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Overstating inpatient deaths due to medical error erodes trust in healthcare and the patient safety movement. | PSNet

psnet.ahrq.gov/issue/overstating-inpatient-deaths-due-medical-error-erodes-trust-healthcare-and-patient-safety

April 01, 2020 - Commentary Overstating inpatient deaths due to medical error erodes trust in healthcare and the patient safety movement. Citation Text: Gunderson CG, Rodwin BA. Overstating inpatient deaths due to medical error erodes trust in healthcare and the patient safety movement. J Hosp Med. 2022;…

Implementation science for ambulatory care safety: a novel method to develop context-sensitive interventions to reduce quality gaps in monitoring high-risk patients. | PSNet

psnet.ahrq.gov/issue/implementation-science-ambulatory-care-safety-novel-method-develop-context-sensitive

April 17, 2019 - Study Implementation science for ambulatory care safety: a novel method to develop context-sensitive interventions to reduce quality gaps in monitoring high-risk patients. Citation Text: McDonald KM, Su G, Lisker S, et al. Implementation science for ambulatory care safety: a novel method…

Orders on file but no labs drawn: investigation of machine and human errors caused by an interface idiosyncrasy. | PSNet

psnet.ahrq.gov/issue/orders-file-no-labs-drawn-investigation-machine-and-human-errors-caused-interface

April 29, 2018 - Commentary Orders on file but no labs drawn: investigation of machine and human errors caused by an interface idiosyncrasy. Citation Text: Schreiber R, Sittig DF, Ash JS, et al. Orders on file but no labs drawn: investigation of machine and human errors caused by an interface idiosyncras…

Work system barriers and facilitators in inpatient care transitions of pediatric trauma patients. | PSNet

psnet.ahrq.gov/issue/work-system-barriers-and-facilitators-inpatient-care-transitions-pediatric-trauma-patients

September 11, 2019 - Study Work system barriers and facilitators in inpatient care transitions of pediatric trauma patients. Citation Text: Wooldridge AR, Carayon P, Hoonakker P, et al. Work system barriers and facilitators in inpatient care transitions of pediatric trauma patients. App Ergon. 2020;85:103059…

Measuring patient safety climate: a review of surveys. | PSNet

psnet.ahrq.gov/issue/measuring-patient-safety-climate-review-surveys

June 14, 2011 - Review Classic Measuring patient safety climate: a review of surveys. Citation Text: Colla JB, Bracken AC, Kinney LM, et al. Measuring patient safety climate: a review of surveys. Qual Saf Health Care. 2005;14(5):364-6. Copy Citation Format: Goog…

Measuring harm and informing quality improvement in the Welsh NHS: the longitudinal Welsh national adverse events study. | PSNet

psnet.ahrq.gov/issue/measuring-harm-and-informing-quality-improvement-welsh-nhs-longitudinal-welsh-national

October 12, 2016 - Book/Report Measuring harm and informing quality improvement in the Welsh NHS: the longitudinal Welsh national adverse events study. Citation Text: Mayor S, Baines E, Vincent CA, et al. Measuring Harm And Informing Quality Improvement In The Welsh Nhs: The Longitudinal Welsh National Adv…

Whistleblowing over patient safety and care quality: a review of the literature. | PSNet

psnet.ahrq.gov/issue/whistleblowing-over-patient-safety-and-care-quality-review-literature

April 08, 2019 - Review Emerging Classic Whistleblowing over patient safety and care quality: a review of the literature. Citation Text: Blenkinsopp J, Snowden N, Mannion R, et al. Whistleblowing over patient safety and care quality: a review of the literature. J Health Org Mana…

Public reporting of antibiotic timing in patients with pneumonia: lessons from a flawed performance measure. | PSNet

psnet.ahrq.gov/issue/public-reporting-antibiotic-timing-patients-pneumonia-lessons-flawed-performance-measure

May 08, 2017 - Study Classic Public reporting of antibiotic timing in patients with pneumonia: lessons from a flawed performance measure. Citation Text: Wachter R, Flanders S, Fee C, et al. Public reporting of antibiotic timing in patients with pneumonia: lessons from a flaw…

American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update. | PSNet

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October 23, 2018 - Review American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update. Citation Text: Ban KA, Minei JP, Laronga C, et al. American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update. J Am Coll …

Adopting high reliability organization principles to lead a large scale clinical transformation. | PSNet

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November 21, 2021 - Commentary Adopting high reliability organization principles to lead a large scale clinical transformation. Citation Text: Pozzobon LD, Lam J, Chimonides E, et al. Adopting high reliability organization principles to lead a large scale clinical transformation. Healthc Manage Forum. 2023;…

Improving safety outcomes through medical error reduction via virtual reality-based clinical skills training. | PSNet

psnet.ahrq.gov/issue/improving-safety-outcomes-through-medical-error-reduction-virtual-reality-based-clinical

July 27, 2022 - Study Improving safety outcomes through medical error reduction via virtual reality-based clinical skills training. Citation Text: Kennedy GAL, Pedram S, Sanzone S. Improving safety outcomes through medical error reduction via virtual reality-based clinical skills training. Safety Sci. 2…

DEEP SCOPE: a framework for safe healthcare design. | PSNet

psnet.ahrq.gov/issue/deep-scope-framework-safe-healthcare-design

August 18, 2021 - Commentary DEEP SCOPE: a framework for safe healthcare design. Citation Text: Taylor E, Hignett S. DEEP SCOPE: a framework for safe healthcare design. Int J Environ Res Public Health. 2021;18(15):7780. doi:10.3390/ijerph18157780. Copy Citation Format: DOI Google Scholar Bib…

Factors related to serious safety events in a children's hospital patient safety collaborative. | PSNet

psnet.ahrq.gov/issue/factors-related-serious-safety-events-childrens-hospital-patient-safety-collaborative

February 16, 2022 - Study Factors related to serious safety events in a children's hospital patient safety collaborative. Citation Text: Burrus S, Hall M, Tooley E, et al. Factors related to serious safety events in a children's hospital patient safety collaborative. Pediatrics. 2021;148(3):e2020030346. doi…

Evidence-based interventions to reduce adverse events in hospitals: a systematic review of systematic reviews. | PSNet

psnet.ahrq.gov/issue/evidence-based-interventions-reduce-adverse-events-hospitals-systematic-review-systematic

December 04, 2015 - Review Evidence-based interventions to reduce adverse events in hospitals: a systematic review of systematic reviews. Citation Text: Zegers M, Hesselink G, Geense W, et al. Evidence-based interventions to reduce adverse events in hospitals: a systematic review of systematic reviews. BMJ …

Effects of individual nurse and hospital characteristics on patient adverse events and quality of care: a multilevel analysis. | PSNet

psnet.ahrq.gov/issue/effects-individual-nurse-and-hospital-characteristics-patient-adverse-events-and-quality-care

February 08, 2019 - Study Effects of individual nurse and hospital characteristics on patient adverse events and quality of care: a multilevel analysis. Citation Text: Lee SE, Vincent C, Dahinten S, et al. Effects of Individual Nurse and Hospital Characteristics on Patient Adverse Events and Quality of Care…

Interventions to reduce nurses' medication administration errors in inpatient settings: a systematic review and meta-analysis. | PSNet

psnet.ahrq.gov/issue/interventions-reduce-nurses-medication-administration-errors-inpatient-settings-systematic

October 13, 2021 - Review Interventions to reduce nurses' medication administration errors in inpatient settings: a systematic review and meta-analysis. Citation Text: Berdot S, Roudot M, Schramm C, et al. Interventions to reduce nurses' medication administration errors in inpatient settings: A systematic …

Putting the "action" in RCA(2): an analysis of intervention strength after adverse events. | PSNet

psnet.ahrq.gov/issue/putting-action-rca2-analysis-intervention-strength-after-adverse-events

April 17, 2024 - Study Putting the "action" in RCA(2): an analysis of intervention strength after adverse events. Citation Text: Zerillo JA, Tardiff SA, Flood D, et al. Putting the "action" in RCA(2): an analysis of intervention strength after adverse events. Jt Comm J Qual Patient Saf. 2024;50(7):492-49…

Evaluation of a problem-specific SBAR tool to improve after-hours nurse-physician phone communication: a randomized trial. | PSNet

psnet.ahrq.gov/issue/evaluation-problem-specific-sbar-tool-improve-after-hours-nurse-physician-phone-communication

December 30, 2014 - Study Evaluation of a problem-specific SBAR tool to improve after-hours nurse-physician phone communication: a randomized trial. Citation Text: Joffe E, Turley JP, Hwang KO, et al. Evaluation of a problem-specific SBAR tool to improve after-hours nurse-physician phone communication: a ra…

Implementation of a custom alert to prevent medication-timing errors associated with computerized prescriber order entry. | PSNet

psnet.ahrq.gov/issue/implementation-custom-alert-prevent-medication-timing-errors-associated-computerized

April 25, 2016 - Study Implementation of a custom alert to prevent medication-timing errors associated with computerized prescriber order entry. Citation Text: Idemoto LM, Williams BL, Ching JM, et al. Implementation of a custom alert to prevent medication-timing errors associated with computerized presc…

Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication station. | PSNet

psnet.ahrq.gov/issue/designing-distractions-human-factors-approach-decreasing-interruptions-centralised-medication

July 27, 2018 - Study Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication station. Citation Text: Colligan L, Guerlain S, Steck SE, et al. Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication…

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