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Hidden health IT hazards: a qualitative analysis of clinically meaningful documentation discrepancies at transfer out of the pediatric intensive care unit. | PSNet

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January 15, 2020 - Study Hidden health IT hazards: a qualitative analysis of clinically meaningful documentation discrepancies at transfer out of the pediatric intensive care unit. Citation Text: Hidden health IT hazards: a qualitative analysis of clinically meaningful documentation discrepancies at transf…

Emergency department monitor alarms rarely change clinical management: an observational study. | PSNet

psnet.ahrq.gov/issue/emergency-department-monitor-alarms-rarely-change-clinical-management-observational-study

September 30, 2020 - Study Emergency department monitor alarms rarely change clinical management: an observational study. Citation Text: Fleischman W, Ciliberto B, Rozanski N, et al. Emergency department monitor alarms rarely change clinical management: an observational study. Am J Emerg Med. 2020;38(6):1072…

Identification and characterization of failures in infectious agent transmission precaution practices in hospitals: a qualitative study. | PSNet

psnet.ahrq.gov/issue/identification-and-characterization-failures-infectious-agent-transmission-precaution

October 13, 2018 - Study Emerging Classic Identification and characterization of failures in infectious agent transmission precaution practices in hospitals: a qualitative study. Citation Text: Krein SL, Mayer J, Harrod M, et al. Identification and Characterization of Failures in …

Radiologists make more errors interpreting off-hours body CT studies during overnight assignments as compared with daytime assignments. | PSNet

psnet.ahrq.gov/issue/radiologists-make-more-errors-interpreting-hours-body-ct-studies-during-overnight-assignments

November 16, 2022 - Study Radiologists make more errors interpreting off-hours body CT studies during overnight assignments as compared with daytime assignments. Citation Text: Patel AG, Pizzitola VJ, Johnson CD, et al. Radiologists Make More Errors Interpreting Off-Hours Body CT Studies during Overnight As…

Parents' perspective on safety in neonatal intensive care: a mixed-methods study. | PSNet

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November 08, 2017 - Study Parents' perspective on safety in neonatal intensive care: a mixed-methods study. Citation Text: Lyndon A, Jacobson CH, Fagan KM, et al. Parents' perspectives on safety in neonatal intensive care: a mixed-methods study. BMJ Qual Saf. 2014;23(11):902-9. doi:10.1136/bmjqs-2014-003009…

The impact of rapid response team on outcome of patients transferred from the ward to the ICU: a single-center study. | PSNet

psnet.ahrq.gov/issue/impact-rapid-response-team-outcome-patients-transferred-ward-icu-single-center-study

May 27, 2011 - Study The impact of rapid response team on outcome of patients transferred from the ward to the ICU: a single-center study. Citation Text: Karpman C, Keegan MT, Jensen J, et al. The impact of rapid response team on outcome of patients transferred from the ward to the ICU: a single-cent…

US emergency department visits attributed to medication harms, 2017-2019. | PSNet

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December 15, 2021 - Study US emergency department visits attributed to medication harms, 2017-2019. Citation Text: Budnitz DS, Shehab N, Lovegrove MC, et al. US emergency department visits attributed to medication harms, 2017-2019. JAMA. 2021;326(13):1299. doi:10.1001/jama.2021.13844. Copy Citation Fo…

Association of hospital participation in a regional trauma quality improvement collaborative with patient outcomes. | PSNet

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August 20, 2018 - Study Association of hospital participation in a regional trauma quality improvement collaborative with patient outcomes. Citation Text: Hemmila MR, Cain-Nielsen AH, Jakubus JL, et al. Association of Hospital Participation in a Regional Trauma Quality Improvement Collaborative With Patie…

National and local medication error reporting systems—a survey of practices in 16 countries. | PSNet

psnet.ahrq.gov/issue/national-and-local-medication-error-reporting-systems-survey-practices-16-countries

September 09, 2015 - Study National and local medication error reporting systems—a survey of practices in 16 countries. Citation Text: Holmström A-R, Airaksinen M, Weiss M, et al. National and local medication error reporting systems: a survey of practices in 16 countries. J Patient Saf. 2012;8(4):165-76. …

Vestibular syndromes, diagnosis and diagnostic errors in patients with dizziness presenting to the emergency department: a cross-sectional study. | PSNet

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May 17, 2023 - Study Vestibular syndromes, diagnosis and diagnostic errors in patients with dizziness presenting to the emergency department: a cross-sectional study. Citation Text: Comolli L, Korda A, Zamaro E, et al. Vestibular syndromes, diagnosis and diagnostic errors in patients with dizziness pre…

Consumer participation in early detection of the deteriorating patient and call activation to rapid response systems: a literature review. | PSNet

psnet.ahrq.gov/issue/consumer-participation-early-detection-deteriorating-patient-and-call-activation-rapid

February 28, 2024 - Review Consumer participation in early detection of the deteriorating patient and call activation to rapid response systems: a literature review. Citation Text: Vorwerk J, King L. Consumer participation in early detection of the deteriorating patient and call activation to rapid response…

Simulation-based assessment identifies longitudinal changes in cognitive skills in an anesthesiology residency training program. | PSNet

psnet.ahrq.gov/issue/simulation-based-assessment-identifies-longitudinal-changes-cognitive-skills-anesthesiology

August 11, 2021 - Study Simulation-based assessment identifies longitudinal changes in cognitive skills in an anesthesiology residency training program. Citation Text: Sidi A, Gravenstein N, Vasilopoulos T, et al. Simulation-based assessment identifies longitudinal changes in cognitive skills in an anesth…

Factors that drive team participation in surgical safety checks: a prospective study. | PSNet

psnet.ahrq.gov/issue/factors-drive-team-participation-surgical-safety-checks-prospective-study

August 15, 2018 - Study Factors that drive team participation in surgical safety checks: a prospective study. Citation Text: Gillespie BM, Withers TK, Lavin J, et al. Factors that drive team participation in surgical safety checks: a prospective study. Patient Saf Surg. 2016;10:3. doi:10.1186/s13037-015-0…

Handoff strategies in settings with high consequences for failure: lessons for health care operations. | PSNet

psnet.ahrq.gov/issue/handoff-strategies-settings-high-consequences-failure-lessons-health-care-operations

March 14, 2018 - Study Classic Handoff strategies in settings with high consequences for failure: lessons for health care operations. Citation Text: Patterson ES. Handoff strategies in settings with high consequences for failure: lessons for health care operations. Int J Qual …

What defines a high-performing health system: a systematic review. | PSNet

psnet.ahrq.gov/issue/what-defines-high-performing-health-system-systematic-review

August 17, 2022 - Review What defines a high-performing health system: a systematic review. Citation Text: Ahluwalia SC, Damberg CL, Silverman M, et al. What Defines a High-Performing Health Care Delivery System: A Systematic Review. Jt Comm J Qual Patient Saf. 2017;43(9):450-459. doi:10.1016/j.jcjq.2017.…

Where are my instruments? Hazards in delivery of surgical instruments. | PSNet

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September 25, 2008 - Study Where are my instruments? Hazards in delivery of surgical instruments. Citation Text: Guédon ACP, Wauben LSGL, van der Eijk AC, et al. Where are my instruments? Hazards in delivery of surgical instruments. Surg Endosc. 2016;30(7):2728-35. doi:10.1007/s00464-015-4537-7. Copy Citat…

Surgical leadership in a culture of safety: an inter-professional study of metrics and tools for improving clinical practice. | PSNet

psnet.ahrq.gov/issue/surgical-leadership-culture-safety-inter-professional-study-metrics-and-tools-improving

September 14, 2022 - Study Surgical leadership in a culture of safety: an inter-professional study of metrics and tools for improving clinical practice. Citation Text: Gogalniceanu P, Kunduzi B, Ruckley C, et al. Surgical leadership in a culture of safety: an inter-professional study of metrics and tools for…

Immersive high fidelity simulation of critically ill patients to study cognitive errors: a pilot study. | PSNet

psnet.ahrq.gov/issue/immersive-high-fidelity-simulation-critically-ill-patients-study-cognitive-errors-pilot-study

August 15, 2018 - Study Immersive high fidelity simulation of critically ill patients to study cognitive errors: a pilot study. Citation Text: Prakash S, Bihari S, Need P, et al. Immersive high fidelity simulation of critically ill patients to study cognitive errors: a pilot study. BMC Med Educ. 2017;17(1…

Quality measures for patients at risk of adverse outcomes in the Veterans Health Administration: expert panel recommendations. | PSNet

psnet.ahrq.gov/issue/quality-measures-patients-risk-adverse-outcomes-veterans-health-administration-expert-panel

June 22, 2022 - Commentary Quality measures for patients at risk of adverse outcomes in the Veterans Health Administration: expert panel recommendations. Citation Text: Chang ET, Newberry S, Rubenstein LV, et al. Quality Measures for Patients at Risk of Adverse Outcomes in the Veterans Health Administra…

Safety leadership: a meta-analytic review of transformational and transactional leadership styles as antecedents of safety behaviours. | PSNet

psnet.ahrq.gov/issue/safety-leadership-meta-analytic-review-transformational-and-transactional-leadership-styles

June 10, 2020 - Study Safety leadership: a meta-analytic review of transformational and transactional leadership styles as antecedents of safety behaviours. Citation Text: Clarke S. Safety leadership: A meta-analytic review of transformational and transactional leadership styles as antecedents of safet…

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