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Anatomy of an incident disclosure: the importance of dialogue. | PSNet

psnet.ahrq.gov/issue/anatomy-incident-disclosure-importance-dialogue

February 20, 2012 - Commentary Anatomy of an incident disclosure: the importance of dialogue. Citation Text: Iedema R, Allen S. Anatomy of an incident disclosure: the importance of dialogue. Jt Comm J Qual Patient Saf. 2012;38(10):435-42. Copy Citation Format: Google Scholar PubMed BibTeX En…

Patient errors in use of injectable antidiabetic medications: a need for improved clinic-based education. | PSNet

psnet.ahrq.gov/issue/patient-errors-use-injectable-antidiabetic-medications-need-improved-clinic-based-education

March 17, 2021 - Commentary Patient errors in use of injectable antidiabetic medications: a need for improved clinic-based education. Citation Text: Wei ET, Koh E, Kelly MS, et al. Patient errors in use of injectable antidiabetic medications: a need for improved clinic-based education. J Am Pharm Assoc (…

The impact of nursing work environments on patient safety outcomes: the mediating role of burnout engagement. | PSNet

psnet.ahrq.gov/issue/impact-nursing-work-environments-patient-safety-outcomes-mediating-role-burnout-engagement

July 23, 2010 - Study The impact of nursing work environments on patient safety outcomes: the mediating role of burnout engagement. Citation Text: Spence Laschinger HK, Leiter MP. The impact of nursing work environments on patient safety outcomes: the mediating role of burnout/engagement. J Nurs Adm. …

Risk factors for retained surgical items: a meta-analysis and proposed risk stratification system. | PSNet

psnet.ahrq.gov/issue/risk-factors-retained-surgical-items-meta-analysis-and-proposed-risk-stratification-system

January 18, 2013 - Study Risk factors for retained surgical items: a meta-analysis and proposed risk stratification system. Citation Text: Moffatt-Bruce SD, Cook CH, Steinberg SM, et al. Risk factors for retained surgical items: a meta-analysis and proposed risk stratification system. J Surg Res. 2014;190(…

Parents' perspectives on "keeping their children safe" in the hospital. | PSNet

psnet.ahrq.gov/issue/parents-perspectives-keeping-their-children-safe-hospital

June 27, 2018 - Study Parents' perspectives on "keeping their children safe" in the hospital. Citation Text: Rosenberg RE, Rosenfeld P, Williams E, et al. Parents' Perspectives on "Keeping Their Children Safe" in the Hospital. J Nurs Care Qual. 2016;31(4):318-326. doi:10.1097/NCQ.0000000000000193. Cop…

Design and trial of a new ambulance-to-emergency department handover protocol: 'IMIST-AMBO.' | PSNet

psnet.ahrq.gov/issue/design-and-trial-new-ambulance-emergency-department-handover-protocol-imist-ambo

March 14, 2022 - Study Design and trial of a new ambulance-to-emergency department handover protocol: 'IMIST-AMBO.' Citation Text: Iedema R, Ball C, Daly B, et al. Design and trial of a new ambulance-to-emergency department handover protocol: 'IMIST-AMBO'. BMJ Qual Saf. 2012;21(8):627-33. doi:10.1136/b…

Ten years of incident reports on in-hospital cardiac arrest - Are they useful for improvements? | PSNet

psnet.ahrq.gov/issue/ten-years-incident-reports-hospital-cardiac-arrest-are-they-useful-improvements

January 26, 2022 - Study Ten years of incident reports on in-hospital cardiac arrest - Are they useful for improvements? Citation Text: Djärv T. Ten years of incident reports on in-hospital cardiac arrest – Are they useful for improvements? Resusc Plus. 2023;17:100525. doi:10.1016/j.resplu.2023.100525. C…

Multidisciplinary medication review in nursing home residents: what are the most significant drug-related problems? The Bergen District Nursing Home (BEDNURS) study. | PSNet

psnet.ahrq.gov/issue/multidisciplinary-medication-review-nursing-home-residents-what-are-most-significant-drug

August 04, 2021 - Study Multidisciplinary medication review in nursing home residents: what are the most significant drug-related problems? The Bergen District Nursing Home (BEDNURS) study. Citation Text: Ruths S, Straand J, Nygaard HA. Multidisciplinary medication review in nursing home residents: what…

Human-simulation-based learning to prevent medication error: a systematic review. | PSNet

psnet.ahrq.gov/issue/human-simulation-based-learning-prevent-medication-error-systematic-review

February 01, 2012 - Review Human-simulation-based learning to prevent medication error: a systematic review. Citation Text: Sarfati L, Ranchon F, Vantard N, et al. Human-simulation-based learning to prevent medication error: A systematic review. J Eval Clin Pract. 2019;25(1):11-20. doi:10.1111/jep.12883. …

VA Health Care: Improvements Needed in Processes Used to Address Providers' Actions That Contribute to Adverse Events. | PSNet

psnet.ahrq.gov/issue/va-health-care-improvements-needed-processes-used-address-providers-actions-contribute

October 12, 2022 - Book/Report VA Health Care: Improvements Needed in Processes Used to Address Providers' Actions That Contribute to Adverse Events. Citation Text: VA Health Care: Improvements Needed in Processes Used to Address Providers' Actions That Contribute to Adverse Events. Draper D. Washington,…

The compliance with a patient safety bundle for management of placenta accreta spectrum. | PSNet

psnet.ahrq.gov/issue/compliance-patient-safety-bundle-management-placenta-accreta-spectrum

October 19, 2022 - Study The compliance with a patient safety bundle for management of placenta accreta spectrum. Citation Text: Quist-Nelson J, Crank A, Oliver EA, et al. The compliance with a patient-safety bundle for management of placenta accreta spectrum†. J Matern Fetal Neonatal Med. 2021;34(17):2880…

Understanding unwarranted variation in clinical practice: a focus on network effects, reflective medicine and learning health systems. | PSNet

psnet.ahrq.gov/issue/understanding-unwarranted-variation-clinical-practice-focus-network-effects-reflective

March 31, 2021 - Commentary Understanding unwarranted variation in clinical practice: a focus on network effects, reflective medicine and learning health systems. Citation Text: Atsma F, Elwyn G, Westert GP. Understanding unwarranted variation in clinical practice: a focus on network effects, reflective …

Implementation of a preoperative briefing protocol improves accuracy of teamwork assessment in the operating room. | PSNet

psnet.ahrq.gov/issue/implementation-preoperative-briefing-protocol-improves-accuracy-teamwork-assessment-operating

February 25, 2009 - Study Implementation of a preoperative briefing protocol improves accuracy of teamwork assessment in the operating room. Citation Text: Paige JT, Aaron DL, Yang T, et al. Implementation of a preoperative briefing protocol improves accuracy of teamwork assessment in the operating room. …

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.…

The FIRST curriculum: cultivating speaking up behaviors in the Clinical Learning Environment. | PSNet

psnet.ahrq.gov/issue/first-curriculum-cultivating-speaking-behaviors-clinical-learning-environment

May 25, 2022 - Commentary The FIRST curriculum: cultivating speaking up behaviors in the Clinical Learning Environment. Citation Text: Best JA, Kim S. The FIRST Curriculum: Cultivating Speaking Up Behaviors in the Clinical Learning Environment. J Contin Educ Nurs. 2019;50(8):355-361. doi:10.3928/002201…

Managing near-miss reporting in hospitals: the dynamics between staff members’ willingness to report and management’s handling of near-miss events. | PSNet

psnet.ahrq.gov/issue/managing-near-miss-reporting-hospitals-dynamics-between-staff-members-willingness-report-and

March 30, 2016 - Study Managing near-miss reporting in hospitals: the dynamics between staff members’ willingness to report and management’s handling of near-miss events. Citation Text: Caspi H, Perlman Y, Westreich S. Managing near-miss reporting in hospitals: the dynamics between staff members’ willing…

Effect of a multifaceted clinical pharmacist intervention on medication safety after hospitalization in persons prescribed high-risk medications: a randomized clinical trial. | PSNet

psnet.ahrq.gov/issue/effect-multifaceted-clinical-pharmacist-intervention-medication-safety-after-hospitalization

April 28, 2021 - Study Emerging Classic Effect of a multifaceted clinical pharmacist intervention on medication safety after hospitalization in persons prescribed high-risk medications: a randomized clinical trial. Citation Text: Gurwitz JH, Kapoor A, Garber L, et al. Effect of …

In-hospital mortality associated with the misdiagnosis or unidentified site of infection at admission. | PSNet

psnet.ahrq.gov/issue/hospital-mortality-associated-misdiagnosis-or-unidentified-site-infection-admission

June 27, 2011 - Review In-hospital mortality associated with the misdiagnosis or unidentified site of infection at admission. Citation Text: Abe T, Tokuda Y, Shiraishi A, et al. In-hospital mortality associated with the misdiagnosis or unidentified site of infection at admission. Crit Care. 2019;23(1):2…

Diagnostic error in stroke — reasons and proposed solutions. | PSNet

psnet.ahrq.gov/issue/diagnostic-error-stroke-reasons-and-proposed-solutions

March 01, 2023 - Review Diagnostic error in stroke — reasons and proposed solutions. Citation Text: Bakradze E, Liberman AL. Diagnostic Error in Stroke-Reasons and Proposed Solutions. Curr Atheroscler Rep. 2018;20(2):11. doi:10.1007/s11883-018-0712-3. Copy Citation Format: DOI Google Schola…

Developing and evaluating clinical leadership interventions for frontline healthcare providers: a review of the literature. | PSNet

psnet.ahrq.gov/issue/developing-and-evaluating-clinical-leadership-interventions-frontline-healthcare-providers

May 01, 2024 - Review Emerging Classic Developing and evaluating clinical leadership interventions for frontline healthcare providers: a review of the literature. Citation Text: Mianda S, Voce A. Developing and evaluating clinical leadership interventions for frontline healthc…

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