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The problem with preventable deaths. | PSNet

psnet.ahrq.gov/issue/problem-preventable-deaths

July 24, 2024 - Commentary The problem with preventable deaths. Citation Text: Hogan H. The problem with preventable deaths. BMJ Qual Saf. 2016;25(5):320-3. doi:10.1136/bmjqs-2015-004983. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pub…

Exploring the role of salient distracting clinical features in the emergence of diagnostic errors and the mechanisms through which reflection counteracts mistakes. | PSNet

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July 03, 2014 - Study Exploring the role of salient distracting clinical features in the emergence of diagnostic errors and the mechanisms through which reflection counteracts mistakes. Citation Text: Mamede S, Splinter TAW, Van Gog T, et al. Exploring the role of salient distracting clinical features…

Hidden flaws behind expert-level accuracy of multimodal GPT-4 vision in medicine. | PSNet

psnet.ahrq.gov/issue/hidden-flaws-behind-expert-level-accuracy-multimodal-gpt-4-vision-medicine

March 24, 2019 - Study Hidden flaws behind expert-level accuracy of multimodal GPT-4 vision in medicine. Citation Text: Jin Q, Chen F, Zhou Y, et al. Hidden flaws behind expert-level accuracy of multimodal GPT-4 vision in medicine. NPJ Dig Med. 2024;7(1):190. doi:10.1038/s41746-024-01185-7. Copy Citati…

Collaboration between pharmacists, physicians and nurse practitioners: a qualitative investigation of working relationships in the inpatient medical setting. | PSNet

psnet.ahrq.gov/issue/collaboration-between-pharmacists-physicians-and-nurse-practitioners-qualitative

November 16, 2022 - Study Collaboration between pharmacists, physicians and nurse practitioners: a qualitative investigation of working relationships in the inpatient medical setting. Citation Text: Makowsky MJ, Schindel TJ, Rosenthal M, et al. Collaboration between pharmacists, physicians and nurse pract…

An overview of intravenous-related medication administration errors as reported to MEDMARX(R), a national medication error-reporting program. | PSNet

psnet.ahrq.gov/issue/overview-intravenous-related-medication-administration-errors-reported-medmarxr-national

April 14, 2021 - Study An overview of intravenous-related medication administration errors as reported to MEDMARX(R), a national medication error-reporting program. Citation Text: Hicks RW, Becker SC. An overview of intravenous-related medication administration errors as reported to MEDMARX, a national…

Lessons learned from implementing a principled approach to resolution following patient harm. | PSNet

psnet.ahrq.gov/issue/lessons-learned-implementing-principled-approach-resolution-following-patient-harm

February 12, 2020 - Commentary Lessons learned from implementing a principled approach to resolution following patient harm. Citation Text: Smith KM, Smith LL, (Jack) Gentry JC, et al. Lessons learned from implementing a principled approach to resolution following patient harm. J Patient Saf Risk Manag. 201…

After Mid Staffordshire: from acknowledgement, through learning, to improvement. | PSNet

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August 28, 2024 - Special or Theme Issue After Mid Staffordshire: from acknowledgement, through learning, to improvement. Citation Text: Martin G, Dixon-Woods M. After Mid Staffordshire: from acknowledgement, through learning, to improvement. BMJ Qual Saf. 2014;23(9):706-8. doi:10.1136/bmjqs-2014-003359. …

An adverse event screening tool based on routinely collected hospital-acquired diagnoses. | PSNet

psnet.ahrq.gov/issue/adverse-event-screening-tool-based-routinely-collected-hospital-acquired-diagnoses

July 23, 2008 - Study An adverse event screening tool based on routinely collected hospital-acquired diagnoses. Citation Text: Brand CA, Tropea J, Gorelik A, et al. An adverse event screening tool based on routinely collected hospital-acquired diagnoses. Int J Qual Health Care. 2012;24(3):266-78. doi:10…

Feasibility of centre-based incident reporting in primary healthcare: the SPIEGEL study. | PSNet

psnet.ahrq.gov/issue/feasibility-centre-based-incident-reporting-primary-healthcare-spiegel-study

October 05, 2011 - Study Feasibility of centre-based incident reporting in primary healthcare: the SPIEGEL study. Citation Text: Zwart DLM, Steerneman AHM, van Rensen ELJ, et al. Feasibility of centre-based incident reporting in primary healthcare: the SPIEGEL study. BMJ Qual Saf. 2011;20(2):121-7. doi:1…

Addressing the opioid epidemic in the United States: lessons from the Department of Veterans Affairs. | PSNet

psnet.ahrq.gov/issue/addressing-opioid-epidemic-united-states-lessons-department-veterans-affairs

September 07, 2022 - Commentary Classic Addressing the opioid epidemic in the United States: lessons from the Department of Veterans Affairs. Citation Text: Gellad WF, Good CB, Shulkin DJ. Addressing the Opioid Epidemic in the United States: Lessons From the Department of Veterans A…

Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. | PSNet

psnet.ahrq.gov/issue/executive-leadership-and-physician-well-being-nine-organizational-strategies-promote

September 26, 2018 - Review Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Citation Text: Shanafelt TD, Noseworthy JH. Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnou…

AI: promise or peril for patient safety. | PSNet

psnet.ahrq.gov/issue/ai-promise-or-peril-patient-safety

July 20, 2022 - Commentary AI: promise or peril for patient safety. Citation Text: Ullem BD, Hatlie MJ, Lounsbury O. AI: promise or peril for patient safety. J Patient Saf. 2025;21(1):34-37. doi:10.1097/pts.0000000000001301. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML En…

Using incident reporting to improve patient safety: a conceptual model. | PSNet

psnet.ahrq.gov/issue/using-incident-reporting-improve-patient-safety-conceptual-model

June 29, 2009 - Commentary Using incident reporting to improve patient safety: a conceptual model. Citation Text: Pronovost PJ, Holzmueller CG, Young J, et al. Using Incident Reporting to Improve Patient Safety. J Patient Saf. 2008;3(1). doi:10.1097/pts.0b013e318030ca05. Copy Citation Format: …

Deficiencies in the Veterans Crisis Line Response to a Veteran Caller Who Died. | PSNet

psnet.ahrq.gov/issue/deficiencies-veterans-crisis-line-response-veteran-caller-who-died

September 30, 2020 - Book/Report Deficiencies in the Veterans Crisis Line Response to a Veteran Caller Who Died. Citation Text: Deficiencies in the Veterans Crisis Line Response to a Veteran Caller Who Died. Washington, DC: Department of Veterans Affairs, Office of Inspector General; November 17, 2020. Repor…

VHA's movement for change: implementing high-reliability principles and practices. | PSNet

psnet.ahrq.gov/issue/vhas-movement-change-implementing-high-reliability-principles-and-practices

August 21, 2024 - Commentary VHA's movement for change: implementing high-reliability principles and practices. Citation Text: Cox GR, Starr LM. VHA's movement for change: implementing high-reliability principles and practices. J Healthc Manag. 2023;68(3):151-157. doi:10.1097/jhm-d-23-00056. Copy Citati…

An integrative review of the current evidence on the relationship between hand hygiene interventions and the incidence of health care-associated infections. | PSNet

psnet.ahrq.gov/issue/integrative-review-current-evidence-relationship-between-hand-hygiene-interventions-and

February 22, 2023 - Review An integrative review of the current evidence on the relationship between hand hygiene interventions and the incidence of health care-associated infections. Citation Text: Backman C, Zoutman DE, Marck PB. An integrative review of the current evidence on the relationship between h…

An initiative to improve the management of clinically significant test results in a large health care network. | PSNet

psnet.ahrq.gov/issue/initiative-improve-management-clinically-significant-test-results-large-health-care-network

November 26, 2014 - Study An initiative to improve the management of clinically significant test results in a large health care network. Citation Text: Roy CL, Rothschild JM, Dighe AS, et al. An initiative to improve the management of clinically significant test results in a large health care network. Jt …

Diagnostic errors in the neonatal intensive care unit: state of the science and new directions. | PSNet

psnet.ahrq.gov/issue/diagnostic-errors-neonatal-intensive-care-unit-state-science-and-new-directions

March 23, 2022 - Review Diagnostic errors in the neonatal intensive care unit: state of the science and new directions. Citation Text: Shafer G, Singh H, Suresh G. Diagnostic errors in the neonatal intensive care unit: State of the science and new directions. Semin Perinatol. 2019;43(8):151175. doi:10.10…

A pilot study examining undesirable events among emergency department–boarded patients awaiting inpatient beds. | PSNet

psnet.ahrq.gov/issue/pilot-study-examining-undesirable-events-among-emergency-department-boarded-patients-awaiting

August 04, 2021 - Study A pilot study examining undesirable events among emergency department–boarded patients awaiting inpatient beds. Citation Text: Liu SW, Thomas SH, Gordon JA, et al. A pilot study examining undesirable events among emergency department-boarded patients awaiting inpatient beds. Ann E…

A novel process audit for standardized perioperative handoff protocols. | PSNet

psnet.ahrq.gov/issue/novel-process-audit-standardized-perioperative-handoff-protocols

June 27, 2018 - Commentary A novel process audit for standardized perioperative handoff protocols. Citation Text: Pallekonda V, Scholl AT, McKelvey GM, et al. A Novel Process Audit for Standardized Perioperative Handoff Protocols. Jt Comm J Qual Patient Saf. 2017;43(11):611-618. doi:10.1016/j.jcjq.2017.…

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