue/multi-professional-patterns-and-methods-communication-during-patient-handoffs
January 30, 2019 - Study
Multi-professional patterns and methods of communication during patient handoffs.
Citation Text:
Benham-Hutchins MM, Effken JA. Multi-professional patterns and methods of communication during patient handoffs. Int J Med Inform. 2010;79(4):252-67. doi:10.1016/j.ijmedinf.2009.12.00…
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psnet.ahrq.gov/issue/effect-systems-intervention-quality-and-safety-patient-handoffs-internal-medicine-residency
May 08, 2017 - Study
Effect of a systems intervention on the quality and safety of patient handoffs in an internal medicine residency program.
Citation Text:
Graham KL, Marcantonio ER, Huang GC, et al. Effect of a systems intervention on the quality and safety of patient handoffs in an internal medicin…
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psnet.ahrq.gov/issue/systematic-review-falls-hospital-patients-communication-disability-highlighting-invisible
April 15, 2016 - Review
A systematic review of falls in hospital for patients with communication disability: highlighting an invisible population.
Citation Text:
Hemsley B, Steel J, Worrall L, et al. A systematic review of falls in hospital for patients with communication disability: Highlighting an invi…
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psnet.ahrq.gov/issue/theoretical-framework-and-competency-based-approach-improving-handoffs
March 28, 2011 - Commentary
A theoretical framework and competency-based approach to improving handoffs.
Citation Text:
Arora VM, Johnson JK, Meltzer DO, et al. A theoretical framework and competency-based approach to improving handoffs. Qual Saf Health Care. 2008;17(1):11-4. doi:10.1136/qshc.2006.0189…
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psnet.ahrq.gov/issue/patient-and-physician-experience-interhospital-transfer-qualitative-study
April 12, 2023 - Study
Patient and physician experience with interhospital transfer: a qualitative study.
Citation Text:
Mueller SK, Shannon E, Dalal A, et al. Patient and Physician Experience with Interhospital Transfer: A Qualitative Study. J Patient Saf. 2021;17(8):e752-e757. doi:10.1097/PTS.000000000…
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psnet.ahrq.gov/issue/safe-use-electronic-health-records-and-health-information-technology-systems-trust-verify
August 02, 2015 - Study
Safe use of electronic health records and health information technology systems: trust but verify.
Citation Text:
Denham CR, Classen D, Swenson SJ, et al. Safe use of electronic health records and health information technology systems: trust but verify. J Patient Saf. 2013;9(4):17…
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psnet.ahrq.gov/issue/nature-and-occurrence-registration-errors-emergency-department
September 28, 2016 - Study
The nature and occurrence of registration errors in the emergency department.
Citation Text:
Hakimzada AF, Green RA, Sayan OR, et al. The nature and occurrence of registration errors in the emergency department. Int J Med Inform. 2007;77(3). doi:10.1016/j.ijmedinf.2007.04.011.
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psnet.ahrq.gov/issue/listening-and-question-asking-behaviors-resident-and-nurse-handoff-conversations-prospective
June 27, 2018 - Study
Listening and question-asking behaviors in resident and nurse handoff conversations: a prospective observational study.
Citation Text:
Kannampallil TG, Abraham J. Listening and question-asking behaviors in resident and nurse handoff conversations: a prospective observational study.…
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psnet.ahrq.gov/issue/drug-formulations-require-potentially-inaccurate-volumes-prepare-doses-infants-and-children
April 22, 2011 - Study
Drug formulations that require potentially inaccurate volumes to prepare doses for infants and children.
Citation Text:
Uppal N, Yasseen B, Seto W, et al. Drug formulations that require less than 0.1 mL of stock solution to prepare doses for infants and children. CMAJ. 2011;183(4…
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psnet.ahrq.gov/issue/management-arterial-lines-and-blood-sampling-intensive-care-threat-patient-safety
November 12, 2014 - Study
Management of arterial lines and blood sampling in intensive care: a threat to patient safety.
Citation Text:
Leslie RA, Gouldson S, Habib N, et al. Management of arterial lines and blood sampling in intensive care: a threat to patient safety. Anaesthesia. 2013;68(11). doi:10.1111…
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psnet.ahrq.gov/issue/psych-mnemonic-help-psychiatric-residents-decrease-patient-handoff-communication-errors
November 16, 2022 - Study
PSYCH: a mnemonic to help psychiatric residents decrease patient handoff communication errors.
Citation Text:
Mariano MT, Brooks V, DiGiacomo M. PSYCH: A Mnemonic to Help Psychiatric Residents Decrease Patient Handoff Communication Errors. Jt Comm J Qual Patient Saf. 2016;42(7):316…
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psnet.ahrq.gov/issue/prospective-memory-icu-effect-visual-cues-task-execution-representative-simulation
April 24, 2018 - Study
Prospective memory in the ICU: the effect of visual cues on task execution in a representative simulation.
Citation Text:
Grundgeiger T, Sanderson PM, Orihuela B, et al. Prospective memory in the ICU: the effect of visual cues on task execution in a representative simulation. Ergo…
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psnet.ahrq.gov/issue/evidence-guiding-practice-reported-versus-observed-adherence-contact-precautions-pilot-study
June 28, 2017 - Study
Is evidence guiding practice? Reported versus observed adherence to contact precautions: a pilot study.
Citation Text:
Jessee MA, Mion LC. Is evidence guiding practice? Reported versus observed adherence to contact precautions: a pilot study. Am J Infect Control. 2013;41(11):965-…
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psnet.ahrq.gov/issue/e-prescribing-errors-community-pharmacies-exploring-consequences-and-contributing-factors
January 07, 2015 - Study
E-prescribing errors in community pharmacies: exploring consequences and contributing factors.
Citation Text:
Odukoya OK, Stone JA, Chui MA. E-prescribing errors in community pharmacies: exploring consequences and contributing factors. Int J Med Inform. 2014;83(6):427-37. doi:10.10…