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A case of the birth and death of a high reliability healthcare organisation. | PSNet

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June 18, 2013 - Commentary A case of the birth and death of a high reliability healthcare organisation. Citation Text: Roberts KH, Madsen P, Desai V, et al. A case of the birth and death of a high reliability healthcare organisation. Qual Saf Health Care. 2005;14(3):216-20. Copy Citation Format:…

Linking Joint Commission inpatient core measures and National Patient Safety Goals with evidence. | PSNet

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October 19, 2022 - Commentary Linking Joint Commission inpatient core measures and National Patient Safety Goals with evidence. Citation Text: Masica AL, Richter KM, Convery P, et al. Linking joint commission inpatient core measures and national patient safety goals with evidence. Proc (Bayl Univ Med Cen…

Optimizing situation awareness to reduce emergency transfers in hospitalized children. | PSNet

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January 19, 2022 - Study Optimizing situation awareness to reduce emergency transfers in hospitalized children. Citation Text: Sosa T, Sitterding M, Dewan M, et al. Optimizing situation awareness to reduce emergency transfers in hospitalized children. Pediatrics. 2021;148(4):e2020034603. doi:10.1542/peds.2…

Critical incident stress management (CISM) in complex systems: cultural adaptation and safety impacts in healthcare. | PSNet

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December 29, 2014 - Study Critical incident stress management (CISM) in complex systems: cultural adaptation and safety impacts in healthcare. Citation Text: Müller-Leonhardt A, Mitchell SG, Vogt J, et al. Critical Incident Stress Management (CISM) in complex systems: cultural adaptation and safety impacts …

Interruptions in emergency department work: an observational and interview study. | PSNet

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September 29, 2021 - Study Interruptions in emergency department work: an observational and interview study. Citation Text: Berg LM, Källberg A-S, Göransson KE, et al. Interruptions in emergency department work: an observational and interview study. BMJ Qual Saf. 2013;22(8):656-63. doi:10.1136/bmjqs-2013-001…

The Preventable Harm Index: an effective motivator to facilitate the drive to zero. | PSNet

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January 15, 2014 - Commentary The Preventable Harm Index: an effective motivator to facilitate the drive to zero. Citation Text: Brilli RJ, McClead RE, Davis T, et al. The Preventable Harm Index: an effective motivator to facilitate the drive to zero. J Pediatr. 2010;157(4):681-3. doi:10.1016/j.jpeds.201…

Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction. | PSNet

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March 14, 2022 - Study Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction. Citation Text: Salisbury AC, Reid KJ, Alexander KP, et al. Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction. Arch Intern Med…

Patient safety in Taiwan: a survey on orthopedic surgeons. | PSNet

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October 27, 2016 - Study Patient safety in Taiwan: a survey on orthopedic surgeons. Citation Text: Yang C-T, Chen H-H, Hou S-M. Patient safety in Taiwan: a survey on orthopedic surgeons. J Formos Med Assoc. 2007;106(3):212-6. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML…

A growth mindset approach to preparing trainees for medical error. | PSNet

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August 19, 2020 - Commentary A growth mindset approach to preparing trainees for medical error. Citation Text: Klein J, Delany C, Fischer MD, et al. A growth mindset approach to preparing trainees for medical error. BMJ Qual Saf. 2017;26(9):771-774. doi:10.1136/bmjqs-2016-006416. Copy Citation Forma…

Errors in the MRI evaluation of musculoskeletal tumors and tumorlike lesions. | PSNet

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September 04, 2019 - Study Errors in the MRI evaluation of musculoskeletal tumors and tumorlike lesions. Citation Text: Heck RK, O'Malley AM, Kellum EL, et al. Errors in the MRI evaluation of musculoskeletal tumors and tumorlike lesions. Clin Orthop Relat Res. 2007;459:28-33. Copy Citation Format: …

Intraoperative code blue: improving teamwork and code response through interprofessional, in situ simulation. | PSNet

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April 28, 2021 - Study Intraoperative code blue: improving teamwork and code response through interprofessional, in situ simulation. Citation Text: Wu G, Podlinski L, Wang C, et al. Intraoperative code blue: improving teamwork and code response through interprofessional, in situ simulation. Jt Comm J Qua…

Cognitive error in an academic emergency department. | PSNet

psnet.ahrq.gov/issue/cognitive-error-academic-emergency-department

July 29, 2020 - Study Cognitive error in an academic emergency department. Citation Text: Schnapp BH, Sun JE, Kim JL, et al. Cognitive error in an academic emergency department. Diagnosis (Berl). 2018;5(3):135-142. doi:10.1515/dx-2018-0011. Copy Citation Format: DOI Google Scholar PubMed B…

Using HFMEA to assess potential for patient harm from tubing misconnections. | PSNet

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April 19, 2013 - Commentary Using HFMEA to assess potential for patient harm from tubing misconnections. Citation Text: Kimehi-Woods J, Shultz JP. Using HFMEA to assess potential for patient harm from tubing misconnections. Jt Comm J Qual Patient Saf. 2006;32(7):373-381. Copy Citation Format: …

Prevalence of polypharmacy exposure among hospitalized children in the United States. | PSNet

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August 20, 2016 - Study Prevalence of polypharmacy exposure among hospitalized children in the United States. Citation Text: Feudtner C, Dai D, Hexem KR, et al. Prevalence of polypharmacy exposure among hospitalized children in the United States. Arch Pediatr Adolesc Med. 2012;166(1):9-16. doi:10.1001/a…

Enhancing patient safety and resident education during the academic year-end transfer of outpatients: lessons from the suicide of a psychiatric patient. | PSNet

psnet.ahrq.gov/issue/enhancing-patient-safety-and-resident-education-during-academic-year-end-transfer-outpatients

March 25, 2017 - Commentary Enhancing patient safety and resident education during the academic year-end transfer of outpatients: lessons from the suicide of a psychiatric patient. Citation Text: Young JQ, Eisendrath SJ. Enhancing patient safety and resident education during the academic year-end trans…

Drug-related harms in hospitalized Medicare beneficiaries: results from the Healthcare Cost and Utilization Project, 2000–2008. | PSNet

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September 15, 2011 - Study Drug-related harms in hospitalized Medicare beneficiaries: results from the Healthcare Cost and Utilization Project, 2000–2008. Citation Text: Shamliyan TA, Kane RL. Drug-Related Harms in Hospitalized Medicare Beneficiaries: Results From the Healthcare Cost and Utilization Project,…

Requirements for implementing a 'just culture' within healthcare organisations: an integrative review. | PSNet

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October 31, 2014 - Review Requirements for implementing a 'just culture' within healthcare organisations: an integrative review. Citation Text: Murray JS, Lee J, Larson S, et al. Requirements for implementing a ‘just culture’ within healthcare organisations: an integrative review. BMJ Open Qual. 2023;12(2)…

Medical morbidity and mortality conferences: past, present and future. | PSNet

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November 30, 2022 - Review Medical morbidity and mortality conferences: past, present and future. Citation Text: George J. Medical morbidity and mortality conferences: past, present and future. Postgrad Med J. 2017;93(1097):148-152. doi:10.1136/postgradmedj-2016-134103. Copy Citation Format: D…

A multistep approach to improving biopsy site identification in dermatology: physician, staff, and patient roles based on a Delphi consensus. | PSNet

psnet.ahrq.gov/issue/multistep-approach-improving-biopsy-site-identification-dermatology-physician-staff-and

October 12, 2022 - Study A multistep approach to improving biopsy site identification in dermatology: physician, staff, and patient roles based on a Delphi consensus. Citation Text: Alam M, Lee A, Ibrahimi OA, et al. A multistep approach to improving biopsy site identification in dermatology: physician, st…

What ring tone should be used for patient safety? Early results with a Blackberry-based telementoring safety solution. | PSNet

psnet.ahrq.gov/issue/what-ring-tone-should-be-used-patient-safety-early-results-blackberry-based-telementoring

February 28, 2011 - Study What ring tone should be used for patient safety? Early results with a Blackberry-based telementoring safety solution. Citation Text: Parker A, Rubinfeld IS, Azuh O, et al. What ring tone should be used for patient safety? Early results with a Blackberry-based telementoring safety…

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