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Root cause analysis and actions for the prevention of medical errors: quality improvement and resident education. | PSNet

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October 19, 2016 - Commentary Root cause analysis and actions for the prevention of medical errors: quality improvement and resident education. Citation Text: Charles R, Hood B, DeRosier JM, et al. Root Cause Analysis and Actions for the Prevention of Medical Errors: Quality Improvement and Resident Educat…

Linking acknowledgement to action: closing the loop on non-urgent, clinically significant test results in the electronic health record. | PSNet

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July 02, 2019 - Study Linking acknowledgement to action: closing the loop on non-urgent, clinically significant test results in the electronic health record. Citation Text: Dalal A, Pesterev BM, Eibensteiner K, et al. Linking acknowledgement to action: closing the loop on non-urgent, clinically signific…

Pending studies at hospital discharge: a pre-post analysis of an electronic medical record tool to improve communication at hospital discharge. | PSNet

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September 16, 2020 - Study Pending studies at hospital discharge: a pre-post analysis of an electronic medical record tool to improve communication at hospital discharge. Citation Text: Kantor MA, Evans KH, Shieh L. Pending studies at hospital discharge: a pre-post analysis of an electronic medical record to…

American College of Surgeons' Committee on Trauma performance improvement and patient safety program: maximal impact in a mature trauma center. | PSNet

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September 23, 2020 - Study American College of Surgeons' Committee on Trauma performance improvement and patient safety program: maximal impact in a mature trauma center. Citation Text: Sarkar B, Brunsvold ME, Cherry-Bukoweic JR, et al. American College of Surgeons' Committee on Trauma Performance Improvem…

Medication safety and knowledge-based functions: a stepwise approach against information overload. | PSNet

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December 22, 2008 - Study Medication safety and knowledge-based functions: a stepwise approach against information overload. Citation Text: Patapovas A, Dormann H, Sedlmayr B, et al. Medication safety and knowledge-based functions: a stepwise approach against information overload. Br J Clin Pharmacol. 2013…

Use of strategies from high-reliability organisations to the patient hand-off by resident physicians: practical implications. | PSNet

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July 02, 2014 - Study Use of strategies from high-reliability organisations to the patient hand-off by resident physicians: practical implications. Citation Text: Philibert I. Use of strategies from high-reliability organisations to the patient hand-off by resident physicians: practical implications. Qu…

Association of display of patient photographs in the electronic health record with wrong-patient order entry errors. | PSNet

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May 29, 2019 - Study Association of display of patient photographs in the electronic health record with wrong-patient order entry errors. Citation Text: Salmasian H, Blanchfield BB, Joyce K, et al. Association of display of patient photographs in the electronic health record with wrong-patient order e…

Quantification and classification of errors associated with hand-repackaging of medications in long-term care facilities in Germany. | PSNet

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April 21, 2021 - Study Quantification and classification of errors associated with hand-repackaging of medications in long-term care facilities in Germany. Citation Text: Gerber A, Kohaupt I, Lauterbach KW, et al. Quantification and classification of errors associated with hand-repackaging of medicat…

Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care units. | PSNet

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March 31, 2021 - Study Classic Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care units. Citation Text: Cullen DJ, Sweitzer BJ, Bates DW, et al. Preventable adverse drug events in hospitalized patients. Crit Care Me…

Quality and safety implications of emergency department information systems. | PSNet

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November 30, 2012 - Commentary Quality and safety implications of emergency department information systems. Citation Text: Farley HL, Baumlin KM, Hamedani A, et al. Quality and safety implications of emergency department information systems. Ann Emerg Med. 2013;62(4):399-407. doi:10.1016/j.annemergmed.201…

Effectiveness of patient safety training in equipping medical students to recognise safety hazards and propose robust interventions. | PSNet

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March 23, 2011 - Study Effectiveness of patient safety training in equipping medical students to recognise safety hazards and propose robust interventions. Citation Text: Hall LW, Scott SD, Cox KR, et al. Effectiveness of patient safety training in equipping medical students to recognise safety hazards…

Effects of learning climate and registered nurse staffing on medication errors. | PSNet

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February 15, 2011 - Study Effects of learning climate and registered nurse staffing on medication errors. Citation Text: Chang YK, Mark BA. Effects of Learning Climate and Registered Nurse Staffing on Medication Errors. Nurs Res. 2010;60(1). doi:10.1097/nnr.0b013e3181ff73cc. Copy Citation Format: …

Creating a safer health care system: finding the constraint. | PSNet

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February 24, 2011 - Commentary Creating a safer health care system: finding the constraint. Citation Text: Pauker SG, Zane EM, Salem D. Creating a safer health care system: finding the constraint. JAMA. 2005;294(22):2906-8. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML En…

Wrong-patient ordering errors in peripartum mother-newborn pairs: a unique patient-safety challenge in obstetrics. | PSNet

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July 28, 2021 - Commentary Wrong-patient ordering errors in peripartum mother-newborn pairs: a unique patient-safety challenge in obstetrics. Citation Text: Kern-Goldberger AR, Adelman JS, Applebaum JR, et al. Wrong-patient ordering errors in peripartum mother-newborn pairs: a unique patient-safety chal…

The nature of reported safety events related to care coordination in the operating room setting in a tertiary academic center. | PSNet

psnet.ahrq.gov/issue/nature-reported-safety-events-related-care-coordination-operating-room-setting-tertiary

May 11, 2022 - Study The nature of reported safety events related to care coordination in the operating room setting in a tertiary academic center. Citation Text: Krishnan S, Wheeler KK, Pimentel MP, et al. The nature of reported safety events related to care coordination in the operating room setting …

Factors associated with workarounds in barcode-assisted medication administration in hospitals. | PSNet

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January 23, 2019 - Study Factors associated with workarounds in barcode-assisted medication administration in hospitals. Citation Text: Veen W, Taxis K, Wouters H, et al. Factors associated with workarounds in barcode‐assisted medication administration in hospitals. J Clin Nurs. 2020;29(13-14):2239-2250. d…

From box ticking to the black box: the evolution of operating room safety. | PSNet

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October 29, 2017 - Commentary From box ticking to the black box: the evolution of operating room safety. Citation Text: Goldenberg MG, Elterman D. From box ticking to the black box: the evolution of operating room safety. World J Urol. 2019;38(6):1369-1372. doi:10.1007/s00345-019-02886-5. Copy Citation …

Measuring adverse events and levels of harm in pediatric inpatients with the Global Trigger Tool. | PSNet

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December 18, 2013 - Study Measuring adverse events and levels of harm in pediatric inpatients with the Global Trigger Tool. Citation Text: Kirkendall E, Kloppenborg E, Papp J, et al. Measuring adverse events and levels of harm in pediatric inpatients with the Global Trigger Tool. Pediatrics. 2012;130(5):e12…

Overestimation of clinical diagnostic performance caused by low necropsy rates. | PSNet

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February 09, 2011 - Study Overestimation of clinical diagnostic performance caused by low necropsy rates. Citation Text: Shojania KG, Burton EC, McDonald KM, et al. Overestimation of clinical diagnostic performance caused by low necropsy rates. Qual Saf Health Care. 2005;14(6):408-13. Copy Citation …

Discrepancies between clinical and autopsy diagnosis and the value of post mortem histology: a meta-analysis and review. | PSNet

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September 22, 2021 - Review Discrepancies between clinical and autopsy diagnosis and the value of post mortem histology: a meta-analysis and review. Citation Text: Roulson J, Benbow EW, Hasleton PS. Discrepancies between clinical and autopsy diagnosis and the value of post mortem histology; a meta-analysis a…

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