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Crossing academic boundaries for diagnostic safety: 10 complex challenges and potential solutions from clinical perspectives and high-reliability organizing principles. | PSNet

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November 30, 2022 - Commentary Crossing academic boundaries for diagnostic safety: 10 complex challenges and potential solutions from clinical perspectives and high-reliability organizing principles. Citation Text: Yousef EA, Sutcliffe KM, McDonald KM, et al. Crossing academic boundaries for diagnostic safe…

A cognitive task analysis of information management strategies in a computerized provider order entry environment. | PSNet

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May 27, 2011 - Study A cognitive task analysis of information management strategies in a computerized provider order entry environment. Citation Text: Weir C, Nebeker JJR, Hicken BL, et al. A cognitive task analysis of information management strategies in a computerized provider order entry environme…

Preserving organizational resilience, patient safety, and staff retention during COVID-19 requires a holistic consideration of the psychological safety of healthcare workers | PSNet

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May 08, 2019 - Commentary Classic Preserving organizational resilience, patient safety, and staff retention during COVID-19 requires a holistic consideration of the psychological safety of healthcare workers Citation Text: Rangachari P, L. Woods J. Preserving organizational re…

Communication through the electronic health record: frequency and implications of free text orders. | PSNet

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May 12, 2021 - Study Communication through the electronic health record: frequency and implications of free text orders. Citation Text: Kandaswamy S, Hettinger AZ, Hoffman DJ, et al. Communication through the electronic health record: frequency and implications of free text orders. JAMIA Open. 2020;3(2…

Overestimation of clinical diagnostic performance caused by low necropsy rates. | PSNet

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February 09, 2011 - Study Overestimation of clinical diagnostic performance caused by low necropsy rates. Citation Text: Shojania KG, Burton EC, McDonald KM, et al. Overestimation of clinical diagnostic performance caused by low necropsy rates. Qual Saf Health Care. 2005;14(6):408-13. Copy Citation …

A qualitative analysis of outpatient medication use in community settings: observed safety vulnerabilities and recommendations for improved patient safety. | PSNet

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October 26, 2022 - Study A qualitative analysis of outpatient medication use in community settings: observed safety vulnerabilities and recommendations for improved patient safety. Citation Text: Lyson HC, Sharma AE, Cherian R, et al. A Qualitative Analysis of Outpatient Medication Use in Community Setting…

Can we rely on patients' reports of adverse events? | PSNet

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December 29, 2014 - Study Classic Can we rely on patients' reports of adverse events? Citation Text: Zhu J, Stuver SO, Epstein AM, et al. Can we rely on patients' reports of adverse events? Med Care. 2011;49(10):948-55. doi:10.1097/MLR.0b013e31822047a8. Copy Citation Format…

Healthcare team resilience during COVID-19: a qualitative study. | PSNet

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February 20, 2019 - Study Healthcare team resilience during COVID-19: a qualitative study. Citation Text: Ambrose JW, Catchpole K, Evans HL, et al. Healthcare team resilience during COVID-19: a qualitative study. BMC Health Serv Res. 2024;24(1):459. doi:10.1186/s12913-024-10895-3. Copy Citation Format…

Patient safety strategies targeted at diagnostic errors: a systematic review. | PSNet

psnet.ahrq.gov/issue/patient-safety-strategies-targeted-diagnostic-errors-systematic-review

March 20, 2013 - Review Patient safety strategies targeted at diagnostic errors: a systematic review. Citation Text: McDonald KM, Matesic B, Contopoulos-Ioannidis DG, et al. Patient safety strategies targeted at diagnostic errors: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):381-389. doi:10.7…

Characteristics and contributing factors of diagnostic error in surgery: analysis of closed medico-legal cases and complaints in Canada. | PSNet

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April 16, 2019 - Study Characteristics and contributing factors of diagnostic error in surgery: analysis of closed medico-legal cases and complaints in Canada. Citation Text: Kwan JL, Calder LA, Bowman CL, et al. Characteristics and contributing factors of diagnostic error in surgery: analysis of closed …

Evaluating a patient safety learning laboratory to create an interdisciplinary ecosystem for health care innovation. | PSNet

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December 21, 2022 - Study Evaluating a patient safety learning laboratory to create an interdisciplinary ecosystem for health care innovation. Citation Text: Atkinson MK, Benneyan JC, Bambury EA, et al. Evaluating a patient safety learning laboratory to create an interdisciplinary ecosystem for health care …

Provider-to-provider communication during transitions of care from outpatient to acute care: a systematic review. | PSNet

psnet.ahrq.gov/issue/provider-provider-communication-during-transitions-care-outpatient-acute-care-systematic

October 29, 2017 - Review Provider-to-provider communication during transitions of care from outpatient to acute care: a systematic review. Citation Text: Luu N-P, Pitts S, Petty BG, et al. Provider-to-Provider Communication during Transitions of Care from Outpatient to Acute Care: A Systematic Review. J G…

Care Deficiencies and Leaders' Inadequate Reviews of a Patient Who Died at the Lt. Col. Luke Weathers, Jr. VA Medical Center in Memphis, Tennessee. | PSNet

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April 10, 2024 - Book/Report Care Deficiencies and Leaders' Inadequate Reviews of a Patient Who Died at the Lt. Col. Luke Weathers, Jr. VA Medical Center in Memphis, Tennessee. Citation Text: Care Deficiencies and Leaders' Inadequate Reviews of a Patient Who Died at the Lt. Col. Luke Weathers, Jr. VA Me…

Hospital- and system-wide interventions for health care-associated infections: a systematic review. | PSNet

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January 12, 2022 - Review Hospital- and system-wide interventions for health care-associated infections: a systematic review. Citation Text: Maurer NR, Hogan TH, Walker DM. Hospital- and system-wide interventions for health care-associated infections: a systematic review. Med Care Res Rev. 2021;78(6):643-6…

Perioperative COVID-19 defense: an evidence-based approach for optimization of infection control and operating room management. | PSNet

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November 30, 2012 - Commentary Classic Perioperative COVID-19 defense: an evidence-based approach for optimization of infection control and operating room management. Citation Text: Dexter F, Parra MC, Brown JR, et al. Perioperative COVID-19 defense: an evidence-based approach for …

Diagnostic performance dashboards: tracking diagnostic errors using big data. | PSNet

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July 28, 2023 - Commentary Diagnostic performance dashboards: tracking diagnostic errors using big data. Citation Text: Mane KK, Rubenstein KB, Nassery N, et al. Diagnostic performance dashboards: tracking diagnostic errors using big data. BMJ Qual Saf. 2018;27(7):567-570. doi:10.1136/bmjqs-2018-007945.…

CLER Report of Findings 2021: Subprotocol for Operative and Procedural Areas. | PSNet

psnet.ahrq.gov/issue/cler-report-findings-2021-subprotocol-operative-and-procedural-areas

October 18, 2017 - Book/Report CLER Report of Findings 2021: Subprotocol for Operative and Procedural Areas. Citation Text: CLER Report of Findings 2021: Subprotocol for Operative and Procedural Areas. Kuhn CM, Newton RC, Damewood MD, et al, on behalf of the CLER Evaluation Committee, the CLER Operative an…

Failure to administer recommended chemotherapy: acceptable variation or cancer care quality blind spot? | PSNet

psnet.ahrq.gov/issue/failure-administer-recommended-chemotherapy-acceptable-variation-or-cancer-care-quality-blind

September 02, 2020 - Study Failure to administer recommended chemotherapy: acceptable variation or cancer care quality blind spot? Citation Text: Ellis RJ, Schlick CJR, Feinglass J, et al. Failure to administer recommended chemotherapy: acceptable variation or cancer care quality blind spot? BMJ Qual Saf. 20…

The perfect storm: exam of a medical error and factors contributing to its possible escalation. | PSNet

psnet.ahrq.gov/issue/perfect-storm-exam-medical-error-and-factors-contributing-its-possible-escalation

October 20, 2021 - Commentary The perfect storm: exam of a medical error and factors contributing to its possible escalation. Citation Text: Walters GK. The perfect storm: exam of a medical error and factors contributing to its possible escalation. J Patient Saf. 2021;17(4):e264-e267. doi:10.1097/pts.00000…

Modified Early Warning System improves patient safety and clinical outcomes in an academic community hospital. | PSNet

psnet.ahrq.gov/issue/modified-early-warning-system-improves-patient-safety-and-clinical-outcomes-academic

September 18, 2019 - Study Modified Early Warning System improves patient safety and clinical outcomes in an academic community hospital. Citation Text: Mathukia C, Fan WQ, Vadyak K, et al. Modified Early Warning System improves patient safety and clinical outcomes in an academic community hospital. J Commun…

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