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Registered nurses' and medical doctors' experiences of patient safety in health information exchange during interorganizational care transitions: a qualitative review. | PSNet

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July 22, 2020 - Review Registered nurses' and medical doctors' experiences of patient safety in health information exchange during interorganizational care transitions: a qualitative review. Citation Text: Hyvämäki P, Kääriäinen M, Tuomikoski A-M, et al. Registered nurses' and medical doctors' experienc…

Clinical decision support alert malfunctions: analysis and empirically derived taxonomy. | PSNet

psnet.ahrq.gov/issue/clinical-decision-support-alert-malfunctions-analysis-and-empirically-derived-taxonomy

December 04, 2016 - Study Clinical decision support alert malfunctions: analysis and empirically derived taxonomy. Citation Text: Wright A, Ai A, Ash JS, et al. Clinical decision support alert malfunctions: analysis and empirically derived taxonomy. J Am Med Inform Assoc. 2018;25(5):496-506. doi:10.1093/jam…

Streamlining care in crisis: rapid creation and implementation of a digital support tool for COVID-19. | PSNet

psnet.ahrq.gov/issue/streamlining-care-crisis-rapid-creation-and-implementation-digital-support-tool-covid-19

October 21, 2020 - Commentary Streamlining care in crisis: rapid creation and implementation of a digital support tool for COVID-19. Citation Text: Stark N, Kerrissey M, Grade M, et al. Streamlining care in crisis: rapid creation and implementation of a digital support tool for COVID-19. West J Emerg Med. …

Using the Generic Analysis Method to analyze sentinel event reports across hospitals: a retrospective cross-sectional study. | PSNet

psnet.ahrq.gov/issue/using-generic-analysis-method-analyze-sentinel-event-reports-across-hospitals-retrospective

May 18, 2022 - Study Using the Generic Analysis Method to analyze sentinel event reports across hospitals: a retrospective cross-sectional study. Citation Text: Baartmans MC, van Schoten SM, Smit BJ, et al. Using the Generic Analysis Method to analyze sentinel event reports across hospitals: a retrospe…

Keeping patients at risk for self-harm safe in the emergency department: a protocolized approach. | PSNet

psnet.ahrq.gov/issue/keeping-patients-risk-self-harm-safe-emergency-department-protocolized-approach

December 02, 2020 - Study Keeping patients at risk for self-harm safe in the emergency department: a protocolized approach. Citation Text: Donovan AL, Aaronson EL, Black L, et al. Keeping patients at risk for self-harm safe in the emergency department: a protocolized approach. Jt Comm J Qual Patient Saf. 20…

Identifying health information technology usability issues contributing to medication errors across medication process stages. | PSNet

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November 03, 2021 - Study Identifying health information technology usability issues contributing to medication errors across medication process stages. Citation Text: Adams KT, Pruitt Z, Kazi S, et al. Identifying health information technology usability issues contributing to medication errors across medic…

A scoping review of real-time automated clinical deterioration alerts and evidence of impacts on hospitalised patient outcomes. | PSNet

psnet.ahrq.gov/issue/scoping-review-real-time-automated-clinical-deterioration-alerts-and-evidence-impacts

February 16, 2022 - Review A scoping review of real-time automated clinical deterioration alerts and evidence of impacts on hospitalised patient outcomes. Citation Text: Blythe R, Parsons R, White NM, et al. A scoping review of real-time automated clinical deterioration alerts and evidence of impacts on hos…

Human factors and ergonomics to improve performance in intensive care units during the COVID-19 pandemic. | PSNet

psnet.ahrq.gov/issue/human-factors-and-ergonomics-improve-performance-intensive-care-units-during-covid-19

December 23, 2020 - Commentary Human factors and ergonomics to improve performance in intensive care units during the COVID-19 pandemic. Citation Text: Della Torre V, E. Nacul F, Rosseel P, et al. Human factors and ergonomics to improve performance in intensive care units during the COVID-19 pandemic. Anaes…

Collaborative case review: a systems-based approach to patient safety event investigation and analysis. | PSNet

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May 04, 2022 - Study Collaborative case review: a systems-based approach to patient safety event investigation and analysis. Citation Text: Lacson R, Khorasani R, Fiumara K, et al. Collaborative case review: a systems-based approach to patient safety event investigation and analysis. J Patient Saf. 202…

Improving allergy documentation: a retrospective electronic health record system-wide patient safety initiative. | PSNet

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June 15, 2022 - Study Improving allergy documentation: a retrospective electronic health record system-wide patient safety initiative. Citation Text: Li L, Foer D, Hallisey RK, et al. Improving allergy documentation: a retrospective electronic health record system-wide patient safety initiative. J Patie…

Patient harm and institutional avoidability of out-of-hours discharge from intensive care: an analysis using mixed methods. | PSNet

psnet.ahrq.gov/issue/patient-harm-and-institutional-avoidability-out-hours-discharge-intensive-care-analysis-using

February 10, 2021 - Study Patient harm and institutional avoidability of out-of-hours discharge from intensive care: an analysis using mixed methods. Citation Text: Vollam S, Gustafson O, Morgan L, et al. Patient harm and institutional avoidability of out-of-hours discharge from intensive care: an analysis …

Unscheduled return visits to the emergency department with ICU admission: a trigger tool for diagnostic error. | PSNet

psnet.ahrq.gov/issue/unscheduled-return-visits-emergency-department-icu-admission-trigger-tool-diagnostic-error

December 02, 2020 - Study Unscheduled return visits to the emergency department with ICU admission: a trigger tool for diagnostic error. Citation Text: Aaronson E, Jansson P, Wittbold K, et al. Unscheduled return visits to the emergency department with ICU admission: A trigger tool for diagnostic error. Am …

A qualitative analysis of physician perspectives on missed and delayed outpatient diagnosis: the focus on system-related factors. | PSNet

psnet.ahrq.gov/issue/qualitative-analysis-physician-perspectives-missed-and-delayed-outpatient-diagnosis-focus

October 19, 2012 - Study A qualitative analysis of physician perspectives on missed and delayed outpatient diagnosis: the focus on system-related factors. Citation Text: Sarkar U, Simchowitz B, Bonacum D, et al. A Qualitative Analysis of Physician Perspectives on Missed and Delayed Outpatient Diagnosis: Th…

Racial disparities in preventable adverse events attributed to poor care coordination reported in a national study of older US adults. | PSNet

psnet.ahrq.gov/issue/racial-disparities-preventable-adverse-events-attributed-poor-care-coordination-reported

January 18, 2023 - Study Racial disparities in preventable adverse events attributed to poor care coordination reported in a national study of older US adults. Citation Text: Pinheiro LC, Reshetnyak E, Safford MM, et al. Racial disparities in preventable adverse events attributed to poor care coordination …

Talking about falls: a qualitative exploration of spoken communication of patients' fall risks in hospitals and implications for multifactorial approaches to fall prevention. | PSNet

psnet.ahrq.gov/issue/talking-about-falls-qualitative-exploration-spoken-communication-patients-fall-risks

July 20, 2022 - Study Talking about falls: a qualitative exploration of spoken communication of patients' fall risks in hospitals and implications for multifactorial approaches to fall prevention. Citation Text: McVey L, Alvarado N, Healey F, et al. Talking about falls: a qualitative exploration of spok…

Managing the prevention of retained surgical instruments: what is the value of counting? | PSNet

psnet.ahrq.gov/issue/managing-prevention-retained-surgical-instruments-what-value-counting

September 25, 2008 - Study Classic Managing the prevention of retained surgical instruments: what is the value of counting? Citation Text: Egorova NN, Moskowitz A, Gelijns A, et al. Managing the prevention of retained surgical instruments: what is the value of counting? Ann Surg. …

Diagnostic error among vulnerable populations presenting to the emergency department with cardiovascular and cerebrovascular or neurological symptoms: a systematic review. | PSNet

psnet.ahrq.gov/issue/diagnostic-error-among-vulnerable-populations-presenting-emergency-department-cardiovascular

March 16, 2022 - Review Diagnostic error among vulnerable populations presenting to the emergency department with cardiovascular and cerebrovascular or neurological symptoms: a systematic review. Citation Text: Herasevich S, Soleimani J, Huang C, et al. Diagnostic error among vulnerable populations prese…

An estimate of missed pediatric sepsis in the emergency department. | PSNet

psnet.ahrq.gov/issue/estimate-missed-pediatric-sepsis-emergency-department

December 08, 2021 - Study An estimate of missed pediatric sepsis in the emergency department. Citation Text: Cifra CL, Westlund E, Ten Eyck P, et al. An estimate of missed pediatric sepsis in the emergency department. Diagnosis (Berl). 2020;8(2):193-198. doi:10.1515/dx-2020-0023. Copy Citation Format:…

Patient safety incidents in advance care planning for serious illness: a mixed-methods analysis | PSNet

psnet.ahrq.gov/issue/patient-safety-incidents-advance-care-planning-serious-illness-mixed-methods-analysis

February 22, 2019 - Study Patient safety incidents in advance care planning for serious illness: a mixed-methods analysis Citation Text: Dinnen T, Williams H, Yardley S, et al. Patient safety incidents in advance care planning for serious illness: a mixed-methods analysis. BMJ Support Palliat Care. 2019. do…

Failure to engage hospitalized elderly patients and their families in advance care planning. | PSNet

psnet.ahrq.gov/issue/failure-engage-hospitalized-elderly-patients-and-their-families-advance-care-planning

November 21, 2016 - Study Classic Failure to engage hospitalized elderly patients and their families in advance care planning. Citation Text: Heyland DK, Barwich D, Pichora D, et al. Failure to engage hospitalized elderly patients and their families in advance care planning. JAMA I…

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