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Using in situ simulation to identify and resolve latent environmental threats to patient safety: case study involving a labor and delivery ward. | PSNet

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April 17, 2011 - Commentary Using in situ simulation to identify and resolve latent environmental threats to patient safety: case study involving a labor and delivery ward. Citation Text: Hamman WR, Beaudin-Seiler BM, Beaubien JM, et al. Using in situ simulation to identify and resolve latent environme…

Confidential clinician-reported surveillance of adverse events among medical inpatients. | PSNet

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June 29, 2011 - Study Classic Confidential clinician-reported surveillance of adverse events among medical inpatients. Citation Text: Weingart SN, Ship AN, Aronson MD. Confidential clinician-reported surveillance of adverse events among medical inpatients. J Gen Intern Med. 2…

Error or "act of God"? A study of patients' and operating room team members' perceptions of error definition, reporting, and disclosure. | PSNet

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August 10, 2011 - Study Error or "act of God"? A study of patients' and operating room team members' perceptions of error definition, reporting, and disclosure. Citation Text: Espin S, Levinson W, Regehr G, et al. Error or "act of God"? A study of patients' and operating room team members' perceptions o…

What do patients think about year-end resident continuity clinic handoffs?: a qualitative study. | PSNet

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March 28, 2018 - Study What do patients think about year-end resident continuity clinic handoffs?: a qualitative study. Citation Text: Pincavage A, Lee WW, Beiting KJ, et al. What do patients think about year-end resident continuity clinic handoffs? A qualitative study. J Gen Intern Med. 2013;28(8):999-1…

Crossing the communication chasm: challenges and opportunities in transitions of care from the hospital to the primary care clinic. | PSNet

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October 23, 2024 - Study Crossing the communication chasm: challenges and opportunities in transitions of care from the hospital to the primary care clinic. Citation Text: Rattray NA, Sico JJ, Cox LAM, et al. Crossing the Communication Chasm: Challenges and Opportunities in Transitions of Care from the Hos…

Actions and implementation strategies to reduce suicidal events in the Veterans Health Administration. | PSNet

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January 05, 2017 - Study Actions and implementation strategies to reduce suicidal events in the Veterans Health Administration. Citation Text: Mills PD, Neily J, Luan D, et al. Actions and Implementation Strategies to Reduce Suicidal Events in the Veterans Health Administration. The Joint Commission Journa…

Are physicians safely prescribing opioids for chronic noncancer pain? A systematic review of current evidence. | PSNet

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November 07, 2018 - Review Are physicians safely prescribing opioids for chronic noncancer pain? A systematic review of current evidence. Citation Text: Tournebize J, Gibaja V, Muszczak A, et al. Are Physicians Safely Prescribing Opioids for Chronic Noncancer Pain? A Systematic Review of Current Evidence. P…

A framework for engaging physicians in quality and safety. | PSNet

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July 10, 2008 - Study Classic A framework for engaging physicians in quality and safety. Citation Text: Taitz JM, Lee TH, Sequist TD. A framework for engaging physicians in quality and safety. BMJ Qual Saf. 2012;21(9):722-728. doi:10.1136/bmjqs-2011-000167. Copy Citation …

Pathology trainees rarely report safety incidents: a review of 13,722 safety reports and a call to action. | PSNet

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September 15, 2021 - Study Pathology trainees rarely report safety incidents: a review of 13,722 safety reports and a call to action. Citation Text: Harris CK, Chen Y, Yarsky B, et al. Pathology trainees rarely report safety incidents: a review of 13,722 safety reports and a call to action. Acad Pathol. 2022…

The next step in learning from sentinel events in healthcare. | PSNet

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June 12, 2024 - Commentary The next step in learning from sentinel events in healthcare. Citation Text: Bos K, Dongelmans DA, Greuters S, et al. The next step in learning from sentinel events in healthcare. BMJ Open Qual. 2020;9(1):e000739. doi:10.1136/bmjoq-2019-000739. Copy Citation Format: …

Use of a daily goals checklist for morning ICU rounds: a mixed-methods study. | PSNet

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November 21, 2021 - Study Use of a daily goals checklist for morning ICU rounds: a mixed-methods study. Citation Text: Centofanti JE, Duan EH, Hoad NC, et al. Use of a daily goals checklist for morning ICU rounds: a mixed-methods study. Crit Care Med. 2014;42(8):1797-803. doi:10.1097/CCM.0000000000000331. …

Organizational response to known medical errors: does peer review protection impede improvement? | PSNet

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April 24, 2018 - Commentary Organizational response to known medical errors: does peer review protection impede improvement? Citation Text: Wenner WJ, Choi SW. Organizational Response to Known Medical Errors: Does Peer Review Protection Impede Improvement? Am J Med Qual. 2018;33(5):552-553. doi:10.1177/1…

Risks of complications by attending physicians after performing nighttime procedures. | PSNet

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February 14, 2018 - Study Classic Risks of complications by attending physicians after performing nighttime procedures. Citation Text: Rothschild JM. Risks of Complications by Attending Physicians After Performing Nighttime Procedures. JAMA. 2009;302(14):1565-1572. doi:10.1001/ja…

Clinical oversight: conceptualizing the relationship between supervision and safety. | PSNet

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June 23, 2010 - Study Clinical oversight: conceptualizing the relationship between supervision and safety. Citation Text: Kennedy TJT, Lingard LA, Baker R, et al. Clinical oversight: conceptualizing the relationship between supervision and safety. J Gen Intern Med. 2007;22(8):1080-5. Copy Citation …

The Accreditation Council for Graduate Medical Education resident duty hour new standards: history, changes, and impact on staffing of intensive care units. | PSNet

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November 21, 2021 - Commentary The Accreditation Council for Graduate Medical Education resident duty hour new standards: history, changes, and impact on staffing of intensive care units. Citation Text: Pastores SM, O'Connor MF, Kleinpell R, et al. The Accreditation Council for Graduate Medical Education …

Avoiding handover fumbles: a controlled trial of a structured handover tool versus traditional handover methods. | PSNet

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January 19, 2022 - Study Avoiding handover fumbles: a controlled trial of a structured handover tool versus traditional handover methods. Citation Text: Payne CE, Stein JM, Leong T, et al. Avoiding handover fumbles: a controlled trial of a structured handover tool versus traditional handover methods. BMJ…

Overlooked guide wire: a multicomplicated Swiss Cheese Model example. Analysis of a case and review of the literature. | PSNet

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September 15, 2021 - Commentary Overlooked guide wire: a multicomplicated Swiss Cheese Model example. Analysis of a case and review of the literature. Citation Text: Thonon H, Espeel F, Frederic F, et al. Overlooked guide wire: a multicomplicated Swiss Cheese Model example. Analysis of a case and review of t…

The "To Err Is Human Report" and the patient safety literature. | PSNet

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November 16, 2022 - Review The "To Err Is Human Report" and the patient safety literature. Citation Text: Stelfox HT, Palmisani S, Scurlock C, et al. The "To Err is Human" report and the patient safety literature. Qual Saf Health Care. 2006;15(3):174-8. Copy Citation Format: Google Scholar P…

How do hospitalized patients feel about resident work hours, fatigue, and discontinuity of care? | PSNet

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July 02, 2008 - Study How do hospitalized patients feel about resident work hours, fatigue, and discontinuity of care? Citation Text: Fletcher KE, Wiest FC, Halasyamani L, et al. How do hospitalized patients feel about resident work hours, fatigue, and discontinuity of care? J Gen Intern Med. 2008;23(…

A novel approach to increase residents' involvement in reporting adverse events. | PSNet

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September 23, 2020 - Study A novel approach to increase residents' involvement in reporting adverse events. Citation Text: Scott DR, Weimer M, English C, et al. A novel approach to increase residents' involvement in reporting adverse events. Acad Med. 2011;86(6):742-746. doi:10.1097/ACM.0b013e318217e12a. C…

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