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  1. Diagnostic error as a result of drug-laboratory test interactions. | PSNet

    psnet.ahrq.gov/issue/diagnostic-error-result-drug-laboratory-test-interactions
    November 21, 2018 - Review Diagnostic error as a result of drug-laboratory test interactions. Citation Text: van Balveren JA, van de Venne WPHGV-, Erdem-Eraslan L, et al. Diagnostic error as a result of drug-laboratory test interactions. Diagnosis (Berl). 2019;6(1):69-71. doi:10.1515/dx-2018-0098. Copy Ci…

  2. 'Skating on thin ice?' Consultant surgeon's contemporary experience of adverse surgical events. | PSNet

    psnet.ahrq.gov/issue/skating-thin-ice-consultant-surgeons-contemporary-experience-adverse-surgical-events
    April 17, 2024 - Study 'Skating on thin ice?' Consultant surgeon's contemporary experience of adverse surgical events. Citation Text: Skevington SM, Langdon JE, Giddins G. ‘Skating on thin ice?’ Consultant surgeon's contemporary experience of adverse surgical events. Psychol Health Med. 2011;17(1). doi…

  3. Voluntarily reported emergency department errors. | PSNet

    psnet.ahrq.gov/issue/voluntarily-reported-emergency-department-errors
    June 20, 2011 - Study Voluntarily reported emergency department errors. Citation Text: Henneman PL, Blank FSJ, Smithline HA, et al. Voluntarily Reported Emergency Department Errors. J Patient Saf. 2008;1(3):126-132. doi:10.1097/01.jps.0000175694.39559.12. Copy Citation Format: DOI Google…

  4. What went right: lessons for the intensivist from the crew of US Airways Flight 1549. | PSNet

    psnet.ahrq.gov/issue/what-went-right-lessons-intensivist-crew-us-airways-flight-1549
    February 23, 2009 - Commentary What went right: lessons for the intensivist from the crew of US Airways Flight 1549. Citation Text: Eisen LA, Savel RH. What went right: lessons for the intensivist from the crew of US Airways Flight 1549. Chest. 2009;136(3):910-917. doi:10.1378/chest.09-0377. Copy Citation…

  5. Cardiac surgical ICU care: eliminating "preventable" complications. | PSNet

    psnet.ahrq.gov/issue/cardiac-surgical-icu-care-eliminating-preventable-complications
    August 04, 2021 - Review Cardiac surgical ICU care: eliminating "preventable" complications. Citation Text: Shake JG, Pronovost P, Whitman GJR. Cardiac surgical ICU care: eliminating "preventable" complications. J Card Surg. 2013;28(4):406-13. doi:10.1111/jocs.12124. Copy Citation Format: D…

  6. A trigger tool fails to identify serious errors and adverse events in pediatric otolaryngology. | PSNet

    psnet.ahrq.gov/issue/trigger-tool-fails-identify-serious-errors-and-adverse-events-pediatric-otolaryngology
    May 06, 2009 - Study A trigger tool fails to identify serious errors and adverse events in pediatric otolaryngology. Citation Text: Lander L, Roberson DW, Plummer KM, et al. A trigger tool fails to identify serious errors and adverse events in pediatric otolaryngology. Otolaryngol Head Neck Surg. 201…

  7. Potentially inappropriate medications and adverse drug effects in elders in the ED. | PSNet

    psnet.ahrq.gov/issue/potentially-inappropriate-medications-and-adverse-drug-effects-elders-ed
    December 23, 2020 - Study Potentially inappropriate medications and adverse drug effects in elders in the ED. Citation Text: Nixdorff N, Hustey FM, Brady AK, et al. Potentially inappropriate medications and adverse drug effects in elders in the ED. Am J Emerg Med. 2008;26(6):697-700. doi:10.1016/j.ajem.20…

  8. Cascade iatrogenesis: factors leading to the development of adverse events in hospitalized older adults. | PSNet

    psnet.ahrq.gov/issue/cascade-iatrogenesis-factors-leading-development-adverse-events-hospitalized-older-adults
    June 27, 2012 - Commentary Cascade iatrogenesis: factors leading to the development of adverse events in hospitalized older adults. Citation Text: Thornlow D, Anderson RA, Oddone E. Cascade iatrogenesis: factors leading to the development of adverse events in hospitalized older adults. Int J Nurs Stud…

  9. How to develop a second victim support program: a toolkit for health care organizations. | PSNet

    psnet.ahrq.gov/issue/how-develop-second-victim-support-program-toolkit-health-care-organizations
    April 03, 2019 - Commentary How to develop a second victim support program: a toolkit for health care organizations. Citation Text: Pratt SD, Kenney L, Scott SD, et al. How to develop a second victim support program: a toolkit for health care organizations. Jt Comm J Qual Patient Saf. 2012;38(5):235-40, …

  10. Fatigue, performance and the work environment: a survey of registered nurses. | PSNet

    psnet.ahrq.gov/issue/fatigue-performance-and-work-environment-survey-registered-nurses
    November 18, 2020 - Study Fatigue, performance and the work environment: a survey of registered nurses. Citation Text: Barker LM, Nussbaum MA. Fatigue, performance and the work environment: a survey of registered nurses. J Adv Nurs. 2011;67(6):1370-82. doi:10.1111/j.1365-2648.2010.05597.x. Copy Citation…

  11. An observational study of direct oral anticoagulant awareness indicating inadequate recognition with potential for patient harm. | PSNet

    psnet.ahrq.gov/issue/observational-study-direct-oral-anticoagulant-awareness-indicating-inadequate-recognition
    April 24, 2018 - Study An observational study of direct oral anticoagulant awareness indicating inadequate recognition with potential for patient harm. Citation Text: Olaiya A, Lurie B, Watt B, et al. An observational study of direct oral anticoagulant awareness indicating inadequate recognition with pot…

  12. Mandatory reporting of impaired medical practitioners: protecting patients, supporting practitioners. | PSNet

    psnet.ahrq.gov/issue/mandatory-reporting-impaired-medical-practitioners-protecting-patients-supporting
    September 01, 2016 - Commentary Mandatory reporting of impaired medical practitioners: protecting patients, supporting practitioners. Citation Text: Bismark MM, Morris JM, Clarke C. Mandatory reporting of impaired medical practitioners: protecting patients, supporting practitioners. Intern Med J. 2014;44(12a…

  13. Factors associated with disclosure of medical errors by housestaff. | PSNet

    psnet.ahrq.gov/issue/factors-associated-disclosure-medical-errors-housestaff
    January 27, 2019 - Study Factors associated with disclosure of medical errors by housestaff. Citation Text: Kronman AC, Paasche-Orlow MK, Orlander JD. Factors associated with disclosure of medical errors by housestaff. BMJ Qual Saf. 2011;21(4). doi:10.1136/bmjqs-2011-000084. Copy Citation Format: …

  14. Medication reconciliation at hospital discharge: evaluating discrepancies. | PSNet

    psnet.ahrq.gov/issue/medication-reconciliation-hospital-discharge-evaluating-discrepancies
    July 08, 2008 - Study Medication reconciliation at hospital discharge: evaluating discrepancies. Citation Text: Wong JD, Bajcar J, Wong GG, et al. Medication reconciliation at hospital discharge: evaluating discrepancies. Ann Pharmacother. 2008;42(10):1373-9. doi:10.1345/aph.1L190. Copy Citation …

  15. Medical error, incident investigation and the second victim: doing better but feeling worse? | PSNet

    psnet.ahrq.gov/issue/medical-error-incident-investigation-and-second-victim-doing-better-feeling-worse
    July 29, 2020 - Commentary Medical error, incident investigation and the second victim: doing better but feeling worse? Citation Text: Wu AW, Steckelberg RC. Medical error, incident investigation and the second victim: doing better but feeling worse? BMJ Qual Saf. 2012;21(4):267-70. doi:10.1136/bmjqs-20…

  16. Electronic health records and National Patient-Safety Goals. | PSNet

    psnet.ahrq.gov/issue/electronic-health-records-and-national-patient-safety-goals
    December 06, 2023 - Commentary Electronic health records and National Patient-Safety Goals. Citation Text: Sittig DF, Singh H. Electronic Health Records and National Patient-Safety Goals. New England Journal of Medicine. 2012;367(19). doi:10.1056/nejmsb1205420. Copy Citation Format: DOI Goog…

  17. Twenty-four/seven: a mixed-method systematic review of the off-shift literature. | PSNet

    psnet.ahrq.gov/issue/twenty-fourseven-mixed-method-systematic-review-shift-literature
    March 10, 2021 - Review Twenty-four/seven: a mixed-method systematic review of the off-shift literature. Citation Text: de Cordova PB, Phibbs CS, Bartel AP, et al. Twenty-four/seven: a mixed-method systematic review of the off-shift literature. J Adv Nurs. 2012;68(7):1454-68. Copy Citation Forma…

  18. The clinical transformation of Ascension Health: eliminating all preventable injuries and deaths. | PSNet

    psnet.ahrq.gov/issue/clinical-transformation-ascension-health-eliminating-all-preventable-injuries-and-deaths
    January 05, 2017 - Commentary The clinical transformation of Ascension Health: eliminating all preventable injuries and deaths. Citation Text: Pryor DB, Tolchin SF, Hendrich A, et al. The clinical transformation of Ascension Health: eliminating all preventable injuries and deaths. Jt Comm J Qual Patient Sa…

  19. A leadership framework for culture change in health care. | PSNet

    psnet.ahrq.gov/issue/leadership-framework-culture-change-health-care
    January 02, 2017 - Commentary A leadership framework for culture change in health care. Citation Text: Rose JS, Thomas CS, Tersigni AR, et al. A leadership framework for culture change in health care. Jt Comm J Qual Patient Saf. 2006;32(8):433-42. Copy Citation Format: Google Scholar PubMed B…

  20. Disclosing medical mistakes: a communication management plan for physicians. | PSNet

    psnet.ahrq.gov/issue/disclosing-medical-mistakes-communication-management-plan-physicians
    November 16, 2022 - Commentary Disclosing medical mistakes: a communication management plan for physicians. Citation Text: Petronio S, Torke A, Bosslet G, et al. Disclosing medical mistakes: a communication management plan for physicians. Perm J. 2013;17(2):73-9. doi:10.7812/TPP/12-106. Copy Citation …
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