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Using crew resource management and a 'read-and-do checklist' to reduce failure-to-rescue events on a step-down unit. | PSNet

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November 04, 2020 - Study Using crew resource management and a 'read-and-do checklist' to reduce failure-to-rescue events on a step-down unit. Citation Text: Young-Xu Y, Fore AM, Metcalf A, et al. Using crew resource management and a 'read-and-do checklist' to reduce failure-to-rescue events on a step-down …

Reducing errors through discharge medication reconciliation by pharmacy services. | PSNet

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October 20, 2021 - Study Reducing errors through discharge medication reconciliation by pharmacy services. Citation Text: Bishop MA, Cohen BA, Billings LK, et al. Reducing errors through discharge medication reconciliation by pharmacy services. Am J Health Syst Pharm. 2015;72(17 Suppl 2):S120-6. doi:10.21…

Between choice and chance: the role of human factors in acute care equipment decisions. | PSNet

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February 22, 2023 - Study Between choice and chance: the role of human factors in acute care equipment decisions. Citation Text: Nemeth CP, Nunnally M, Bitan Y, et al. Between choice and chance: the role of human factors in acute care equipment decisions. J Patient Saf. 2009;5(2):114-21. doi:10.1097/PTS.0…

What 'just culture' doesn't understand about just punishment. | PSNet

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December 30, 2014 - Commentary What 'just culture' doesn't understand about just punishment. Citation Text: Reis-Dennis S. What 'Just Culture' doesn't understand about just punishment. J Med Ethics. 2018;44(11):739-742. doi:10.1136/medethics-2018-104911. Copy Citation Format: DOI Google Schola…

Implementing an interprofessional patient safety learning initiative: insights from participants, project leads and steering committee members. | PSNet

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August 14, 2014 - Study Implementing an interprofessional patient safety learning initiative: insights from participants, project leads and steering committee members. Citation Text: Jeffs L, Abramovich IA, Hayes C, et al. Implementing an interprofessional patient safety learning initiative: insights fr…

Predicting dispensing errors in community pharmacies: an application of the Systematic Human Error Reduction and Prediction Approach (SHERPA). | PSNet

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February 06, 2019 - EMERGING INNOVATIONS Predicting dispensing errors in community pharmacies: an application of the Systematic Human Error Reduction and Prediction Approach (SHERPA). Citation Text: Predicting dispensing errors in community pharmacies: an application of the Systematic Human Error Reduction and Predic…

A review of educational strategies to improve nurses' roles in recognizing and responding to deteriorating patients. | PSNet

psnet.ahrq.gov/issue/review-educational-strategies-improve-nurses-roles-recognizing-and-responding-deteriorating

October 16, 2013 - Review A review of educational strategies to improve nurses' roles in recognizing and responding to deteriorating patients. Citation Text: Liaw SY, Scherpbier A, Klainin-Yobas P, et al. A review of educational strategies to improve nurses' roles in recognizing and responding to deterio…

Preventable morbidity at a mature trauma center. | PSNet

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September 22, 2021 - Study Preventable morbidity at a mature trauma center. Citation Text: Preventable morbidity at a mature trauma center. Teixeira PGR, Inaba K, Salim A, et al. Arch Surg. 2009;144(6):536-541. Copy Citation Save Save to your library Print Download PDF …

Effect on diagnostic accuracy of cognitive reasoning tools for the workplace setting: systematic review and meta-analysis. | PSNet

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February 02, 2022 - Review Effect on diagnostic accuracy of cognitive reasoning tools for the workplace setting: systematic review and meta-analysis. Citation Text: Staal J, Hooftman J, Gunput STG, et al. Effect on diagnostic accuracy of cognitive reasoning tools for the workplace setting: systematic review…

Cognitive debiasing; part 1 and part 2. | PSNet

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September 18, 2024 - Commentary Cognitive debiasing; part 1 and part 2. Citation Text: Croskerry P, Singhal G, Mamede S. Cognitive debiasing 1: origins of bias and theory of debiasing. BMJ Qual Saf. 2013;22 Suppl 2:ii58-ii64. doi:10.1136/bmjqs-2012-001712. Copy Citation Format: DOI Google S…

Same behavior, different provider: American medical students' attitudes toward reporting risky behaviors committed by doctors, nurses, and classmates. | PSNet

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May 12, 2021 - Study Same behavior, different provider: American medical students' attitudes toward reporting risky behaviors committed by doctors, nurses, and classmates. Citation Text: Aggarwal S, Kheriaty A. Same behavior, different provider: American medical students' attitudes toward reporting ris…

Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Health Care. | PSNet

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November 23, 2016 - Book/Report Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Health Care. Citation Text: Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Health Care. Roundtable on Joy and Meaning in Work and Workforce Safety, The Lucian Leape Institute. Boston, MA:…

Capturing essential information to achieve safe interoperability. | PSNet

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February 23, 2015 - Commentary Capturing essential information to achieve safe interoperability. Citation Text: Weininger S, Jaffe MB, Rausch T, et al. Capturing Essential Information to Achieve Safe Interoperability. Anesth Analg. 2017;124(1):83-94. Copy Citation Format: Google Scholar PubMed…

Shift-to-shift handoff effects on patient safety and outcomes: a systematic review. | PSNet

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January 22, 2016 - Review Shift-to-shift handoff effects on patient safety and outcomes: a systematic review. Citation Text: Mardis M, Davis JJ, Benningfield B, et al. Shift-to-Shift Handoff Effects on Patient Safety and Outcomes. Am J Med Qual. 2017;32(1):34-42. doi:10.1177/1062860615612923. Copy Citati…

Good and bad reasons: the Swiss cheese model and its critics. | PSNet

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September 14, 2022 - Commentary Classic Good and bad reasons: the Swiss cheese model and its critics. Citation Text: Larouzee J, Le Coze J-C. Good and bad reasons: the Swiss cheese model and its critics. Safety Sci. 2020;126:104660. doi:10.1016/j.ssci.2020.104660. Copy Citation …

Using a modified A3 lean framework to identify ways to increase students' reporting of mistreatment behaviors. | PSNet

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May 25, 2010 - Commentary Using a modified A3 lean framework to identify ways to increase students' reporting of mistreatment behaviors. Citation Text: Ross PT, Abdoler E, Flygt LA, et al. Using a Modified A3 Lean Framework to Identify Ways to Increase Students' Reporting of Mistreatment Behaviors. Aca…

Opportunities to mine EHRs for malpractice risk management and patient safety. | PSNet

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October 28, 2020 - Commentary Opportunities to mine EHRs for malpractice risk management and patient safety. Citation Text: Adler-Milstein J, Sarkar U, Wachter RM. Opportunities to mine EHRs for malpractice risk management and patient safety. J Patient Saf Risk Manag. 2022;27(4):160-162. doi:10.1177/251604…

Advancing diagnostic safety research: results of a systematic research priority setting exercise. | PSNet

psnet.ahrq.gov/issue/advancing-diagnostic-safety-research-results-systematic-research-priority-setting-exercise

April 05, 2023 - Commentary Advancing diagnostic safety research: results of a systematic research priority setting exercise. Citation Text: Zwaan L, El-Kareh R, Meyer AND, et al. Advancing diagnostic safety research: results of a systematic research priority setting exercise. J Gen Intern Med. 2021;36(1…

Influence of perioperative handoffs on complications and outcomes. | PSNet

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October 14, 2020 - Commentary Influence of perioperative handoffs on complications and outcomes. Citation Text: Burden AR, Potestio C, Pukenas E. Influence of perioperative handoffs on complications and outcomes. Adv Anesth. 2021;39:133-148. doi:10.1016/j.aan.2021.07.008. Copy Citation Format: …

Tiered daily huddles: the power of teamwork in managing large healthcare organisations. | PSNet

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December 09, 2020 - Commentary Tiered daily huddles: the power of teamwork in managing large healthcare organisations. Citation Text: Mihaljevic T. Tiered daily huddles: the power of teamwork in managing large healthcare organisations. BMJ Qual Saf. 2020;29(12):1050-1052. doi:10.1136/bmjqs-2019-010575. Co…

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