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Going to the COVID-19 Gemba: using observation and high reliability strategies to achieve safety in a time of crisis. | PSNet

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May 12, 2021 - Commentary Going to the COVID-19 Gemba: using observation and high reliability strategies to achieve safety in a time of crisis. Citation Text: Thull-Freedman J, Mondoux S, Stang A, et al. Going to the COVID-19 Gemba: Using observation and high reliability strategies to achieve safety in…

Rates and types of events reported to established incident reporting systems in two US hospitals. | PSNet

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January 02, 2017 - Study Rates and types of events reported to established incident reporting systems in two US hospitals. Citation Text: Nuckols TK, Bell D, Liu H, et al. Rates and types of events reported to established incident reporting systems in two US hospitals. Qual Saf Health Care. 2007;16(3):16…

Effect of crew resource management training in a multidisciplinary obstetrical setting. | PSNet

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March 06, 2005 - Study Effect of crew resource management training in a multidisciplinary obstetrical setting. Citation Text: Haller G, Garnerin P, Morales M-A, et al. Effect of crew resource management training in a multidisciplinary obstetrical setting. Int J Qual Health Care. 2008;20(4):254-63. doi:…

Correlates of missed or late versus timely diagnosis of dementia in healthcare settings. | PSNet

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March 09, 2022 - Study Correlates of missed or late versus timely diagnosis of dementia in healthcare settings. Citation Text: Chen Y, Power MC, Grodstein F, et al. Correlates of missed or late versus timely diagnosis of dementia in healthcare settings. Alzheimers Dement. 2024;20(8):5551-5560. doi:10.100…

Changes in hospital safety following penalties in the US Hospital Acquired Condition Reduction Program: retrospective cohort study. | PSNet

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September 29, 2021 - Study Changes in hospital safety following penalties in the US Hospital Acquired Condition Reduction Program: retrospective cohort study. Citation Text: Sankaran R, Sukul D, Nuliyalu U, et al. Changes in hospital safety following penalties in the US Hospital Acquired Condition Reduction …

Patient safety in actioning and communicating blood test results in primary care: a UK wide audit using the Primary Care Academic CollaboraTive (PACT). | PSNet

psnet.ahrq.gov/issue/patient-safety-actioning-and-communicating-blood-test-results-primary-care-uk-wide-audit

August 03, 2022 - Study Patient safety in actioning and communicating blood test results in primary care: a UK wide audit using the Primary Care Academic CollaboraTive (PACT). Citation Text: Watson J, Duncan P, Burrell A, et al. Patient safety in actioning and communicating blood test results in primary c…

Medical team training and coaching in the veterans health administration; assessment and impact on the first 32 facilities in the programme. | PSNet

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December 21, 2014 - Study Medical team training and coaching in the veterans health administration; assessment and impact on the first 32 facilities in the programme. Citation Text: Neily J, Mills PD, Lee P, et al. Medical team training and coaching in the Veterans Health Administration; assessment and im…

Closing the loop on test results to reduce communication failures: a rapid review of evidence, practice and patient perspectives. | PSNet

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March 11, 2020 - Review Closing the loop on test results to reduce communication failures: a rapid review of evidence, practice and patient perspectives. Citation Text: Wright B, Lennox A, Graber ML, et al. Closing the loop on test results to reduce communication failures: a rapid review of evidence, pra…

Adverse events experienced by homecare patients: a scoping review of the literature. | PSNet

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October 19, 2022 - Review Adverse events experienced by homecare patients: a scoping review of the literature. Citation Text: Masotti P, McColl MA, Green M. Adverse events experienced by homecare patients: a scoping review of the literature. Int J Health Care Qual. 2010;22(2):115-125. doi:10.1093/intqhc/…

Health care safety during the pandemic and beyond--building a system that ensures resilience. | PSNet

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July 20, 2022 - Commentary Health care safety during the pandemic and beyond--building a system that ensures resilience. Citation Text: Fleisher LA, Schreiber M, Cardo D, et al. Health care safety during the pandemic and beyond--building a system that ensures resilience. N Engl J Med. 2022;386(7):609-61…

Workplace violence pervasiveness in the perioperative environment: a multiprofessional survey. | PSNet

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November 11, 2020 - Study Workplace violence pervasiveness in the perioperative environment: a multiprofessional survey. Citation Text: Lin DM, Lane-Fall MB, Lea JA, et al. Workplace violence pervasiveness in the perioperative environment: a multiprofessional survey. Jt Comm J Qual Patient Saf. 2024;50(11):…

Out of sight, out of mind: a prospective observational study to estimate the duration of the Hawthorne effect on hand hygiene events. | PSNet

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September 09, 2020 - Study Out of sight, out of mind: a prospective observational study to estimate the duration of the Hawthorne effect on hand hygiene events. Citation Text: Vaisman A, Bannerman G, Matelski J, et al. Out of sight, out of mind: a prospective observational study to estimate the duration of t…

Opportunities for improvement in nursing homes: variance of six patient safety climate factor scores across nursing homes and wards—assessed by the Safety Attitudes Questionnaire. | PSNet

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September 29, 2017 - Study Opportunities for improvement in nursing homes: variance of six patient safety climate factor scores across nursing homes and wards—assessed by the Safety Attitudes Questionnaire. Citation Text: Deilkås ECT, Hofoss D, Husebo BS, et al. Opportunities for improvement in nursing homes…

Implementing the clinical occurrence reporting and learning system: a double-loop learning incident reporting system in long-term care. | PSNet

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May 05, 2021 - Study Implementing the clinical occurrence reporting and learning system: a double-loop learning incident reporting system in long-term care. Citation Text: Goh HS, Tan V, Chang J, et al. Implementing the clinical occurrence reporting and learning system: a double-loop learning incident …

Hospital-Acquired Condition Reduction Program is not associated with additional patient safety improvement. | PSNet

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May 29, 2019 - Study Hospital-Acquired Condition Reduction Program is not associated with additional patient safety improvement. Citation Text: Sheetz KH, Dimick JB, Englesbe MJ, et al. Hospital-Acquired Condition Reduction Program Is Not Associated With Additional Patient Safety Improvement. Health Af…

Identifying hospitalized patients at risk for harm: a comparison of nurse perceptions vs. electronic risk assessment tool scores. | PSNet

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November 03, 2015 - Study Identifying hospitalized patients at risk for harm: a comparison of nurse perceptions vs. electronic risk assessment tool scores. Citation Text: Stafos A, Stark S, Barbay K, et al. CE: Original Research: Identifying Hospitalized Patients at Risk for Harm: A Comparison of Nurse Perc…

Associations of physicians’ prescribing experience, work hours, and workload with prescription errors. | PSNet

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July 21, 2021 - Study Associations of physicians’ prescribing experience, work hours, and workload with prescription errors. Citation Text: Leviatan I, Oberman B, Zimlichman E, et al. Associations of physicians’ prescribing experience, work hours, and workload with prescription errors. J Am Med Inform A…

Preventable adverse events in obstetrics: systemic assessment of their incidence and linked risk factors. | PSNet

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March 01, 2023 - Study Preventable adverse events in obstetrics: systemic assessment of their incidence and linked risk factors. Citation Text: Hüner B, Derksen C, Schmiedhofer M, et al. Preventable adverse events in obstetrics: systemic assessment of their incidence and linked risk factors. Healthcare (…

Improving the approach to defining, classifying, reporting and monitoring adverse events in seriously ill older adults: recommendations from a multi-stakeholder convening. | PSNet

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July 29, 2020 - Commentary Improving the approach to defining, classifying, reporting and monitoring adverse events in seriously ill older adults: recommendations from a multi-stakeholder convening. Citation Text: Baim-Lance A, Ferreira KB, Cohen HJ, et al. Improving the approach to defining, classifyin…

Multiple meanings of resilience: health professionals' experiences of a dual element training intervention designed to help them prepare for coping with error. | PSNet

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August 10, 2022 - Study Multiple meanings of resilience: health professionals' experiences of a dual element training intervention designed to help them prepare for coping with error. Citation Text: Janes G, Harrison R, Johnson J, et al. Multiple meanings of resilience: health professionals' experiences o…

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