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

psnet.ahrq.gov/issue/using-hfmea-assess-potential-patient-harm-tubing-misconnections

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: …

The response of the APPD, CoPS and AAP to the Institute of Medicine report on resident duty hours. | PSNet

psnet.ahrq.gov/issue/response-appd-cops-and-aap-institute-medicine-report-resident-duty-hours

November 12, 2014 - Commentary The response of the APPD, CoPS and AAP to the Institute of Medicine report on resident duty hours. Citation Text: Guralnick S, Rushton J, Bale JF, et al. The response of the APPD, CoPS and AAP to the Institute of Medicine report on resident duty hours. Pediatrics. 2010;125(4…

Connected care: reducing errors through automated vital signs data upload. | PSNet

psnet.ahrq.gov/issue/connected-care-reducing-errors-through-automated-vital-signs-data-upload

September 01, 2018 - Study Connected care: reducing errors through automated vital signs data upload. Citation Text: Smith LB, Banner L, Lozano D, et al. Connected care: reducing errors through automated vital signs data upload. Comput Inform Nurs. 2009;27(5):318-23. doi:10.1097/NCN.0b013e3181b21d65. Cop…

Practice indicators of suboptimal care and avoidable adverse events: a content analysis of a national qualifying examination. | PSNet

psnet.ahrq.gov/issue/practice-indicators-suboptimal-care-and-avoidable-adverse-events-content-analysis-national

May 13, 2015 - Study Practice indicators of suboptimal care and avoidable adverse events: a content analysis of a national qualifying examination. Citation Text: Bordage G, Meguerditchian A-N, Tamblyn R. Practice indicators of suboptimal care and avoidable adverse events: a content analysis of a natio…

Key potentially inappropriate drugs in pediatrics: the KIDs list. | PSNet

psnet.ahrq.gov/issue/key-potentially-inappropriate-drugs-pediatrics-kids-list

September 23, 2020 - Study Emerging Classic Key potentially inappropriate drugs in pediatrics: the KIDs list. Citation Text: Meyers RS, Thackray J, Matson KL, et al. Key potentially inappropriate drugs in pediatrics: the KIDs list. J Pediatr Pharmacol Ther. 2020;25(3). doi:10.5863/1…

Young surgeons on speaking up: when and how surgical trainees voice concerns about supervisors' clinical decisions. | PSNet

psnet.ahrq.gov/issue/young-surgeons-speaking-when-and-how-surgical-trainees-voice-concerns-about-supervisors

April 13, 2017 - Study Young surgeons on speaking up: when and how surgical trainees voice concerns about supervisors' clinical decisions. Citation Text: Sur MD, Schindler N, Singh P, et al. Young surgeons on speaking up: when and how surgical trainees voice concerns about supervisors' clinical decisions…

Reporting medical errors to improve patient safety: a survey of physicians in teaching hospitals. | PSNet

psnet.ahrq.gov/issue/reporting-medical-errors-improve-patient-safety-survey-physicians-teaching-hospitals

February 24, 2011 - Study Reporting medical errors to improve patient safety: a survey of physicians in teaching hospitals. Citation Text: Kaldjian LC, Jones EW, Wu BJ, et al. Reporting medical errors to improve patient safety: a survey of physicians in teaching hospitals. Arch Intern Med. 2008;168(1):40-…

How informatics nurses use bar code technology to reduce medication errors. | PSNet

psnet.ahrq.gov/issue/how-informatics-nurses-use-bar-code-technology-reduce-medication-errors

August 04, 2021 - Commentary How informatics nurses use bar code technology to reduce medication errors. Citation Text: Gann M. How informatics nurses use bar code technology to reduce medication errors. Nursing (Brux). 2015;45(3):60-6. doi:10.1097/01.NURSE.0000458923.18468.37. Copy Citation Format:…

Using system analysis to build a safety culture: improving the reliability of epidural analgesia. | PSNet

psnet.ahrq.gov/issue/using-system-analysis-build-safety-culture-improving-reliability-epidural-analgesia

January 14, 2009 - Study Using system analysis to build a safety culture: improving the reliability of epidural analgesia. Citation Text: Garnerin P, Huchet-Belouard A, Diby M, et al. Using system analysis to build a safety culture: improving the reliability of epidural analgesia. Acta Anaesthesiol Scand…

The problem with 'My Five Moments for Hand Hygiene'. | PSNet

psnet.ahrq.gov/issue/problem-my-five-moments-hand-hygiene

September 09, 2020 - Commentary The problem with 'My Five Moments for Hand Hygiene'. Citation Text: Gould D, Purssell E, Jeanes A, et al. The problem with ‘My Five Moments for Hand Hygiene’. BMJ Qual Saf. 2022;31(4):322-326. doi:10.1136/bmjqs-2020-011911. Copy Citation Format: DOI Google Schola…

The quality 'journey' at Ascension Health: how we've prevented at least 1,500 avoidable deaths a year—and aim to do even better. | PSNet

psnet.ahrq.gov/issue/quality-journey-ascension-health-how-weve-prevented-least-1500-avoidable-deaths-year-and-aim

June 06, 2018 - Commentary The quality 'journey' at Ascension Health: how we've prevented at least 1,500 avoidable deaths a year—and aim to do even better. Citation Text: Pryor D, Hendrich A, Henkel RJ, et al. The quality 'journey' at Ascension Health: how we've prevented at least 1,500 avoidable deaths…

Utilizing information technology to mitigate the handoff risks caused by resident work hour restrictions. | PSNet

psnet.ahrq.gov/issue/utilizing-information-technology-mitigate-handoff-risks-caused-resident-work-hour

March 17, 2010 - Commentary Utilizing information technology to mitigate the handoff risks caused by resident work hour restrictions. Citation Text: Bernstein J, MacCourt DC, Jacob DM, et al. Utilizing information technology to mitigate the handoff risks caused by resident work hour restrictions. Clin …

Feasibility of centre-based incident reporting in primary healthcare: the SPIEGEL study. | PSNet

psnet.ahrq.gov/issue/feasibility-centre-based-incident-reporting-primary-healthcare-spiegel-study

October 05, 2011 - Study Feasibility of centre-based incident reporting in primary healthcare: the SPIEGEL study. Citation Text: Zwart DLM, Steerneman AHM, van Rensen ELJ, et al. Feasibility of centre-based incident reporting in primary healthcare: the SPIEGEL study. BMJ Qual Saf. 2011;20(2):121-7. doi:1…

Prospective memory in the ICU: the effect of visual cues on task execution in a representative simulation. | PSNet

psnet.ahrq.gov/issue/prospective-memory-icu-effect-visual-cues-task-execution-representative-simulation

April 24, 2018 - Study Prospective memory in the ICU: the effect of visual cues on task execution in a representative simulation. Citation Text: Grundgeiger T, Sanderson PM, Orihuela B, et al. Prospective memory in the ICU: the effect of visual cues on task execution in a representative simulation. Ergo…

Developing a framework for nursing handover in the emergency department: an individualised and systematic approach. | PSNet

psnet.ahrq.gov/issue/developing-framework-nursing-handover-emergency-department-individualised-and-systematic

October 06, 2016 - Study Developing a framework for nursing handover in the emergency department: an individualised and systematic approach. Citation Text: Klim S, Kelly A-M, Kerr D, et al. Developing a framework for nursing handover in the emergency department: an individualised and systematic approach. …

The nature and occurrence of registration errors in the emergency department. | PSNet

psnet.ahrq.gov/issue/nature-and-occurrence-registration-errors-emergency-department

September 28, 2016 - Study The nature and occurrence of registration errors in the emergency department. Citation Text: Hakimzada AF, Green RA, Sayan OR, et al. The nature and occurrence of registration errors in the emergency department. Int J Med Inform. 2007;77(3). doi:10.1016/j.ijmedinf.2007.04.011. …

Engaging the front line: tapping into hospital-wide quality and safety initiatives. | PSNet

psnet.ahrq.gov/issue/engaging-front-line-tapping-hospital-wide-quality-and-safety-initiatives

March 20, 2019 - Commentary Engaging the front line: tapping into hospital-wide quality and safety initiatives. Citation Text: Wolpaw J, Schwengel D, Hensley N, et al. Engaging the Front Line: Tapping into Hospital-Wide Quality and Safety Initiatives. J Cardiothorac Vasc Anesth. 2018;32(1):522-533. doi:1…

Organisational conditions for safety management practice in homecare and nursing homes, pre-pandemic and in pandemic. | PSNet

psnet.ahrq.gov/issue/organisational-conditions-safety-management-practice-homecare-and-nursing-homes-pre-pandemic

August 03, 2022 - Study Organisational conditions for safety management practice in homecare and nursing homes, pre-pandemic and in pandemic. Citation Text: Dellve L, Skagert K. Organisational conditions for safety management practice in homecare and nursing homes, pre-pandemic and in pandemic. Safety Sci…

Microsystems in health care: Part 2. Creating a rich information environment. | PSNet

psnet.ahrq.gov/issue/microsystems-health-care-part-2-creating-rich-information-environment

July 19, 2023 - Study Classic Microsystems in health care: Part 2. Creating a rich information environment. Citation Text: Nelson EC, Batalden PB, Homa K, et al. Microsystems in health care: Part 2. Creating a rich information environment. Jt Comm J Qual Patient Saf. 2003;29(…

Exploring the relationship between contact frequency, leader-member relationships, and patient safety culture | PSNet

psnet.ahrq.gov/issue/exploring-relationship-between-contact-frequency-leader-member-relationships-and-patient

February 10, 2021 - Study Exploring the relationship between contact frequency, leader-member relationships, and patient safety culture Citation Text: Anderson AD, Floegel TA, Hofler L, et al. Exploring the Relationship Between Contact Frequency, Leader-Member Relationships, and Patient Safety Culture. J Nu…

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