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Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes Prior to COVID-19 Pandemic. | PSNet

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April 29, 2020 - Book/Report Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes Prior to COVID-19 Pandemic. Citation Text: Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes Prior to COVID-19 Pandemic. Washington, DC: United States Government Accoun…

Characterization of prescribing errors in an internal medicine clinic. | PSNet

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March 04, 2011 - Study Characterization of prescribing errors in an internal medicine clinic. Citation Text: Devine EB, Wilson-Norton JL, Lawless NM, et al. Characterization of prescribing errors in an internal medicine clinic. Am J Health Syst Pharm. 2007;64(10):1062-70. Copy Citation Format: …

‘Ladder’-based safety culture assessments inversely predict safety outcomes. | PSNet

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January 22, 2025 - Commentary ‘Ladder’-based safety culture assessments inversely predict safety outcomes. Citation Text: Boskeljon‐Horst L, Sillem S, Dekker SWA. ‘Ladder’‐based safety culture assessments inversely predict safety outcomes. J Contingencies Crisis Manag. 2022;31(3):372-391. doi:10.1111/1468-…

Honest communication and social asymmetries inside a hospital: pitfalls for clinicians. | PSNet

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March 02, 2022 - Commentary Honest communication and social asymmetries inside a hospital: pitfalls for clinicians. Citation Text: Redelmeier DA, Etchells EE, Najeeb U. Honest communication and social asymmetries inside a hospital: pitfalls for clinicians. J Hosp Med. 2022;17(5):405-409. doi:10.1002/jhm.…

Identification and safe storage of look-alike, sound-alike medicines in automated dispensing cabinets. | PSNet

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June 23, 2009 - Study Identification and safe storage of look-alike, sound-alike medicines in automated dispensing cabinets. Citation Text: Ruutiainen HK, Kallio MM, Kuitunen SK. Identification and safe storage of look-alike, sound-alike medicines in automated dispensing cabinets. Eur J Hosp Pharm. 2021…

Learning from incidents in healthcare: the journey, not the arrival, matters. | PSNet

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June 12, 2024 - Commentary Learning from incidents in healthcare: the journey, not the arrival, matters. Citation Text: Leistikow I, Mulder S, Vesseur J, et al. Learning from incidents in healthcare: the journey, not the arrival, matters. BMJ Qual Saf. 2017;26(3):252-256. doi:10.1136/bmjqs-2015-004853. …

Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction. | PSNet

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March 14, 2022 - Study Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction. Citation Text: Salisbury AC, Reid KJ, Alexander KP, et al. Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction. Arch Intern Med…

Problems with health information technology and their effects on care delivery and patient outcomes: a systematic review. | PSNet

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February 14, 2024 - Review Problems with health information technology and their effects on care delivery and patient outcomes: a systematic review. Citation Text: Kim MO, Coiera E, Magrabi F. Problems with health information technology and their effects on care delivery and patient outcomes: a systematic r…

SAFER Care: improving caregiver comprehension of discharge instructions. | PSNet

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October 26, 2022 - Study SAFER Care: improving caregiver comprehension of discharge instructions. Citation Text: Uong A, Philips K, Hametz P, et al. SAFER care: improving caregiver comprehension of discharge instructions. Pediatrics. 2021;147(4):e20200031. doi:10.1542/peds.2020-0031. Copy Citation Fo…

Assessment of a safety enhancement to the hospital medication reconciliation process for elderly patients. | PSNet

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August 04, 2021 - Study Assessment of a safety enhancement to the hospital medication reconciliation process for elderly patients. Citation Text: Gizzi LA, Slain D, Hare JT, et al. Assessment of a safety enhancement to the hospital medication reconciliation process for elderly patients. Am J Geriatr Phar…

Exploring the impact of employee engagement and patient safety. | PSNet

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July 27, 2022 - Review Exploring the impact of employee engagement and patient safety. Citation Text: Scott G, Hogden A, Taylor R, et al. Exploring the impact of employee engagement and patient safety. Int J Qual Health Care. 2022;34(3):mzac059. doi:10.1093/intqhc/mzac059. Copy Citation Format: …

Reducing readmission at an academic medical center: results of a pharmacy-facilitated discharge counseling and medication reconciliation program. | PSNet

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August 04, 2021 - Study Reducing readmission at an academic medical center: results of a pharmacy-facilitated discharge counseling and medication reconciliation program. Citation Text: Zemaitis CT, Morris G, Cabie M, et al. Reducing Readmission at an Academic Medical Center: Results of a Pharmacy-Facilita…

Relationships among psychological safety, the principles of high reliability, and safety reporting intentions in pediatric nursing. | PSNet

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September 16, 2015 - Study Relationships among psychological safety, the principles of high reliability, and safety reporting intentions in pediatric nursing. Citation Text: Pfeifer L, Vessey J, Cazzell M, et al. Relationships among psychological safety, the principles of high reliability, and safety reporti…

ProvenCare: quality improvement model for designing highly reliable care in cardiac surgery. | PSNet

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February 09, 2011 - Study ProvenCare: quality improvement model for designing highly reliable care in cardiac surgery. Citation Text: Berry SA, Doll MC, McKinley KE, et al. ProvenCare: quality improvement model for designing highly reliable care in cardiac surgery. Qual Saf Health Care. 2009;18(5):360-8. d…

TeamSTEPPS: an evidence-based approach to reduce clinical errors threatening safety in outpatient settings: an integrative review. | PSNet

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November 18, 2009 - Review TeamSTEPPS: an evidence-based approach to reduce clinical errors threatening safety in outpatient settings: an integrative review. Citation Text: Parker AL, Forsythe LL, Kohlmorgen IK. TeamSTEPPS : An evidence-based approach to reduce clinical errors threatening safety in outpatie…

Hospitals as cultures of entrapment: a re-analysis of the Bristol Royal Infirmary. | PSNet

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May 21, 2019 - Commentary Classic Hospitals as cultures of entrapment: a re-analysis of the Bristol Royal Infirmary. Citation Text: Weick KE, Sutcliffe KM. Hospitals as Cultures of Entrapment: A Re-Analysis of the Bristol Royal Infirmary. Calif Manage Rev. 2012;45(2):73-84. do…

Safe chemotherapy administration: using failure mode and effects analysis in computerized prescriber order entry. | PSNet

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October 19, 2022 - Commentary Safe chemotherapy administration: using failure mode and effects analysis in computerized prescriber order entry. Citation Text: Kozakiewicz JM, Benis LJ, Fisher SM, et al. Safe chemotherapy administration: Using failure mode and effects analysis in computerized prescriber o…

The impact of power on health care team performance and patient safety: a review of the literature. | PSNet

psnet.ahrq.gov/issue/impact-power-health-care-team-performance-and-patient-safety-review-literature

February 01, 2023 - Review The impact of power on health care team performance and patient safety: a review of the literature. Citation Text: Stevens EL, Hulme A, Salmon PM. The impact of power on health care team performance and patient safety: a review of the literature. Ergonomics. 2021;64(8):1072-1090. …

Frequency and severity of parenteral nutrition medication errors at a large children's hospital after implementation of electronic ordering and compounding. | PSNet

psnet.ahrq.gov/issue/frequency-and-severity-parenteral-nutrition-medication-errors-large-childrens-hospital-after

April 11, 2011 - Study Frequency and severity of parenteral nutrition medication errors at a large children's hospital after implementation of electronic ordering and compounding. Citation Text: MacKay M, Anderson C, Boehme S, et al. Frequency and Severity of Parenteral Nutrition Medication Errors at a L…

Handoffs and teamwork: a framework for care transition communication. | PSNet

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September 28, 2022 - Commentary Handoffs and teamwork: a framework for care transition communication. Citation Text: Webster KLW, Keebler JR, Lazzara EH, et al. Handoffs and teamwork: a framework for care transition communication. Jt Comm Qual Patient Saf. 2022;48(6-7):343-353. doi:10.1016/j.jcjq.2022.04.001…

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