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National Aeronautics and Space Administration "threat and error" model applied to pediatric cardiac surgery: error cycles precede ∼85% of patient deaths. | PSNet

psnet.ahrq.gov/issue/national-aeronautics-and-space-administration-threat-and-error-model-applied-pediatric

March 07, 2018 - Study National Aeronautics and Space Administration "threat and error" model applied to pediatric cardiac surgery: error cycles precede ∼85% of patient deaths. Citation Text: Hickey EJ, Nosikova Y, Pham-Hung E, et al. National Aeronautics and Space Administration "threat and error" model…

More than 1 million potential second victims: how many could nursing education prevent? | PSNet

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May 30, 2018 - Study More than 1 million potential second victims: how many could nursing education prevent? Citation Text: Jones JH, Treiber LA. More Than 1 Million Potential Second Victims: How Many Could Nursing Education Prevent? Nurs Edu. 2018;43(3):154-157. doi:10.1097/NNE.0000000000000437. Cop…

Internet of things in healthcare for patient safety: an empirical study. | PSNet

psnet.ahrq.gov/issue/internet-things-healthcare-patient-safety-empirical-study

March 18, 2020 - Study Internet of things in healthcare for patient safety: an empirical study. Citation Text: Yesmin T, Carter MW, Gladman AS. Internet of things in healthcare for patient safety: an empirical study. BMC Health Serv Res. 2022;22(1):278. doi:10.1186/s12913-022-07620-3. Copy Citation …

Challenges in patient safety improvement research in the era of electronic health records. | PSNet

psnet.ahrq.gov/issue/challenges-patient-safety-improvement-research-era-electronic-health-records

November 11, 2020 - Commentary Challenges in patient safety improvement research in the era of electronic health records. Citation Text: Russo E, Sittig DF, Murphy DR, et al. Challenges in patient safety improvement research in the era of electronic health records. Healthc (Amst). 2016;4(4):285-290. doi:10.…

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

psnet.ahrq.gov/issue/organizational-response-known-medical-errors-does-peer-review-protection-impede-improvement

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…

A randomised controlled trial assessing the efficacy of an electronic discharge communication tool for preventing death or hospital readmission. | PSNet

psnet.ahrq.gov/issue/randomised-controlled-trial-assessing-efficacy-electronic-discharge-communication-tool

August 24, 2016 - Study A randomised controlled trial assessing the efficacy of an electronic discharge communication tool for preventing death or hospital readmission. Citation Text: Santana MJ, Holroyd-Leduc J, Southern DA, et al. A randomised controlled trial assessing the efficacy of an electronic dis…

The role of patients and their relatives in 'speaking up' about their own safety—a qualitative study of acute illness. | PSNet

psnet.ahrq.gov/issue/role-patients-and-their-relatives-speaking-about-their-own-safety-qualitative-study-acute

January 19, 2012 - Study The role of patients and their relatives in 'speaking up' about their own safety—a qualitative study of acute illness. Citation Text: Rainey H, Ehrich K, Mackintosh N, et al. The role of patients and their relatives in 'speaking up' about their own safety - a qualitative study of a…

Reduction in preventable time-critical dose omissions: impact of electronic medication management systems on in-patients. | PSNet

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February 03, 2016 - Study Reduction in preventable time-critical dose omissions: impact of electronic medication management systems on in-patients. Citation Text: Graudins LV, Crute S, Poole SG, et al. Reduction in preventable time-critical dose omissions: impact of electronic medication management systems …

The development and psychometric evaluation of a safety climate measure for primary care. | PSNet

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February 29, 2012 - Study The development and psychometric evaluation of a safety climate measure for primary care. Citation Text: de Wet C, Spence W, Mash R, et al. The development and psychometric evaluation of a safety climate measure for primary care. BMJ Qual Saf. 2010;19(6). doi:10.1136/qshc.2008.03…

Educational targets to reduce medication errors by general surgery residents. | PSNet

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October 19, 2022 - Study Educational targets to reduce medication errors by general surgery residents. Citation Text: Chaitoff A, Strong AT, Bauer SR, et al. Educational Targets to Reduce Medication Errors by General Surgery Residents. J Surg Educ. 2019;76(6):1612-1621. doi:10.1016/j.jsurg.2019.04.009. C…

Effect of hospital follow-up appointment on clinical event outcomes and mortality. | PSNet

psnet.ahrq.gov/issue/effect-hospital-follow-appointment-clinical-event-outcomes-and-mortality

April 24, 2018 - Study Effect of hospital follow-up appointment on clinical event outcomes and mortality. Citation Text: Grafft CA, McDonald FS, Ruud KL, et al. Effect of hospital follow-up appointment on clinical event outcomes and mortality. Arch Intern Med. 2010;170(11):955-60. doi:10.1001/archinternm…

Need for standardized sign-out in the emergency department: a survey of emergency medicine residency and pediatric emergency medicine fellowship program directors. | PSNet

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May 27, 2011 - Study Need for standardized sign-out in the emergency department: a survey of emergency medicine residency and pediatric emergency medicine fellowship program directors. Citation Text: Sinha M, Shriki J, Salness R, et al. Need for standardized sign-out in the emergency department: a su…

Adapting cognitive task analysis to investigate clinical decision making and medication safety incidents. | PSNet

psnet.ahrq.gov/issue/adapting-cognitive-task-analysis-investigate-clinical-decision-making-and-medication-safety

March 10, 2021 - Study Adapting cognitive task analysis to investigate clinical decision making and medication safety incidents. Citation Text: Russ AL, Militello LG, Glassman PA, et al. Adapting Cognitive Task Analysis to Investigate Clinical Decision Making and Medication Safety Incidents. J Patient Sa…

Systematic review of clinical debriefing tools: attributes and evidence for use. | PSNet

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March 20, 2024 - Review Systematic review of clinical debriefing tools: attributes and evidence for use. Citation Text: Phillips EC, Smith SE, Tallentire VR, et al. Systematic review of clinical debriefing tools: attributes and evidence for use. BMJ Qual Saf. 2024;33(3):187-198. doi:10.1136/bmjqs-2022-01…

Engaging pediatric resident physicians in quality improvement through resident-led morbidity and mortality conferences. | PSNet

psnet.ahrq.gov/issue/engaging-pediatric-resident-physicians-quality-improvement-through-resident-led-morbidity-and

November 16, 2022 - Study Engaging pediatric resident physicians in quality improvement through resident-led morbidity and mortality conferences. Citation Text: Destino LA, Kahana M, Patel SJ. Engaging Pediatric Resident Physicians in Quality Improvement Through Resident-Led Morbidity and Mortality Conferen…

Analysis of risk factors for patient safety events occurring in the emergency department. | PSNet

psnet.ahrq.gov/issue/analysis-risk-factors-patient-safety-events-occurring-emergency-department

January 26, 2022 - Study Analysis of risk factors for patient safety events occurring in the emergency department. Citation Text: Alsabri M, Boudi Z, Zoubeidi T, et al. Analysis of risk factors for patient safety events occurring in the emergency department. J Patient Saf. 2022;18(1):e124-e135. doi:10.1097…

Verifying patient identity and site of surgery: improving compliance with protocol by audit and feedback. | PSNet

psnet.ahrq.gov/issue/verifying-patient-identity-and-site-surgery-improving-compliance-protocol-audit-and-feedback

October 26, 2010 - Study Verifying patient identity and site of surgery: improving compliance with protocol by audit and feedback. Citation Text: Garnerin P, Arès M, Huchet A, et al. Verifying patient identity and site of surgery: improving compliance with protocol by audit and feedback. Qual Saf Health …

Temporal associations between EHR-derived workload, burnout, and errors: a prospective cohort study. | PSNet

psnet.ahrq.gov/issue/temporal-associations-between-ehr-derived-workload-burnout-and-errors-prospective-cohort

December 03, 2014 - Study Temporal associations between EHR-derived workload, burnout, and errors: a prospective cohort study. Citation Text: Lou SS, Lew D, Harford DR, et al. Temporal associations between EHR-derived workload, burnout, and errors: a prospective cohort study. J Gen Intern Med. 2022;37(9):21…

Association of safety culture with surgical site infection outcomes. | PSNet

psnet.ahrq.gov/issue/association-safety-culture-surgical-site-infection-outcomes

October 23, 2024 - Study Classic Association of safety culture with surgical site infection outcomes. Citation Text: Fan CJ, Pawlik TM, Daniels T, et al. Association of safety culture with surgical site infection outcomes. J Am Coll Surg. 2016;222(2):122-128. doi:10.1016/j.jamcoll…

Factors differentiating nursing homes with strong resident safety climate: a qualitative study of leadership and staff perspectives. | PSNet

psnet.ahrq.gov/issue/factors-differentiating-nursing-homes-strong-resident-safety-climate-qualitative-study

August 26, 2020 - Study Factors differentiating nursing homes with strong resident safety climate: a qualitative study of leadership and staff perspectives. Citation Text: Engle RL, Gillespie C, Clark VA, et al. Factors differentiating nursing homes with strong resident safety climate: a qualitative study…

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