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A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional change. | PSNet

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March 30, 2022 - Commentary A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional change. Citation Text: Clifford SP, Mick PB, Derhake BM. A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional ch…

A prospective study of paediatric cardiac surgical microsystems: assessing the relationships between non-routine events, teamwork and patient outcomes. | PSNet

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February 14, 2024 - Study A prospective study of paediatric cardiac surgical microsystems: assessing the relationships between non-routine events, teamwork and patient outcomes. Citation Text: Schraagen JM, Schouten T, Smit M, et al. A prospective study of paediatric cardiac surgical microsystems: assessi…

Looking back on the history of patient safety: an opportunity to reflect and ponder future challenges. | PSNet

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July 10, 2019 - Commentary Looking back on the history of patient safety: an opportunity to reflect and ponder future challenges. Citation Text: Schiff G, Shojania KG. Looking back on the history of patient safety: an opportunity to reflect and ponder future challenges. BMJ Qual Saf. 2022;31(2):148-152.…

Humanizing harm: using a restorative approach to heal and learn from adverse events. | PSNet

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November 30, 2022 - Commentary Humanizing harm: using a restorative approach to heal and learn from adverse events. Citation Text: Wailling J, Kooijman A, Hughes J, et al. Humanizing harm: Using a restorative approach to heal and learn from adverse events. Health Expect. 2022;25(4):1192-1199. doi:10.1111/he…

Outpatient adverse drug events identified by screening electronic health records. | PSNet

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June 08, 2016 - Study Outpatient adverse drug events identified by screening electronic health records. Citation Text: Gandhi TK, Seger AC, Overhage M, et al. Outpatient adverse drug events identified by screening electronic health records. J Patient Saf. 2010;6(2):91-6. doi:10.1097/PTS.0b013e3181dcae06…

Developing standardized "receiver-driven" handoffs between referring providers and the emergency department: results of a multidisciplinary needs assessment. | PSNet

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June 03, 2020 - Study Developing standardized "receiver-driven" handoffs between referring providers and the emergency department: results of a multidisciplinary needs assessment. Citation Text: Huth K, Stack AM, Chi G, et al. Developing Standardized "Receiver-Driven" Handoffs Between Referring Provider…

Finding diagnostic errors in children admitted to the PICU. | PSNet

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May 21, 2016 - Study Finding diagnostic errors in children admitted to the PICU. Citation Text: Davalos MC, Samuels K, Meyer AND, et al. Finding diagnostic errors in children admitted to the PICU. Pediatr Crit Care Med. 2017;18(3):265-271. doi:10.1097/PCC.0000000000001059. Copy Citation Format: …

Experience feedback committees: a way of implementing a root cause analysis practice in hospital medical departments. | PSNet

psnet.ahrq.gov/issue/experience-feedback-committees-way-implementing-root-cause-analysis-practice-hospital-medical

October 30, 2024 - Study Experience feedback committees: a way of implementing a root cause analysis practice in hospital medical departments. Citation Text: François P, Lecoanet A, Caporossi A, et al. Experience feedback committees: A way of implementing a root cause analysis practice in hospital medical …

Surgical safety does not happen by accident: learning from perioperative near miss case studies. | PSNet

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August 04, 2021 - Commentary Surgical safety does not happen by accident: learning from perioperative near miss case studies. Citation Text: Stucky CH, Michael Hartmann J, Yauger YJ, et al. Surgical safety does not happen by accident: learning from perioperative near miss case studies. J Perianesth Nurs. …

Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. | PSNet

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January 12, 2022 - Review Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Citation Text: Kwan JL, Lo L, Sampson M, et al. Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158…

The impacts of a pharmacist-managed outpatient clinic and chemotherapy-directed electronic order sets for monitoring oral chemotherapy. | PSNet

psnet.ahrq.gov/issue/impacts-pharmacist-managed-outpatient-clinic-and-chemotherapy-directed-electronic-order-sets

June 18, 2014 - Study The impacts of a pharmacist-managed outpatient clinic and chemotherapy-directed electronic order sets for monitoring oral chemotherapy. Citation Text: Battis B, Clifford L, Huq M, et al. The impacts of a pharmacist-managed outpatient clinic and chemotherapy-directed electronic orde…

Development and reliability of the explicit professional oral communication observation tool to quantify the use of non-technical skills in healthcare. | PSNet

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April 23, 2014 - Study Development and reliability of the explicit professional oral communication observation tool to quantify the use of non-technical skills in healthcare. Citation Text: Kemper PF, van Noord I, de Bruijne M, et al. Development and reliability of the explicit professional oral communi…

Community discharge among post-acute nursing home residents: an association with patient safety culture? | PSNet

psnet.ahrq.gov/issue/community-discharge-among-post-acute-nursing-home-residents-association-patient-safety

November 04, 2020 - Study Community discharge among post-acute nursing home residents: an association with patient safety culture? Citation Text: Guo W, Li Y, Temkin-Greener H. Community discharge among post-acute nursing home residents: an association with patient safety culture? J Am Med Dir Assoc. 2021;2…

Fake and expired medications in simulation-based education: an underappreciated risk to patient safety. | PSNet

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September 26, 2012 - Commentary Fake and expired medications in simulation-based education: an underappreciated risk to patient safety. Citation Text: Torrie J, Cumin D, Sheridan J, et al. Fake and expired medications in simulation-based education: an underappreciated risk to patient safety. BMJ Qual Saf. 20…

Providers' and patients' perspectives on diagnostic errors in the acute care setting. | PSNet

psnet.ahrq.gov/issue/providers-and-patients-perspectives-diagnostic-errors-acute-care-setting

October 20, 2021 - Study Providers' and patients' perspectives on diagnostic errors in the acute care setting. Citation Text: Schnock KO, Garber A, Fraser H, et al. Providers' and patients' perspectives on diagnostic errors in the acute care setting. Jt Comm J Qual Patient Saf. 2023;49(2):89-97. doi:10.101…

Influence of surgeon behavior on trainee willingness to speak up: a randomized controlled trial. | PSNet

psnet.ahrq.gov/issue/influence-surgeon-behavior-trainee-willingness-speak-randomized-controlled-trial

February 22, 2019 - Study Influence of surgeon behavior on trainee willingness to speak up: a randomized controlled trial. Citation Text: Salazar MJB, Minkoff H, Bayya J, et al. Influence of surgeon behavior on trainee willingness to speak up: a randomized controlled trial. J Am Coll Surg. 2014;219(5):1001-…

An intervention to decrease patient identification band errors in a children's hospital. | PSNet

psnet.ahrq.gov/issue/intervention-decrease-patient-identification-band-errors-childrens-hospital

October 06, 2016 - Study An intervention to decrease patient identification band errors in a children's hospital. Citation Text: Hain PD, Joers B, Rush M, et al. An intervention to decrease patient identification band errors in a children's hospital. Qual Saf Health Care. 2010;19(3):244-7. doi:10.1136/qs…

Important factors for effective patient safety governance auditing: a questionnaire survey. | PSNet

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December 04, 2015 - Study Important factors for effective patient safety governance auditing: a questionnaire survey. Citation Text: van Gelderen SC, Zegers M, Robben PB, et al. Important factors for effective patient safety governance auditing: a questionnaire survey. BMC Health Serv Res. 2018;18(1):798. d…

Lack of association between intraoperative handoff of care and postoperative complications: a retrospective observational study. | PSNet

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March 14, 2022 - Study Lack of association between intraoperative handoff of care and postoperative complications: a retrospective observational study. Citation Text: O'Reilly-Shah VN, Melanson VG, Sullivan CL, et al. Lack of association between intraoperative handoff of care and postoperative complicat…

Exploring stakeholder perceptions around implementation of the Operating Room Black Box for patient safety research: a qualitative study using the theoretical domains framework. | PSNet

psnet.ahrq.gov/issue/exploring-stakeholder-perceptions-around-implementation-operating-room-black-box-patient

November 04, 2020 - Study Exploring stakeholder perceptions around implementation of the Operating Room Black Box for patient safety research: a qualitative study using the theoretical domains framework. Citation Text: Etherington N, Usama A, Patey AM, et al. Exploring stakeholder perceptions around impleme…

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