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Unit of measurement used and parent medication dosing errors. | PSNet

psnet.ahrq.gov/issue/unit-measurement-used-and-parent-medication-dosing-errors

June 04, 2014 - Study Unit of measurement used and parent medication dosing errors. Citation Text: Yin S, Dreyer BP, Ugboaja DC, et al. Unit of measurement used and parent medication dosing errors. Pediatrics. 2014;134(2):e354-61. doi:10.1542/peds.2014-0395. Copy Citation Format: DOI Googl…

Cognitive biases in surgery: systematic review. | PSNet

psnet.ahrq.gov/issue/cognitive-biases-surgery-systematic-review

April 27, 2022 - Review Cognitive biases in surgery: systematic review. Citation Text: Armstrong BA, Dutescu IA, Tung A, et al. Cognitive biases in surgery: systematic review. Br J Surg. 2023;110(6):645-654. doi:10.1093/bjs/znad004. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3…

Decision support for sensible dosing in electronic prescribing systems. | PSNet

psnet.ahrq.gov/issue/decision-support-sensible-dosing-electronic-prescribing-systems

February 23, 2011 - Study Decision support for sensible dosing in electronic prescribing systems. Citation Text: Coleman JJ, Nwulu U, Ferner RE. Decision support for sensible dosing in electronic prescribing systems. J Clin Pharm Ther. 2012;37(4):415-9. doi:10.1111/j.1365-2710.2011.01310.x. Copy Citatio…

Mislabeled units of umbilical cord blood detected by a quality assurance program at the transplantation center. | PSNet

psnet.ahrq.gov/issue/mislabeled-units-umbilical-cord-blood-detected-quality-assurance-program-transplantation

October 19, 2022 - Study Mislabeled units of umbilical cord blood detected by a quality assurance program at the transplantation center. Citation Text: McCullough JS, McKenna D, Kadidlo D, et al. Mislabeled units of umbilical cord blood detected by a quality assurance program at the transplantation cente…

Striving for a zero-error patient surgical journey through adoption of aviation-style challenge and response flow checklists: a quality improvement project. | PSNet

psnet.ahrq.gov/issue/striving-zero-error-patient-surgical-journey-through-adoption-aviation-style-challenge-and

July 10, 2017 - Study Striving for a zero-error patient surgical journey through adoption of aviation-style challenge and response flow checklists: a quality improvement project. Citation Text: Low DK, Reed MA, Geiduschek JM, et al. Striving for a zero-error patient surgical journey through adoption …

Epidemiology of and risk factors for harmful anti-infective medication errors in a pediatric hospital. | PSNet

psnet.ahrq.gov/issue/epidemiology-and-risk-factors-harmful-anti-infective-medication-errors-pediatric-hospital

March 22, 2017 - Study Epidemiology of and risk factors for harmful anti-infective medication errors in a pediatric hospital. Citation Text: Modi A, Germain E, Soma V, et al. Epidemiology of and Risk Factors for Harmful Anti-Infective Medication Errors in a Pediatric Hospital. Jt Comm J Qual Patient Saf.…

Comprehensive analysis of a medication dosing error related to CPOE. | PSNet

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June 01, 2005 - Commentary Comprehensive analysis of a medication dosing error related to CPOE. Citation Text: Horsky J, Kuperman GJ, Patel VL. Comprehensive Analysis of a Medication Dosing Error Related to CPOE: Table 1. J Am Med Info Assoc. 2005;12(4). doi:10.1197/jamia.m1740. Copy Citation Fo…

Learning from mistakes and near mistakes: using root cause analysis as a risk management tool. | PSNet

psnet.ahrq.gov/issue/learning-mistakes-and-near-mistakes-using-root-cause-analysis-risk-management-tool

June 19, 2024 - Commentary Learning from mistakes and near mistakes: using root cause analysis as a risk management tool. Citation Text: Cerniglia-Lowensen J. Learning From Mistakes and Near Mistakes: Using Root Cause Analysis as a Risk Management Tool. J Radiol Nurs. 2015;34(1). doi:10.1016/j.jradnu.20…

Applying Toyota Production System principles to a psychiatric hospital: making transfers safer and more timely. | PSNet

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January 27, 2016 - Study Applying Toyota Production System principles to a psychiatric hospital: making transfers safer and more timely. Citation Text: Young JQ, Wachter R. Applying Toyota Production System principles to a psychiatric hospital: making transfers safer and more timely. Jt Comm J Qual Patient…

Intensive care units, communication between nurses and physicians, and patients' outcomes. | PSNet

psnet.ahrq.gov/issue/intensive-care-units-communication-between-nurses-and-physicians-and-patients-outcomes

May 28, 2008 - Study Intensive care units, communication between nurses and physicians, and patients' outcomes. Citation Text: Manojlovich M, Antonakos CL, Ronis DL. Intensive care units, communication between nurses and physicians, and patients' outcomes. Am J Crit Care. 2009;18(1):21-30. doi:10.403…

A systemwide strategy to embed equity into patient safety event analysis. | PSNet

psnet.ahrq.gov/issue/systemwide-strategy-embed-equity-patient-safety-event-analysis

November 16, 2022 - Study A systemwide strategy to embed equity into patient safety event analysis. Citation Text: Chandra K, Garcia M, Bajaj K, et al. A systemwide strategy to embed equity into patient safety event analysis. Jt Comm J Qual Patient Saf. 2024;50(8):606-611 . doi:10.1016/j.jcjq.2024.04.004. …

An ethnography of parents' perceptions of patient safety in the neonatal intensive care unit. | PSNet

psnet.ahrq.gov/issue/ethnography-parents-perceptions-patient-safety-neonatal-intensive-care-unit

September 01, 2018 - Study An ethnography of parents' perceptions of patient safety in the neonatal intensive care unit. Citation Text: Ottosen MJ, Engebretson J, Etchegaray J, et al. An Ethnography of Parents' Perceptions of Patient Safety in the Neonatal Intensive Care Unit. Adv Neonatal Care. 2019;19(6):5…

Avoiding a second wave of medical errors: the importance of human factors in the context of a pandemic. | PSNet

psnet.ahrq.gov/issue/avoiding-second-wave-medical-errors-importance-human-factors-context-pandemic

March 09, 2022 - Commentary Avoiding a second wave of medical errors: the importance of human factors in the context of a pandemic. Citation Text: Tejos R, Navia A, Cuadra A, et al. Avoiding a second wave of medical errors: the importance of human factors in the context of a pandemic. Aesthetic Plast Sur…

Creating a Pediatric Joint Council to promote patient safety and quality, governance, and accountability across Johns Hopkins Medicine. | PSNet

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January 29, 2015 - Commentary Creating a Pediatric Joint Council to promote patient safety and quality, governance, and accountability across Johns Hopkins Medicine. Citation Text: Rosen MA, Mueller BU, Milstone AM, et al. Creating a Pediatric Joint Council to Promote Patient Safety and Quality, Governance…

Potassium and phosphorus repletion in hospitalized patients: implications for clinical practice and the potential use of healthcare information technology to improve prescribing and patient safety. | PSNet

psnet.ahrq.gov/issue/potassium-and-phosphorus-repletion-hospitalized-patients-implications-clinical-practice-and

May 09, 2014 - Study Potassium and phosphorus repletion in hospitalized patients: implications for clinical practice and the potential use of healthcare information technology to improve prescribing and patient safety. Citation Text: Hemstreet BA, Stolpman N, Badesch DB, et al. Potassium and phosphor…

Successful remediation of patient safety incidents: a tale of two medication errors. | PSNet

psnet.ahrq.gov/issue/successful-remediation-patient-safety-incidents-tale-two-medication-errors

January 26, 2022 - Commentary Successful remediation of patient safety incidents: a tale of two medication errors. Citation Text: Helmchen LA, Richards MR, McDonald TB. Successful remediation of patient safety incidents: a tale of two medication errors. Health Care Manage Rev. 2011;36(2):114-123. doi:10.10…

Psychometric properties of the Hospital Survey on Patient Safety Culture: findings from the UK. | PSNet

psnet.ahrq.gov/issue/psychometric-properties-hospital-survey-patient-safety-culture-findings-uk

March 22, 2023 - Study Psychometric properties of the Hospital Survey on Patient Safety Culture: findings from the UK. Citation Text: Waterson P, Griffiths P, Stride C, et al. Psychometric properties of the Hospital Survey on Patient Safety Culture: findings from the UK. Qual Saf Health Care. 2010;19(5…

Critical incidents related to cardiac arrests reported to the Danish Patient Safety Database. | PSNet

psnet.ahrq.gov/issue/critical-incidents-related-cardiac-arrests-reported-danish-patient-safety-database

February 18, 2015 - Study Critical incidents related to cardiac arrests reported to the Danish Patient Safety Database. Citation Text: Andersen PO, Maaløe R, Andersen HB. Critical incidents related to cardiac arrests reported to the Danish Patient Safety Database. Resuscitation. 2010;81(3):312-316. doi:10.…

Learning from accident and error: avoiding the hazards of workload, stress, and routine interruptions in the emergency department. | PSNet

psnet.ahrq.gov/issue/learning-accident-and-error-avoiding-hazards-workload-stress-and-routine-interruptions

September 27, 2023 - Commentary Learning from accident and error: avoiding the hazards of workload, stress, and routine interruptions in the emergency department. Citation Text: Morrison B, Rudolph JW. Learning from accident and error: avoiding the hazards of workload, stress, and routine interruptions in th…

Toward the development of the perfect medical team: critical components for adaptation. | PSNet

psnet.ahrq.gov/issue/toward-development-perfect-medical-team-critical-components-adaptation

February 09, 2022 - Review Emerging Classic Toward the development of the perfect medical team: critical components for adaptation. Citation Text: Gregory ME, Hughes AM, Benishek LE, et al. Toward the development of the perfect medical team: critical components for adaptation. J Pa…

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