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Informing the design of a new pragmatic registry to stimulate near miss reporting in ambulatory care. | PSNet

psnet.ahrq.gov/issue/informing-design-new-pragmatic-registry-stimulate-near-miss-reporting-ambulatory-care

January 12, 2011 - Review Informing the design of a new pragmatic registry to stimulate near miss reporting in ambulatory care. Citation Text: Pfoh ER, Engineer L, Singh H, et al. Informing the Design of a New Pragmatic Registry to Stimulate Near Miss Reporting in Ambulatory Care. J Patient Saf. 2021;17(3)…

How to mitigate the effects of cognitive biases during patient safety incident investigations. | PSNet

psnet.ahrq.gov/issue/how-mitigate-effects-cognitive-biases-during-patient-safety-incident-investigations

June 29, 2022 - Commentary How to mitigate the effects of cognitive biases during patient safety incident investigations. Citation Text: Rogers JE, Hilgers TR, Keebler JR, et al. How to mitigate the effects of cognitive biases during patient safety incident investigations. Jt Comm J Qual Patient Saf. 20…

Distraction in the operating room: a narrative review of environmental and self-initiated distractions and their effect on anesthesia providers. | PSNet

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August 28, 2024 - Review Distraction in the operating room: a narrative review of environmental and self-initiated distractions and their effect on anesthesia providers. Citation Text: Gui JL, Nemergut EC, Forkin KT. Distraction in the operating room: a narrative review of environmental and self-initiated…

A structured judgement method to enhance mortality case note review: development and evaluation. | PSNet

psnet.ahrq.gov/issue/structured-judgement-method-enhance-mortality-case-note-review-development-and-evaluation

May 27, 2011 - Study A structured judgement method to enhance mortality case note review: development and evaluation. Citation Text: Hutchinson A, Coster JE, Cooper KL, et al. A structured judgement method to enhance mortality case note review: development and evaluation. BMJ Qual Saf. 2013;22(12). do…

The gap in electronic drug information resources: a systematic review. | PSNet

psnet.ahrq.gov/issue/gap-electronic-drug-information-resources-systematic-review

January 24, 2024 - Review The gap in electronic drug information resources: a systematic review. Citation Text: Rambaran KA, Huynh HA, Zhang Z, et al. The Gap in Electronic Drug Information Resources: A Systematic Review. Cureus. 2018;10(6):e2860. doi:10.7759/cureus.2860. Copy Citation Format: …

Competencies for patient safety and quality improvement: a synthesis of recommendations in influential position papers. | PSNet

psnet.ahrq.gov/issue/competencies-patient-safety-and-quality-improvement-synthesis-recommendations-influential

March 31, 2022 - Review Competencies for patient safety and quality improvement: a synthesis of recommendations in influential position papers. Citation Text: Moran KM, Harris IB, Valenta AL. Competencies for Patient Safety and Quality Improvement: A Synthesis of Recommendations in Influential Position P…

The influence of context on the effectiveness of hospital quality improvement strategies: a review of systematic reviews. | PSNet

psnet.ahrq.gov/issue/influence-context-effectiveness-hospital-quality-improvement-strategies-review-systematic

May 26, 2014 - Review The influence of context on the effectiveness of hospital quality improvement strategies: a review of systematic reviews. Citation Text: Kringos DS, Suñol R, Wagner C, et al. The influence of context on the effectiveness of hospital quality improvement strategies: a review of syst…

Sleep, sleepiness, fatigue, and performance of 12-hour–shift nurses. | PSNet

psnet.ahrq.gov/issue/sleep-sleepiness-fatigue-and-performance-12-hour-shift-nurses

July 22, 2010 - Study Sleep, sleepiness, fatigue, and performance of 12-hour–shift nurses. Citation Text: Geiger-Brown J, Rogers VE, Trinkoff AM, et al. Sleep, Sleepiness, Fatigue, and Performance of 12-Hour-Shift Nurses. Chronobiol Int. 2012;29(2). doi:10.3109/07420528.2011.645752. Copy Citation …

Implementation of bar-code medication administration to reduce patient harm. | PSNet

psnet.ahrq.gov/issue/implementation-bar-code-medication-administration-reduce-patient-harm

September 23, 2020 - Study Implementation of bar-code medication administration to reduce patient harm. Citation Text: Thompson KM, Swanson KM, Cox DL, et al. Implementation of Bar-Code Medication Administration to Reduce Patient Harm. Mayo Clin Proc Innov Qual Outcomes. 2018;2(4):342-351. doi:10.1016/j.mayo…

If only...: failed, missed and absent error recovery opportunities in medication errors. | PSNet

psnet.ahrq.gov/issue/if-only-failed-missed-and-absent-error-recovery-opportunities-medication-errors

July 15, 2009 - Study If only...: failed, missed and absent error recovery opportunities in medication errors. Citation Text: Habraken MMP, van der Schaaf TW. If only..: failed, missed and absent error recovery opportunities in medication errors. Qual Saf Health Care. 2010;19(1):37-41. doi:10.1136/qsh…

Effectiveness of the surgical safety checklist in correcting errors: a literature review applying Reason's Swiss cheese model. | PSNet

psnet.ahrq.gov/issue/effectiveness-surgical-safety-checklist-correcting-errors-literature-review-applying-reasons

January 10, 2018 - Review Effectiveness of the surgical safety checklist in correcting errors: a literature review applying Reason's Swiss cheese model. Citation Text: Collins SJ, Newhouse R, Porter J, et al. Effectiveness of the surgical safety checklist in correcting errors: a literature review applying …

The ritualisation of the surgical safety checklist and its decoupling from patient safety goals. | PSNet

psnet.ahrq.gov/issue/ritualisation-surgical-safety-checklist-and-its-decoupling-patient-safety-goals

January 19, 2022 - Study The ritualisation of the surgical safety checklist and its decoupling from patient safety goals. Citation Text: Facey M, Baxter NN, Hammond Mobilio M, et al. The ritualisation of the surgical safety checklist and its decoupling from patient safety goals. Sociol Health Illn. 2024;46…

Sleep deprivation and medication administration errors in registered nurses- a scoping review. | PSNet

psnet.ahrq.gov/issue/sleep-deprivation-and-medication-administration-errors-registered-nurses-scoping-review

September 23, 2020 - Review Sleep deprivation and medication administration errors in registered nurses- a scoping review. Citation Text: Martin CV, Joyce‐McCoach J, Peddle M, et al. Sleep deprivation and medication administration errors in registered nurses- a scoping review. J Clin Nurs. 2024;33(3):859-873…

Hospital workload and adverse events. | PSNet

psnet.ahrq.gov/issue/hospital-workload-and-adverse-events

August 31, 2011 - Study Classic Hospital workload and adverse events. Citation Text: Weissman JS, Rothschild JM, Bendavid E, et al. Hospital workload and adverse events. Med Care. 2007;45(5):448-55. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML…

Usability evaluation of order sets in a computerized provider order entry system. | PSNet

psnet.ahrq.gov/issue/usability-evaluation-order-sets-computerized-provider-order-entry-system

May 04, 2011 - Study Usability evaluation of order sets in a computerized provider order entry system. Citation Text: Chan J, Shojania KG, Easty AC, et al. Usability evaluation of order sets in a computerised provider order entry system. BMJ Qual Saf. 2011;20(11):932-40. doi:10.1136/bmjqs.2010.050021…

ACR guidance document on MR safe practices: updates and critical information 2019. | PSNet

psnet.ahrq.gov/issue/acr-guidance-document-mr-safe-practices-updates-and-critical-information-2019

June 22, 2022 - Commentary ACR guidance document on MR safe practices: updates and critical information 2019. Citation Text: ACR guidance document on MR safe practices: updates and critical information 2019. ACR Committee on MR Safety, Greenberg TD, Hoff MN, Gilk TB, et al. J Magn Reson Imaging. 20…

Passing the "Yo' Mama" test. | PSNet

psnet.ahrq.gov/issue/passing-yo-mama-test

February 15, 2023 - Commentary Passing the "Yo' Mama" test. Citation Text: Blair R. Passing the "Yo' Mama" test. Atlanta healthcare organization follows the beat of a different drummer in achieving 100 percent CPOE adoption. Health Manag Technol. 2006;27(6):14, 16, 18. Copy Citation Format: …

Resident shift handoff strategies in US internal medicine residency programs. | PSNet

psnet.ahrq.gov/issue/resident-shift-handoff-strategies-us-internal-medicine-residency-programs

July 02, 2014 - Study Resident shift handoff strategies in US internal medicine residency programs. Citation Text: Wray CM, Chaudhry S, Pincavage A, et al. Resident Shift Handoff Strategies in US Internal Medicine Residency Programs. JAMA. 2016;316(21):2273-2275. doi:10.1001/jama.2016.17786. Copy Cita…

What would you ideally do if there were no targets? An ethnographic study of the unintended consequences of top-down governance in two clinical settings. | PSNet

psnet.ahrq.gov/issue/what-would-you-ideally-do-if-there-were-no-targets-ethnographic-study-unintended-consequences

July 27, 2011 - Study What would you ideally do if there were no targets? An ethnographic study of the unintended consequences of top-down governance in two clinical settings. Citation Text: Allard J, Bleakley A. What would you ideally do if there were no targets? An ethnographic study of the unintended…

Use of specific indicators to detect warfarin-related adverse events. | PSNet

psnet.ahrq.gov/issue/use-specific-indicators-detect-warfarin-related-adverse-events

October 19, 2022 - Study Use of specific indicators to detect warfarin-related adverse events. Citation Text: Hartis CE, Gum MO, Lederer JW. Use of specific indicators to detect warfarin-related adverse events. American Journal of Health-System Pharmacy. 2005;62(16). doi:10.2146/ajhp040404. Copy Cita…

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