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How to make medication error reporting systems work—factors associated with their successful development and implementation. | PSNet

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December 05, 2012 - Study How to make medication error reporting systems work—factors associated with their successful development and implementation. Citation Text: Holmström A-R, Laaksonen R, Airaksinen M. How to make medication error reporting systems work--Factors associated with their successful develo…

An electronic trigger to detect telemedicine-related diagnostic errors. | PSNet

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June 21, 2023 - Study An electronic trigger to detect telemedicine-related diagnostic errors. Citation Text: Murphy DR, Kadiyala H, Wei L, et al. An electronic trigger to detect telemedicine-related diagnostic errors. J Telemed Telecare. 2024;Epub Apr 1. doi:10.1177/1357633x241236570. Copy Citation …

Changes made to orders placed by overnight admitting residents on teaching rounds the next day. | PSNet

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July 07, 2021 - Study Changes made to orders placed by overnight admitting residents on teaching rounds the next day. Citation Text: Chiel L, Freiman E, Yarahuan J, et al. Changes made to orders placed by overnight admitting residents on teaching rounds the next day. Hosp Pediatr. 2021;12(1):e35-e38. do…

A review of modifiable health care factors contributing to inpatient suicide: an analysis of coroners' reports using the Human Factors Analysis and Classification System for Healthcare | PSNet

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July 19, 2023 - Study A review of modifiable health care factors contributing to inpatient suicide: an analysis of coroners' reports using the Human Factors Analysis and Classification System for Healthcare Citation Text: Sweeting P, Finlayson M, Hartz D. A review of modifiable health care factors contr…

Iatrogenic events in admitted neonates: a prospective cohort study. | PSNet

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December 18, 2014 - Study Iatrogenic events in admitted neonates: a prospective cohort study. Citation Text: Ligi I, Arnaud F, Jouve E, et al. Iatrogenic events in admitted neonates: a prospective cohort study. Lancet. 2008;371(9610):404-10. doi:10.1016/S0140-6736(08)60204-4. Copy Citation Format: …

Associations between hospitalist shift busyness, diagnostic confidence, and resource utilization: a pilot study. | PSNet

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September 16, 2020 - Study Associations between hospitalist shift busyness, diagnostic confidence, and resource utilization: a pilot study. Citation Text: Gupta AB, Greene MT, Fowler KE, et al. Associations between hospitalist shift busyness, diagnostic confidence, and resource utilization: a pilot study. J …

Team experiences of the root cause analysis process after a sentinel event: a qualitative case study. | PSNet

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October 07, 2020 - Study Team experiences of the root cause analysis process after a sentinel event: a qualitative case study. Citation Text: Liepelt S, Sundal H, Kirchhoff R. Team experiences of the root cause analysis process after a sentinel event: a qualitative case study. BMC Health Serv Res. 2023;23(…

Do physicians clean their hands? Insights from a covert observational study. | PSNet

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July 02, 2019 - Study Do physicians clean their hands? Insights from a covert observational study. Citation Text: Kovacs-Litman A, Wong K, Shojania KG, et al. Do physicians clean their hands? Insights from a covert observational study. J Hosp Med. 2016;11(12):862-864. doi:10.1002/jhm.2632. Copy Citati…

Hospital reputation and perceptions of patient safety. | PSNet

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October 11, 2017 - Study Hospital reputation and perceptions of patient safety. Citation Text: Mira JJ, Lorenzo S, Navarro I. Hospital reputation and perceptions of patient safety. Med Princ Pract. 2014;23(1):92-4. doi:10.1159/000353152. Copy Citation Format: DOI Google Scholar PubMed BibTe…

A new patient safety smartphone application for prevention of "forgotten" ureteral stents: results from a clinical pilot study in 194 patients. | PSNet

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July 01, 2015 - Study A new patient safety smartphone application for prevention of "forgotten" ureteral stents: results from a clinical pilot study in 194 patients. Citation Text: Molina WR, Pessoa R, da Silva RD, et al. A new patient safety smartphone application for prevention of "forgotten" ureteral…

The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. | PSNet

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July 07, 2021 - Study Classic The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. Citation Text: Baker R, Norton PG, Flintoft V, et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients…

Medication reconciliation in ambulatory care: attempts at improvement. | PSNet

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March 28, 2011 - Study Medication reconciliation in ambulatory care: attempts at improvement. Citation Text: Nassaralla CL, Naessens JM, Hunt VL, et al. Medication reconciliation in ambulatory care: attempts at improvement. Qual Saf Health Care. 2009;18(5):402-7. doi:10.1136/qshc.2007.024513. Copy Ci…

The safety of warfarin therapy in the nursing home setting. | PSNet

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March 11, 2011 - Study The safety of warfarin therapy in the nursing home setting. Citation Text: Gurwitz JH, Field T, Radford MJ, et al. The safety of warfarin therapy in the nursing home setting. Am J Med. 2007;120(6):539-44. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3…

Management of the deteriorating adult patient: does simulation-based education improve patient safety? | PSNet

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June 08, 2022 - Review Management of the deteriorating adult patient: does simulation-based education improve patient safety? Citation Text: Bennion J, Mansell SK. Management of the deteriorating adult patient: does simulation-based education improve patient safety? Br J Hosp Med (Lond). 2021;82(8):1-8.…

Qualitative study about the experiences of colleagues of health professionals involved in an adverse event. | PSNet

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September 19, 2016 - Study Qualitative study about the experiences of colleagues of health professionals involved in an adverse event. Citation Text: Ferrús L, Silvestre C, Olivera G, et al. Qualitative Study About the Experiences of Colleagues of Health Professionals Involved in an Adverse Event. J Patient …

Observational study of conformity in yet another medical learning environment: conformity to preceptors during high-fidelity simulation. | PSNet

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June 19, 2019 - Study Observational study of conformity in yet another medical learning environment: conformity to preceptors during high-fidelity simulation. Citation Text: Beran T, Altabbaa G, Oddone Paolucci E. Observational study of conformity in yet another medical learning environment: conformity …

Unintended patient safety risks due to wireless smart infusion pump library update delays. | PSNet

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September 25, 2019 - Study Unintended patient safety risks due to wireless smart infusion pump library update delays. Citation Text: Hsu K-Y, DeLaurentis P, Bitan Y, et al. Unintended Patient Safety Risks Due to Wireless Smart Infusion Pump Library Update Delays. J Patient Saf. 2019;15(1):e8-e14. doi:10.1097…

Learning in radiation oncology: 12-month experience with a new incident learning system. | PSNet

psnet.ahrq.gov/issue/learning-radiation-oncology-12-month-experience-new-incident-learning-system

February 16, 2022 - Study Learning in radiation oncology: 12-month experience with a new incident learning system. Citation Text: Crouch K, Adamson L, Beldham‐Collins R, et al. Learning in radiation oncology: 12‐month experience with a new incident learning system. J Med Radiat Sci. 2024;Epub Sep 15. doi:10…

Transparency, public reporting, and a culture of change to quality and safety in cardiac surgery. | PSNet

psnet.ahrq.gov/issue/transparency-public-reporting-and-culture-change-quality-and-safety-cardiac-surgery

February 17, 2021 - Commentary Transparency, public reporting, and a culture of change to quality and safety in cardiac surgery. Citation Text: Ibrahim M, Szeto WY, Gutsche J, et al. Transparency, public reporting, and a culture of change to quality and safety in cardiac surgery. Ann Thorac Surg. 2022;114(3…

The disclosure dilemma—large-scale adverse events. | PSNet

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January 22, 2017 - Commentary The disclosure dilemma—large-scale adverse events. Citation Text: Dudzinski DM, Hébert PC, Foglia MB, et al. The disclosure dilemma--large-scale adverse events. New Engl J Med. 2010;363(10):978-986. doi:10.1056/NEJMhle1003134. Copy Citation Format: DOI Google S…

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