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The Preventable Harm Index: an effective motivator to facilitate the drive to zero. | PSNet

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January 15, 2014 - Commentary The Preventable Harm Index: an effective motivator to facilitate the drive to zero. Citation Text: Brilli RJ, McClead RE, Davis T, et al. The Preventable Harm Index: an effective motivator to facilitate the drive to zero. J Pediatr. 2010;157(4):681-3. doi:10.1016/j.jpeds.201…

Diagnostic errors and temporal stability in bipolar disorder. | PSNet

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March 09, 2022 - Study Diagnostic errors and temporal stability in bipolar disorder. Citation Text: López J, Baca E, Botillo C, et al. [Diagnostic errors and temporal stability in bipolar disorder]. Actas Esp Psiquiatr. 2008;36(4):205-9. Copy Citation Format: Google Scholar PubMed BibTeX …

Enhancing patient safety and resident education during the academic year-end transfer of outpatients: lessons from the suicide of a psychiatric patient. | PSNet

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March 25, 2017 - Commentary Enhancing patient safety and resident education during the academic year-end transfer of outpatients: lessons from the suicide of a psychiatric patient. Citation Text: Young JQ, Eisendrath SJ. Enhancing patient safety and resident education during the academic year-end trans…

"No-go considerations" for in situ simulation safety. | PSNet

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April 14, 2021 - Commentary Emerging Classic "No-go considerations" for in situ simulation safety. Citation Text: Bajaj K, Minors A, Walker K, et al. "No-Go Considerations" for In Situ Simulation Safety. Simul Healthc. 2018;13(3):221-224. doi:10.1097/SIH.0000000000000301. Copy…

Evidence for anchoring bias during physician decision-making. | PSNet

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November 17, 2021 - Study Evidence for anchoring bias during physician decision-making. Citation Text: Ly DP, Shekelle PG, Song Z. Evidence for anchoring bias during physician decision-making. JAMA Intern Med. 2023;183(8):818-823. doi:10.1001/jamainternmed.2023.2366. Copy Citation Format: DOI …

Utilizing quality improvement methods to prevent falls and injury from falls: enhancing resident safety in long-term care. | PSNet

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September 01, 2021 - Commentary Utilizing quality improvement methods to prevent falls and injury from falls: enhancing resident safety in long-term care. Citation Text: MacLaurin A, McConnell H. Utilizing quality improvement methods to prevent falls and injury from falls: enhancing resident safety in long…

Error codes at autopsy to study potential biases in diagnostic error. | PSNet

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November 30, 2012 - Study Error codes at autopsy to study potential biases in diagnostic error. Citation Text: Goldman BI, Bharadwaj R, Fuller M, et al. Error codes at autopsy to study potential biases in diagnostic error. Diagnosis (Berl). 2023;10(4):375-382. doi:10.1515/dx-2023-0010. Copy Citation F…

Application of an engineering problem-solving methodology to address persistent problems in patient safety: a case study on retained surgical sponges after surgery. | PSNet

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March 18, 2020 - Study Application of an engineering problem-solving methodology to address persistent problems in patient safety: a case study on retained surgical sponges after surgery. Citation Text: Anderson DE, Watts B. Application of an engineering problem-solving methodology to address persistent…

Association between opioid prescribing patterns and abuse in ophthalmology. | PSNet

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April 12, 2019 - Study Association between opioid prescribing patterns and abuse in ophthalmology. Citation Text: Patel S, Sternberg P. Association Between Opioid Prescribing Patterns and Abuse in Ophthalmology. JAMA Ophthalmol. 2017;135(11):1216-1220. doi:10.1001/jamaophthalmol.2017.4055. Copy Citatio…

Hospital and procedure incidence of pediatric retained surgical items. | PSNet

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December 02, 2020 - Study Hospital and procedure incidence of pediatric retained surgical items. Citation Text: Wang B, Tashiro J, Perez EA, et al. Hospital and procedure incidence of pediatric retained surgical items. J Surg Res. 2015;198(2):400-5. doi:10.1016/j.jss.2015.03.054. Copy Citation Format:…

Longitudinal evaluation of a programme for safety culture change in a mental health service. | PSNet

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January 24, 2018 - Study Longitudinal evaluation of a programme for safety culture change in a mental health service. Citation Text: Dickens GL, Salamonson Y, Johnson A, et al. Longitudinal evaluation of a programme for safety culture change in a mental health service. J Nurs Manag. 2021;29(4):690-698. doi…

Copy, paste, and cloned notes in electronic health records: prevalence, benefits, risks, and best practice recommendations. | PSNet

psnet.ahrq.gov/issue/copy-paste-and-cloned-notes-electronic-health-records-prevalence-benefits-risks-and-best

October 19, 2022 - Review Copy, paste, and cloned notes in electronic health records: prevalence, benefits, risks, and best practice recommendations. Citation Text: Weis JM, Levy PC. Copy, paste, and cloned notes in electronic health records: prevalence, benefits, risks, and best practice recommendations. …

Project BOOST: effectiveness of a multihospital effort to reduce rehospitalization. | PSNet

psnet.ahrq.gov/issue/project-boost-effectiveness-multihospital-effort-reduce-rehospitalization

September 10, 2014 - Study Project BOOST: effectiveness of a multihospital effort to reduce rehospitalization. Citation Text: Hansen LO, Greenwald JL, Budnitz T, et al. Project BOOST: effectiveness of a multihospital effort to reduce rehospitalization. J Hosp Med. 2013;8(8):421-7. doi:10.1002/jhm.2054. Co…

Severe hypertension in pregnancy: progress made and future directions for patient safety, quality improvement, and implementation of a patient safety bundle. | PSNet

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October 23, 2024 - Commentary Severe hypertension in pregnancy: progress made and future directions for patient safety, quality improvement, and implementation of a patient safety bundle. Citation Text: Prior A, Taylor I, Gibson KS, et al. Severe hypertension in pregnancy: progress made and future directio…

Hospital commitments to address diagnostic errors: an assessment of 95 US hospitals. | PSNet

psnet.ahrq.gov/issue/hospital-commitments-address-diagnostic-errors-assessment-95-us-hospitals

September 18, 2024 - Study Hospital commitments to address diagnostic errors: an assessment of 95 US hospitals. Citation Text: Campione Russo A, Tilly J‐L, Kaufman L, et al. Hospital commitments to address diagnostic errors: an assessment of 95 US hospitals. J Hosp Med. 2025;20(2):120-134. doi:10.1002/jhm.13…

Impact of interruptions, distractions, and cognitive load on procedure failures and medication administration errors. | PSNet

psnet.ahrq.gov/issue/impact-interruptions-distractions-and-cognitive-load-procedure-failures-and-medication

March 02, 2012 - Study Impact of interruptions, distractions, and cognitive load on procedure failures and medication administration errors. Citation Text: Thomas L, Donohue-Porter P, Fishbein JS. Impact of Interruptions, Distractions, and Cognitive Load on Procedure Failures and Medication Administratio…

A customized triggers program: a children's hospital's experience in improving trigger usability. | PSNet

psnet.ahrq.gov/issue/customized-triggers-program-childrens-hospitals-experience-improving-trigger-usability

September 01, 2021 - Study A customized triggers program: a children's hospital's experience in improving trigger usability. Citation Text: Reinhart RM, Safari-Ferra P, Badh R, et al. A customized triggers program: a children's hospital's experience in improving trigger usability. Pediatrics. 2023;151(2):e20…

Insufficient communication about medication use at the interface between hospital and primary care. | PSNet

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February 03, 2021 - Study Insufficient communication about medication use at the interface between hospital and primary care. Citation Text: Glintborg B, Andersen SE, Dalhoff K. Insufficient communication about medication use at the interface between hospital and primary care. Qual Saf Health Care. 2007;1…

Adopting National Quality Forum medication safe practices: progress and barriers to hospital implementation. | PSNet

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December 16, 2011 - Study Adopting National Quality Forum medication safe practices: progress and barriers to hospital implementation. Citation Text: Rask KJ, Culler SD, Scott T, et al. Adopting National Quality Forum medication safe practices: Progress and barriers to hospital implementation. J Hosp Med.…

Has the Leapfrog Group had an impact on the health care market? | PSNet

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November 13, 2024 - Commentary Has the Leapfrog Group had an impact on the health care market? Citation Text: Galvin RS, Delbanco S, Milstein A, et al. Has the leapfrog group had an impact on the health care market? Health Aff (Millwood). 2005;24(1):228-33. Copy Citation Format: Google Schola…

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