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Blood and blood products transfusion errors: what can we do to improve patient safety. | PSNet

psnet.ahrq.gov/issue/blood-and-blood-products-transfusion-errors-what-can-we-do-improve-patient-safety

September 23, 2020 - Review Blood and blood products transfusion errors: what can we do to improve patient safety. Citation Text: Brown C, Brown M. Blood and blood products transfusion errors: what can we do to improve patient safety? Br J Nurs. 2023;32(7):326-332. doi:10.12968/bjon.2023.32.7.326. Copy Cit…

Implementation of a standardized tool for root cause analysis selection. | PSNet

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November 06, 2024 - Study Implementation of a standardized tool for root cause analysis selection. Citation Text: Wahlstedt E, Levy BE, Scott E, et al. Implementation of a standardized tool for root cause analysis selection. J Patient Saf. 2025;21(2):101-105. doi:10.1097/pts.0000000000001291. Copy Citatio…

Combined SNA and LDA methods to understand adverse medical events | PSNet

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November 15, 2023 - Journal Article Combined SNA and LDA methods to understand adverse medical events Citation Text: Zhu L, Reychav I, McHaney R, et al. Combined SNA and LDA methods to understand adverse medical events. Int J Risk Saf Med. 2019;30(3):129-153. doi:10.3233/JRS-180052. Copy Citation Form…

Shape matters: a neglected feature of medication safety: why regulating the shape of medication containers can improve medication safety. | PSNet

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December 09, 2020 - Commentary Shape matters: a neglected feature of medication safety: why regulating the shape of medication containers can improve medication safety. Citation Text: Bitan Y, Nunnally M. Shape matters: a neglected feature of medication safety: why regulating the shape of medication contain…

Frequency and clinical importance of pages sent to the wrong physician. | PSNet

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October 31, 2011 - Study Frequency and clinical importance of pages sent to the wrong physician. Citation Text: Wong BM, Quan S, Cheung M, et al. Frequency and clinical importance of pages sent to the wrong physician. Arch Intern Med. 2009;169(11):1072-3. doi:10.1001/archinternmed.2009.117. Copy Citation…

The state of the evidence for computerized provider order entry: a systematic review and analysis of the quality of the literature. | PSNet

psnet.ahrq.gov/issue/state-evidence-computerized-provider-order-entry-systematic-review-and-analysis-quality

August 04, 2021 - Review The state of the evidence for computerized provider order entry: a systematic review and analysis of the quality of the literature. Citation Text: Weir C, Staggers N, Phansalkar S. The state of the evidence for computerized provider order entry: a systematic review and analysis …

Healthcare Inspection: Evaluation of the Veterans Health Administration's National Consult Delay Review and Associated Fact Sheet. | PSNet

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September 10, 2014 - Book/Report Healthcare Inspection: Evaluation of the Veterans Health Administration's National Consult Delay Review and Associated Fact Sheet. Citation Text: Healthcare Inspection: Evaluation of the Veterans Health Administration's National Consult Delay Review and Associated Fact Sheet.…

Interventions to improve follow-up of laboratory test results pending at discharge: a systematic review. | PSNet

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May 19, 2021 - Review Interventions to improve follow-up of laboratory test results pending at discharge: a systematic review. Citation Text: Whitehead NS, Williams L, Meleth S, et al. Interventions to Improve Follow-Up of Laboratory Test Results Pending at Discharge: A Systematic Review. J Hosp Med. 2…

Wrong-site nerve blocks: 10 yr experience in a large multihospital health-care system. | PSNet

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January 14, 2011 - Study Wrong-site nerve blocks: 10 yr experience in a large multihospital health-care system. Citation Text: Hudson ME, Chelly JE, Lichter JR. Wrong-site nerve blocks: 10 yr experience in a large multihospital health-care system. Br J Anaesth. 2015;114(5):818-24. doi:10.1093/bja/aeu490. …

Identification errors involving clinical laboratories: a College of American Pathologists Q-Probes study of patient and specimen identification errors at 120 institutions. | PSNet

psnet.ahrq.gov/issue/identification-errors-involving-clinical-laboratories-college-american-pathologists-q-probes

February 15, 2010 - Study Identification errors involving clinical laboratories: a College of American Pathologists Q-Probes study of patient and specimen identification errors at 120 institutions. Citation Text: Pathologists C of A, Valenstein PN, Raab SS, et al. Identification errors involving clinical …

A call to bridge across silos during care transitions. | PSNet

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November 20, 2024 - Commentary A call to bridge across silos during care transitions. Citation Text: Sheikh F, Gathecha E, Bellantoni M, et al. A Call to Bridge Across Silos during Care Transitions. Jt Comm J Qual Patient Saf. 2018;44(5):270-278. doi:10.1016/j.jcjq.2017.10.006. Copy Citation Format: …

An observational analysis of surgical team compliance with perioperative safety practices after crew resource management training. | PSNet

psnet.ahrq.gov/issue/observational-analysis-surgical-team-compliance-perioperative-safety-practices-after-crew

May 04, 2012 - Study An observational analysis of surgical team compliance with perioperative safety practices after crew resource management training. Citation Text: France DJ, Leming-Lee S, Jackson T, et al. An observational analysis of surgical team compliance with perioperative safety practices a…

Cross-Check QA: a quality assurance workflow to prevent missed diagnoses by alerting inadvertent discordance between the radiologist and AI in the interpretation of high acuity CT scans. | PSNet

psnet.ahrq.gov/issue/cross-check-qa-quality-assurance-workflow-prevent-missed-diagnoses-alerting-inadvertent

March 04, 2015 - Study Cross-Check QA: a quality assurance workflow to prevent missed diagnoses by alerting inadvertent discordance between the radiologist and AI in the interpretation of high acuity CT scans. Citation Text: Chekmeyan M, Baccei SJ, Garwood ER. Cross-Check QA: a quality assurance workflow…

Automated communication tools and computer-based medication reconciliation to decrease hospital discharge medication errors. | PSNet

psnet.ahrq.gov/issue/automated-communication-tools-and-computer-based-medication-reconciliation-decrease-hospital

September 23, 2020 - Study Automated communication tools and computer-based medication reconciliation to decrease hospital discharge medication errors. Citation Text: Smith KJ, Handler S, Kapoor WN, et al. Automated Communication Tools and Computer-Based Medication Reconciliation to Decrease Hospital Dischar…

Patient safety. Factors for and perceived consequences of nursing errors by nursing staff in home care services. | PSNet

psnet.ahrq.gov/issue/patient-safety-factors-and-perceived-consequences-nursing-errors-nursing-staff-home-care

May 18, 2022 - Study Patient safety. Factors for and perceived consequences of nursing errors by nursing staff in home care services. Citation Text: Jachan DE, Müller‐Werdan U, Lahmann NA. Patient safety. Factors for and perceived consequences of nursing errors by nursing staff in home care services. N…

The heart of darkness: the impact of perceived mistakes on physicians. | PSNet

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April 24, 2018 - Study Classic The heart of darkness: the impact of perceived mistakes on physicians. Citation Text: Christensen JF, Levinson W, Dunn PM. The heart of darkness: the impact of perceived mistakes on physicians. J Gen Intern Med. 1992;7(4):424-31. Copy Citation …

Views of nurses and other health and social care workers on the use of assistive humanoid and animal-like robots in health and social care: a scoping review. | PSNet

psnet.ahrq.gov/issue/views-nurses-and-other-health-and-social-care-workers-use-assistive-humanoid-and-animal

July 27, 2022 - Review Emerging Classic Views of nurses and other health and social care workers on the use of assistive humanoid and animal-like robots in health and social care: a scoping review. Citation Text: Papadopoulos I, Koulouglioti C, Ali S. Views of nurses and other …

Real-time clinical alerting: effect of an automated paging system on response time to critical laboratory values—a randomised controlled trial. | PSNet

psnet.ahrq.gov/issue/real-time-clinical-alerting-effect-automated-paging-system-response-time-critical-laboratory

October 31, 2011 - Study Real-time clinical alerting: effect of an automated paging system on response time to critical laboratory values—a randomised controlled trial. Citation Text: Etchells E, Adhikari NKJ, Cheung C, et al. Real-time clinical alerting: effect of an automated paging system on response …

Biasing influence of 'mental shortcuts' on diagnostic decision-making: radiologists can overlook breast cancer in mamograms when prior diagnostic information is available. | PSNet

psnet.ahrq.gov/issue/biasing-influence-mental-shortcuts-diagnostic-decision-making-radiologists-can-overlook

April 07, 2021 - Study Biasing influence of 'mental shortcuts' on diagnostic decision-making: radiologists can overlook breast cancer in mamograms when prior diagnostic information is available. Citation Text: Branch F, Santana I, Hegdé J. Biasing influence of 'mental shortcuts' on diagnostic decision-ma…

Transparency when things go wrong: physician attitudes about reporting medical errors to patients, peers, and institutions. | PSNet

psnet.ahrq.gov/issue/transparency-when-things-go-wrong-physician-attitudes-about-reporting-medical-errors-patients

April 13, 2011 - Study Transparency when things go wrong: physician attitudes about reporting medical errors to patients, peers, and institutions. Citation Text: Bell SK, White AA, Yi JC, et al. Transparency When Things Go Wrong. J Patient Saf. 2015;13(4):243-248. doi:10.1097/pts.0000000000000153. Copy…

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