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Safety first! Using a checklist for intrafacility transport of adult intensive care patients. | PSNet

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October 09, 2024 - Commentary Safety first! Using a checklist for intrafacility transport of adult intensive care patients. Citation Text: Comeau OY, Armendariz-Batiste J, Woodby SA. Safety First! Using a Checklist for Intrafacility Transport of Adult Intensive Care Patients. Crit Care Nurse. 2015;35(5):16…

A review of healthcare failure mode and effects analysis (HFMEA) in radiotherapy. | PSNet

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June 13, 2011 - Review A review of healthcare failure mode and effects analysis (HFMEA) in radiotherapy. Citation Text: Giardina M, Cantone MC, Tomarchio E, et al. A Review of Healthcare Failure Mode and Effects Analysis (HFMEA) in Radiotherapy. Health Phys. 2016;111(4):317-26. doi:10.1097/HP.0000000000…

Alternative medications for medications in the Use of High-Risk Medications in the Elderly and Potentially Harmful Drug–Disease Interactions in the Elderly quality measures. | PSNet

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April 27, 2011 - Review Alternative medications for medications in the Use of High-Risk Medications in the Elderly and Potentially Harmful Drug–Disease Interactions in the Elderly quality measures. Citation Text: Hanlon JT, Semla TP, Schmader KE. Alternative Medications for Medications in the Use of High…

TRIAD XII: are patients aware of and agree with DNR or POLST orders in their medical records. | PSNet

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September 15, 2021 - Study TRIAD XII: are patients aware of and agree with DNR or POLST orders in their medical records. Citation Text: Mirarchi FL, Juhasz K, Cooney TE, et al. TRIAD XII: Are Patients Aware of and Agree With DNR or POLST Orders in Their Medical Records. J Patient Saf. 2019;15(3):230-237. doi…

Frequency of passive EHR alerts in the ICU: another form of alert fatigue? | PSNet

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January 23, 2017 - Study Frequency of passive EHR alerts in the ICU: another form of alert fatigue? Citation Text: Kizzier-Carnahan V, Artis KA, Mohan V, et al. Frequency of Passive EHR Alerts in the ICU: Another Form of Alert Fatigue? J Patient Saf. 2019;15(3):246-250. doi:10.1097/PTS.0000000000000270. …

Older folks in hospitals: the contributing factors and recommendations for incident prevention. | PSNet

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April 13, 2022 - Study Older folks in hospitals: the contributing factors and recommendations for incident prevention. Citation Text: Mansah M, Griffiths R, Fernandez R, et al. Older folks in hospitals: the contributing factors and recommendations for incident prevention. J Patient Saf. 2014;10(3):146-53…

The Joint Commission's ongoing professional practice evaluation process: costly, ineffective, and potentially harmful to safety culture. | PSNet

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July 01, 2017 - Study The Joint Commission's ongoing professional practice evaluation process: costly, ineffective, and potentially harmful to safety culture. Citation Text: Donnelly LF, Podberesky DJ, Towbin AJ, et al. The Joint Commission's ongoing professional practice evaluation process: costly, ine…

Initial assessment of patient handoff in accredited general surgery residency programs in the United States and Canada: a cross-sectional survey. | PSNet

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October 19, 2022 - Study Initial assessment of patient handoff in accredited general surgery residency programs in the United States and Canada: a cross-sectional survey. Citation Text: Saleem AM, Paulus JK, Vassiliou MC, et al. Initial assessment of patient handoff in accredited general surgery residency …

Can patients report patient safety incidents in a hospital setting? A systematic review. | PSNet

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December 21, 2016 - Review Can patients report patient safety incidents in a hospital setting? A systematic review. Citation Text: Ward JK, Armitage G. Can patients report patient safety incidents in a hospital setting? A systematic review. BMJ Qual Saf. 2012;21(8):685-99. doi:10.1136/bmjqs-2011-000213. …

Early adopters of computerized physician order entry in hospitals that care for children: a picture of US health care shortly after the Institute of Medicine reports on quality. | PSNet

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December 20, 2023 - Study Early adopters of computerized physician order entry in hospitals that care for children: a picture of US health care shortly after the Institute of Medicine reports on quality. Citation Text: Teufel RJ, Kazley AS, Basco WT. Early adopters of computerized physician order entry in…

Seeing risk and allocating responsibility: talk of culture and its consequences on the work of patient safety. | PSNet

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November 03, 2015 - Study Seeing risk and allocating responsibility: talk of culture and its consequences on the work of patient safety. Citation Text: Szymczak JE. Seeing risk and allocating responsibility: talk of culture and its consequences on the work of patient safety. Soc Sci Med. 2014;120:252-9. doi…

Cognitive bias during clinical decision-making and its influence on patient outcomes in the emergency department: a scoping review. | PSNet

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September 21, 2022 - Review Cognitive bias during clinical decision-making and its influence on patient outcomes in the emergency department: a scoping review. Citation Text: Jala S, Fry M, Elliott R. Cognitive bias during clinical decision‐making and its influence on patient outcomes in the emergency depart…

Avoiding the unintended consequences of growth in medical care: how might more be worse? | PSNet

psnet.ahrq.gov/issue/avoiding-unintended-consequences-growth-medical-care-how-might-more-be-worse

April 24, 2018 - Commentary Classic Avoiding the unintended consequences of growth in medical care: how might more be worse? Citation Text: Fisher ES, Welch HG. Avoiding the unintended consequences of growth in medical care: how might more be worse? JAMA. 1999;281(5):446-53. …

Efficacy of an incident-reporting system in cellular pathology: a practical experience. | PSNet

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August 21, 2024 - Study Efficacy of an incident-reporting system in cellular pathology: a practical experience. Citation Text: Rakha EA, Clark D, Chohan BS, et al. Efficacy of an incident-reporting system in cellular pathology: a practical experience. J Clin Pathol. 2012;65(7):643-8. doi:10.1136/jclinpa…

Meaningful Use stage 2 e-prescribing threshold and adverse drug events in the Medicare Part D population with diabetes. | PSNet

psnet.ahrq.gov/issue/meaningful-use-stage-2-e-prescribing-threshold-and-adverse-drug-events-medicare-part-d

July 05, 2017 - Study Meaningful Use stage 2 e-prescribing threshold and adverse drug events in the Medicare Part D population with diabetes. Citation Text: Powers C, Gabriel MH, Encinosa W, et al. Meaningful use stage 2 e-prescribing threshold and adverse drug events in the Medicare Part D population w…

Residents, responsibility, and error: how residents learn to navigate the intersection. | PSNet

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August 21, 2019 - Study Residents, responsibility, and error: how residents learn to navigate the intersection. Citation Text: Shepherd L, Chilton S, Cristancho SM. Residents, responsibility, and error: how residents learn to navigate the intersection. Acad Med. 2023;98(8):934-940. doi:10.1097/acm.0000000…

Using simulation to improve first-year pharmacy students' ability to identify medication errors involving the top 100 prescription medications. | PSNet

psnet.ahrq.gov/issue/using-simulation-improve-first-year-pharmacy-students-ability-identify-medication-errors

January 23, 2017 - Study Using simulation to improve first-year pharmacy students' ability to identify medication errors involving the top 100 prescription medications. Citation Text: Atayee RS, Awdishu L, Namba J. Using Simulation to Improve First-Year Pharmacy Students' Ability to Identify Medication Err…

Contributing factors identified by hospital incident report narratives. | PSNet

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January 02, 2017 - Study Contributing factors identified by hospital incident report narratives. Citation Text: Nuckols TK, Bell DS, Paddock SM, et al. Contributing factors identified by hospital incident report narratives. Qual Saf Health Care. 2008;17(5):368-72. doi:10.1136/qshc.2007.023721. Copy Cit…

Empowering frontline nurses: a structured intervention enables nurses to improve medication administration accuracy. | PSNet

psnet.ahrq.gov/issue/empowering-frontline-nurses-structured-intervention-enables-nurses-improve-medication

March 13, 2012 - Study Empowering frontline nurses: a structured intervention enables nurses to improve medication administration accuracy. Citation Text: Kliger J, Blegen MA, Gootee D, et al. Empowering frontline nurses: a structured intervention enables nurses to improve medication administration accur…

Exploring error in team-based acute care scenarios: an observational study from the United Kingdom. | PSNet

psnet.ahrq.gov/issue/exploring-error-team-based-acute-care-scenarios-observational-study-united-kingdom

November 02, 2011 - Study Exploring error in team-based acute care scenarios: an observational study from the United Kingdom. Citation Text: Tallentire VR, Smith SE, Skinner J, et al. Exploring error in team-based acute care scenarios: an observational study from the United kingdom. Acad Med. 2012;87(6):79…

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