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Development and preliminary testing of the Coordination Process Error Reporting Tool (CPERT), a prospective clinical surveillance mechanism for teamwork errors in the pediatric cardiac ICU. | PSNet

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May 25, 2016 - Study Development and preliminary testing of the Coordination Process Error Reporting Tool (CPERT), a prospective clinical surveillance mechanism for teamwork errors in the pediatric cardiac ICU. Citation Text: Bates KE, Shea JA, Bird GL, et al. Development and Preliminary Testing of the…

What do we really know about crew resource management in healthcare?: An umbrella review on crew resource management and its effectiveness. | PSNet

psnet.ahrq.gov/issue/what-do-we-really-know-about-crew-resource-management-healthcare-umbrella-review-crew

September 29, 2021 - Review What do we really know about crew resource management in healthcare?: An umbrella review on crew resource management and its effectiveness. Citation Text: Buljac-Samardzic M, Dekker-van Doorn CM, Maynard MT. What do we really know about crew resource management in healthcare?: An …

Putting out fires: a qualitative study exploring the use of patient complaints to drive improvement at three academic hospitals. | PSNet

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October 27, 2021 - Study Putting out fires: a qualitative study exploring the use of patient complaints to drive improvement at three academic hospitals. Citation Text: Liu JJ, Rotteau L, Bell CM, et al. Putting out fires: a qualitative study exploring the use of patient complaints to drive improvement at …

Impact of simulation-based closed-loop communication training on medical errors in a pediatric emergency department. | PSNet

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July 22, 2020 - Study Impact of simulation-based closed-loop communication training on medical errors in a pediatric emergency department. Citation Text: Diaz MCG, Dawson K. Impact of Simulation-Based Closed-Loop Communication Training on Medical Errors in a Pediatric Emergency Department. Am J Med Qual…

Prevention of ventilator-associated pneumonia: an evidence-based systematic review. | PSNet

psnet.ahrq.gov/issue/prevention-ventilator-associated-pneumonia-evidence-based-systematic-review

July 14, 2010 - Study Classic Prevention of ventilator-associated pneumonia: an evidence-based systematic review. Citation Text: Collard HR, Saint S, Matthay MA. Prevention of ventilator-associated pneumonia: an evidence-based systematic review. Ann Intern Med. 2003;138(6):49…

Improving safety and eliminating redundant tests: cutting costs in U.S. hospitals. | PSNet

psnet.ahrq.gov/issue/improving-safety-and-eliminating-redundant-tests-cutting-costs-us-hospitals

May 27, 2011 - Study Classic Improving safety and eliminating redundant tests: cutting costs in U.S. hospitals. Citation Text: Jha AK, Chan DC, Ridgway AB, et al. Improving safety and eliminating redundant tests: cutting costs in U.S. hospitals. Health Aff (Millwood). 2009;28(…

Using four-phased unit-based patient safety walkrounds to uncover correctable system flaws. | PSNet

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October 05, 2022 - Study Using four-phased unit-based patient safety walkrounds to uncover correctable system flaws. Citation Text: Taylor AM, Chuo J, Figueroa-Altmann A, et al. Using four-phased unit-based patient safety walkrounds to uncover correctable system flaws. Jt Comm J Qual Patient Saf. 2013;39…

Quantifying the burden of opioid medication errors in adult oncology and palliative care settings: a systematic review. | PSNet

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May 22, 2019 - Review Quantifying the burden of opioid medication errors in adult oncology and palliative care settings: a systematic review. Citation Text: Heneka N, Shaw T, Rowett D, et al. Quantifying the burden of opioid medication errors in adult oncology and palliative care settings: A systematic…

Clinical predictors for unsafe direct discharge home patients from intensive care units. | PSNet

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January 12, 2011 - Study Clinical predictors for unsafe direct discharge home patients from intensive care units. Citation Text: Lau VI, Priestap FA, Lam JNH, et al. Clinical predictors for unsafe direct discharge home patients from intensive care units. J Intensive Care Med. 2020;35(10):1067-1073. doi:10.…

System hazards in managing laboratory test requests and results in primary care: medical protection database analysis and conceptual model. | PSNet

psnet.ahrq.gov/issue/system-hazards-managing-laboratory-test-requests-and-results-primary-care-medical-protection

November 08, 2017 - Study System hazards in managing laboratory test requests and results in primary care: medical protection database analysis and conceptual model. Citation Text: Bowie P, Price J, Hepworth N, et al. System hazards in managing laboratory test requests and results in primary care: medical p…

Clinician perspectives on the management of abnormal subcritical tests in an urban academic safety-net health care system. | PSNet

psnet.ahrq.gov/issue/clinician-perspectives-management-abnormal-subcritical-tests-urban-academic-safety-net-health

February 22, 2011 - Study Clinician perspectives on the management of abnormal subcritical tests in an urban academic safety-net health care system. Citation Text: Clarity C, Sarkar U, Lee J, et al. Clinician Perspectives on the Management of Abnormal Subcritical Tests in an Urban Academic Safety-Net Health…

Individual surgeon mortality rates: can outliers be detected? A national utility analysis. | PSNet

psnet.ahrq.gov/issue/individual-surgeon-mortality-rates-can-outliers-be-detected-national-utility-analysis

October 27, 2021 - Study Individual surgeon mortality rates: can outliers be detected? A national utility analysis. Citation Text: Harrison EM, Drake TM, O'Neill S, et al. Individual surgeon mortality rates: can outliers be detected? A national utility analysis. BMJ Open. 2016;6(10):e012471. doi:10.1136/bm…

The impact of medication reconciliation and review in patients using oral chemotherapy. | PSNet

psnet.ahrq.gov/issue/impact-medication-reconciliation-and-review-patients-using-oral-chemotherapy

November 17, 2021 - Study The impact of medication reconciliation and review in patients using oral chemotherapy. Citation Text: Darcis E, Germeys J, Stragier M, et al. The impact of medication reconciliation and review in patients using oral chemotherapy. J Oncol Pharm Pract. 2023;29(2):270-275. doi:10.117…

Delayed workup of rectal bleeding in adult primary care: examining process-of-care failures. | PSNet

psnet.ahrq.gov/issue/delayed-workup-rectal-bleeding-adult-primary-care-examining-process-care-failures

April 24, 2018 - Study Delayed workup of rectal bleeding in adult primary care: examining process-of-care failures. Citation Text: Weingart SN, Stoffel EM, Chung DC, et al. Delayed Workup of Rectal Bleeding in Adult Primary Care: Examining Process-of-Care Failures. The Joint Commission Journal on Quality…

Facilitating a safe transition from the pediatric emergency department to home with a post-discharge phone call: a quality-improvement initiative to improve patient safety. | PSNet

psnet.ahrq.gov/issue/facilitating-safe-transition-pediatric-emergency-department-home-post-discharge-phone-call

March 13, 2015 - Study Facilitating a safe transition from the pediatric emergency department to home with a post-discharge phone call: a quality-improvement initiative to improve patient safety. Citation Text: Bucaro PJ, Black E. Facilitating a safe transition from the pediatric emergency department to …

Adverse health events related to self-medication practices among elderly: a systematic review. | PSNet

psnet.ahrq.gov/issue/adverse-health-events-related-self-medication-practices-among-elderly-systematic-review

June 15, 2022 - Review Adverse health events related to self-medication practices among elderly: a systematic review. Citation Text: Locquet M, Honvo G, Rabenda V, et al. Adverse health events related to self-medication practices among elderly: a systematic review. Drugs Aging. 2017;34(5):359-365. doi:1…

Reporting of sentinel events in Swedish hospitals: a comparison of severe adverse events reported by patients and providers. | PSNet

psnet.ahrq.gov/issue/reporting-sentinel-events-swedish-hospitals-comparison-severe-adverse-events-reported

December 09, 2020 - Study Reporting of sentinel events in Swedish hospitals: a comparison of severe adverse events reported by patients and providers. Citation Text: Öhrn A, Elfström J, Liedgren C, et al. Reporting of sentinel events in Swedish hospitals: a comparison of severe adverse events reported by …

Outcomes of emergency department patients presenting with adverse drug events. | PSNet

psnet.ahrq.gov/issue/outcomes-emergency-department-patients-presenting-adverse-drug-events

April 22, 2011 - Study Outcomes of emergency department patients presenting with adverse drug events. Citation Text: Hohl CM, Nosyk B, Kuramoto L, et al. Outcomes of emergency department patients presenting with adverse drug events. Ann Emerg Med. 2011;58(3):270-279.e4. doi:10.1016/j.annemergmed.2011.0…

Incidence of clinically relevant medication errors in the era of electronically prepopulated medication reconciliation forms: a retrospective chart review. | PSNet

psnet.ahrq.gov/issue/incidence-clinically-relevant-medication-errors-era-electronically-prepopulated-medication

September 14, 2016 - Study Incidence of clinically relevant medication errors in the era of electronically prepopulated medication reconciliation forms: a retrospective chart review. Citation Text: Stockton KR, Wickham ME, Lai S, et al. Incidence of clinically relevant medication errors in the era of elect…

Detection of missed fractures of hand and forearm in whole-body CT in a blinded reassessment. | PSNet

psnet.ahrq.gov/issue/detection-missed-fractures-hand-and-forearm-whole-body-ct-blinded-reassessment

February 05, 2020 - Study Detection of missed fractures of hand and forearm in whole-body CT in a blinded reassessment. Citation Text: Kim S, Goelz L, Münn F, et al. Detection of missed fractures of hand and forearm in whole-body CT in a blinded reassessment. BMC Musculoskelet Disord. 2021;22(1):589. doi:10…

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