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The next organizational challenge: finding and addressing diagnostic error. | PSNet

psnet.ahrq.gov/issue/next-organizational-challenge-finding-and-addressing-diagnostic-error

November 16, 2022 - Commentary The next organizational challenge: finding and addressing diagnostic error. Citation Text: Graber ML, Trowbridge RL, Myers JS, et al. The next organizational challenge: finding and addressing diagnostic error. Jt Comm J Qual Patient Saf. 2014;40(3):102-10. Copy Citation …

Two fatal cases of accidental intrathecal vincristine administration: learning from death events. | PSNet

psnet.ahrq.gov/issue/two-fatal-cases-accidental-intrathecal-vincristine-administration-learning-death-events

March 24, 2021 - Commentary Two fatal cases of accidental intrathecal vincristine administration: learning from death events. Citation Text: Chotsampancharoen T, Sripornsawan P, Wongchanchailert M. Two fatal cases of accidental intrathecal vincristine administration: learning from death event. Chemothera…

In situ simulation-based team training and its significance for transfer of learning to clinical practice--a qualitative focus group interview study of anaesthesia personnel. | PSNet

psnet.ahrq.gov/issue/situ-simulation-based-team-training-and-its-significance-transfer-learning-clinical-practice

June 14, 2023 - Study In situ simulation-based team training and its significance for transfer of learning to clinical practice--a qualitative focus group interview study of anaesthesia personnel. Citation Text: Finstad AS, Aase I, Bjørshol CA, et al. In situ simulation-based team training and its signi…

Training in safe opioid prescribing and treatment of opioid use disorder in internal medicine residencies: a national survey of program directors. | PSNet

psnet.ahrq.gov/issue/training-safe-opioid-prescribing-and-treatment-opioid-use-disorder-internal-medicine

March 17, 2021 - Study Training in safe opioid prescribing and treatment of opioid use disorder in internal medicine residencies: a national survey of program directors. Citation Text: Windish DM, Catalanotti JS, Zaas A, et al. Training in safe opioid prescribing and treatment of opioid use disorder in i…

Sustaining improvement of hospital-wide initiative for patient safety and quality: a systematic scoping review. | PSNet

psnet.ahrq.gov/issue/sustaining-improvement-hospital-wide-initiative-patient-safety-and-quality-systematic-scoping

September 01, 2021 - Review Sustaining improvement of hospital-wide initiative for patient safety and quality: a systematic scoping review. Citation Text: Moon SEJ, Hogden A, Eljiz K. Sustaining improvement of hospital-wide initiative for patient safety and quality: a systematic scoping review. BMJ Open Qual…

ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: a meta-analysis. | PSNet

psnet.ahrq.gov/issue/ed-misdiagnosis-cerebrovascular-events-era-modern-neuroimaging-meta-analysis

August 19, 2020 - Review ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: a meta-analysis. Citation Text: Tarnutzer AA, Lee S-H, Robinson K, et al. ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: A meta-analysis. Neurology. 2017;88(15):1468-1477. do…

How do hospital boards govern for quality improvement? A mixed methods study of 15 organisations in England. | PSNet

psnet.ahrq.gov/issue/how-do-hospital-boards-govern-quality-improvement-mixed-methods-study-15-organisations

February 20, 2019 - Study How do hospital boards govern for quality improvement? A mixed methods study of 15 organisations in England. Citation Text: Jones L, Pomeroy L, Robert G, et al. How do hospital boards govern for quality improvement? A mixed methods study of 15 organisations in England. BMJ Qual Saf…

Evaluation of medication errors at the transition of care from an ICU to non-ICU location. | PSNet

psnet.ahrq.gov/issue/evaluation-medication-errors-transition-care-icu-non-icu-location

September 23, 2020 - Study Emerging Classic Evaluation of medication errors at the transition of care from an ICU to non-ICU location. Citation Text: Tully AP, Hammond DA, Li C, et al. Evaluation of Medication Errors at the Transition of Care From an ICU to Non-ICU Location. Crit Ca…

Potentially preventable 30-day hospital readmissions at a children's hospital. | PSNet

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July 11, 2017 - Study Potentially preventable 30-day hospital readmissions at a children's hospital. Citation Text: Toomey SL, Peltz A, Loren S, et al. Potentially Preventable 30-Day Hospital Readmissions at a Children's Hospital. Pediatrics. 2016;138(2). doi:10.1542/peds.2015-4182. Copy Citation …

Combined proactive risk assessment: unifying proactive and reactive risk assessment techniques in health care. | PSNet

psnet.ahrq.gov/issue/combined-proactive-risk-assessment-unifying-proactive-and-reactive-risk-assessment-techniques

May 11, 2022 - Study Combined proactive risk assessment: unifying proactive and reactive risk assessment techniques in health care. Citation Text: Bender JA, Kulju S, Soncrant C. Combined proactive risk assessment: unifying proactive and reactive risk assessment techniques in health care. Jt Comm J Qua…

Unscheduled radiologic examination orders in the electronic health record: a novel resource for targeting ambulatory diagnostic errors in radiology. | PSNet

psnet.ahrq.gov/issue/unscheduled-radiologic-examination-orders-electronic-health-record-novel-resource-targeting

March 30, 2022 - Study Unscheduled radiologic examination orders in the electronic health record: a novel resource for targeting ambulatory diagnostic errors in radiology. Citation Text: Lacson R, Healey MJ, Cochon LR, et al. Unscheduled Radiologic Examination Orders in the Electronic Health Record: A No…

Decreasing prescribing errors during pediatric emergencies: a randomized simulation trial. | PSNet

psnet.ahrq.gov/issue/decreasing-prescribing-errors-during-pediatric-emergencies-randomized-simulation-trial

October 08, 2013 - Study Decreasing prescribing errors during pediatric emergencies: a randomized simulation trial. Citation Text: Larose G, Levy A, Bailey B, et al. Decreasing Prescribing Errors During Pediatric Emergencies: A Randomized Simulation Trial. Pediatrics. 2017;139(3). doi:10.1542/peds.2016-320…

Exposing physicians to reduced residency work hours did not adversely affect patient outcomes after residency. | PSNet

psnet.ahrq.gov/issue/exposing-physicians-reduced-residency-work-hours-did-not-adversely-affect-patient-outcomes

June 21, 2016 - Study Exposing physicians to reduced residency work hours did not adversely affect patient outcomes after residency. Citation Text: Jena AB, Schoemaker L, Bhattacharya J. Exposing physicians to reduced residency work hours did not adversely affect patient outcomes after residency. Health…

Using Health Care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective risk analysis system. | PSNet

psnet.ahrq.gov/issue/using-health-care-failure-mode-and-effect-analysis-va-national-center-patient-safetys

January 17, 2012 - Study Classic Using Health Care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective risk analysis system. Citation Text: DeRosier JM, Stalhandske E, Bagian JP, et al. Using health care Failure Mode and Effect Analysis: the V…

Patient handoffs and multi-specialty trainee perspectives across an institution: informing recommendations for health systems and an expanded conceptual framework for handoffs. | PSNet

psnet.ahrq.gov/issue/patient-handoffs-and-multi-specialty-trainee-perspectives-across-institution-informing

February 23, 2022 - Study Patient handoffs and multi-specialty trainee perspectives across an institution: informing recommendations for health systems and an expanded conceptual framework for handoffs. Citation Text: Williams SR, Sebok-Syer SS, Caretta-Weyer H, et al. Patient handoffs and multi-specialty t…

The nurse's experience of decision-making processes in missed nursing care: a qualitative study. | PSNet

psnet.ahrq.gov/issue/nurses-experience-decision-making-processes-missed-nursing-care-qualitative-study

May 11, 2022 - Study The nurse's experience of decision-making processes in missed nursing care: a qualitative study. Citation Text: Abdelhadi N, Drach‐Zahavy A, Srulovici E. The nurse’s experience of decision‐making processes in missed nursing care: a qualitative study. J Adv Nurs. 2020;76(8):2161-217…

Outcomes in two Massachusetts hospital systems give reason for optimism about communication-and-resolution programs. | PSNet

psnet.ahrq.gov/issue/outcomes-two-massachusetts-hospital-systems-give-reason-optimism-about-communication-and

December 19, 2018 - Study Outcomes in two Massachusetts hospital systems give reason for optimism about communication-and-resolution programs. Citation Text: Mello MM, Kachalia A, Roche S, et al. Outcomes In Two Massachusetts Hospital Systems Give Reason For Optimism About Communication-And-Resolution Progr…

Preventing medication errors in long-term care: results and evaluation of a large scale web-based error reporting system. | PSNet

psnet.ahrq.gov/issue/preventing-medication-errors-long-term-care-results-and-evaluation-large-scale-web-based

June 15, 2011 - Study Preventing medication errors in long-term care: results and evaluation of a large scale web-based error reporting system. Citation Text: Pierson S, Hansen RA, Greene SB, et al. Preventing medication errors in long-term care: results and evaluation of a large scale web-based error…

Defining, identifying and addressing problematic polypharmacy within multimorbidity in primary care: a scoping review. | PSNet

psnet.ahrq.gov/issue/defining-identifying-and-addressing-problematic-polypharmacy-within-multimorbidity-primary

July 22, 2015 - Review Defining, identifying and addressing problematic polypharmacy within multimorbidity in primary care: a scoping review. Citation Text: Tsang JY, Sperrin M, Blakeman T, et al. Defining, identifying and addressing problematic polypharmacy within multimorbidity in primary care: a scop…

The burden and risk factors for adverse drug events in older patients--a prospective cross-sectional study. | PSNet

psnet.ahrq.gov/issue/burden-and-risk-factors-adverse-drug-events-older-patients-prospective-cross-sectional-study

May 20, 2020 - Study The burden and risk factors for adverse drug events in older patients--a prospective cross-sectional study. Citation Text: Tipping B, Kalula S, Badri M. The burden and risk factors for adverse drug events in older patients--a prospective cross-sectional study. S Afr Med J. 2006;9…

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