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Systems approach and systems engineering applied to health care: improving patient safety and health care delivery. | PSNet

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August 12, 2020 - Commentary Systems approach and systems engineering applied to health care: improving patient safety and health care delivery. Citation Text: Systems approach and systems engineering applied to health care: improving patient safety and health care delivery. Ravitz AD, Sapirstein A, Pha…

The Physician Practice Patient Safety Assessment. | PSNet

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April 24, 2018 - Measurement Tool/Indicator The Physician Practice Patient Safety Assessment. Citation Text: Pohl JM, Nath R, Zheng K, et al. Use of a comprehensive patient safety tool in primary care practices. Journal of the American Association of Nurse Practitioners. 2013;25(8):415-8. doi:10.1111/174…

How surgeons disclose medical errors to patients: a study using standardized patients. | PSNet

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July 10, 2008 - Study How surgeons disclose medical errors to patients: a study using standardized patients. Citation Text: Chan DK, Gallagher TH, Reznick R, et al. How surgeons disclose medical errors to patients: a study using standardized patients. Surgery. 2005;138(5):851-8. Copy Citation …

The epidemiology of prescribing errors: the potential impact of computerized prescriber order entry. | PSNet

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May 04, 2010 - Study The epidemiology of prescribing errors: the potential impact of computerized prescriber order entry. Citation Text: Bobb A, Gleason KM, Husch M, et al. The epidemiology of prescribing errors: the potential impact of computerized prescriber order entry. Arch Intern Med. 2004;164(7…

Unintentionally retained guidewires: a descriptive study of 73 sentinel events. | PSNet

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April 27, 2019 - Study Unintentionally retained guidewires: a descriptive study of 73 sentinel events. Citation Text: Steelman VM, Thenuwara K, Shaw C, et al. Unintentionally Retained Guidewires: A Descriptive Study of 73 Sentinel Events. Jt Comm J Qual Saf. 2019;45(2):81-90. doi:10.1016/j.jcjq.2018.08.0…

Designing a safer process to prevent retained surgical sponges: a healthcare failure mode and effect analysis. | PSNet

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April 27, 2019 - Study Designing a safer process to prevent retained surgical sponges: a healthcare failure mode and effect analysis. Citation Text: Steelman VM, Cullen JJ. Designing a safer process to prevent retained surgical sponges: a healthcare failure mode and effect analysis. AORN J. 2011;94(2):1…

When to err is inhuman: an examination of the influence of artificial intelligence-driven nursing care on patient safety. | PSNet

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October 19, 2022 - Commentary When to err is inhuman: an examination of the influence of artificial intelligence-driven nursing care on patient safety. Citation Text: Johnson EA, Dudding KM, Carrington JM. When to err is inhuman: an examination of the influence of artificial intelligence‐driven nursing car…

'The ABC of Handover': impact on shift handover in the emergency department. | PSNet

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June 17, 2010 - Study 'The ABC of Handover': impact on shift handover in the emergency department. Citation Text: Farhan M, Brown R, Vincent CA, et al. The ABC of handover: impact on shift handover in the emergency department. Emerg Med J. 2012;29(12):947-53. doi:10.1136/emermed-2011-200201. Copy Ci…

Twelve tips for implementing a patient safety curriculum in an undergraduate programme in medicine. | PSNet

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June 19, 2018 - Commentary Twelve tips for implementing a patient safety curriculum in an undergraduate programme in medicine. Citation Text: Armitage G, Cracknell A, Forrest K, et al. Twelve tips for implementing a patient safety curriculum in an undergraduate programme in medicine. Med Teach. 2011;3…

Communicating pathology and laboratory errors: anatomic pathologists' and laboratory medical directors' attitudes and experiences. | PSNet

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May 18, 2022 - Study Communicating pathology and laboratory errors: anatomic pathologists' and laboratory medical directors' attitudes and experiences. Citation Text: Dintzis SM, Stetsenko GY, Sitlani CM, et al. Communicating pathology and laboratory errors: anatomic pathologists' and laboratory medi…

Enhancing medication use safety: benefits of learning from your peers. | PSNet

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May 07, 2008 - Study Enhancing medication use safety: benefits of learning from your peers. Citation Text: Kazandjian VA, Ogunbo S, Wicker KG, et al. Enhancing medication use safety: benefits of learning from your peers. Qual Saf Health Care. 2009;18(5):331-5. doi:10.1136/qshc.2008.027938. Copy Cit…

Nurse/physician communication through a sensemaking lens: shifting the paradigm to improve patient safety. | PSNet

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June 05, 2024 - Review Nurse/physician communication through a sensemaking lens: shifting the paradigm to improve patient safety. Citation Text: Manojlovich M. Nurse/physician communication through a sensemaking lens: shifting the paradigm to improve patient safety. Med Care. 2010;48(11):941-6. doi:10…

Kadcyla (ado-trastuzumab emtansine): drug safety communication—potential medication errors resulting from name confusion. | PSNet

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October 09, 2013 - Press Release/Announcement Kadcyla (ado-trastuzumab emtansine): drug safety communication—potential medication errors resulting from name confusion. Citation Text: Kadcyla (ado-trastuzumab emtansine): drug safety communication—potential medication errors resulting from name confusion. …

The importance of failing forward. All of us will fail and make mistakes, but how can they benefit us and our organizations? | PSNet

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July 27, 2016 - Newspaper/Magazine Article The importance of failing forward. All of us will fail and make mistakes, but how can they benefit us and our organizations? Citation Text: Hofmann PB. The importance of failing forward. All of us will fail and make mistakes, but how can they benefit us and ou…

The reliability of AHRQ Common Format Harm Scales in rating patient safety events. | PSNet

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January 23, 2017 - Study The reliability of AHRQ Common Format Harm Scales in rating patient safety events. Citation Text: Williams TL, Szekendi MK, Pavkovic S, et al. The reliability of AHRQ Common Format Harm Scales in rating patient safety events. J Patient Saf. 2015;11(1):52-59. doi:10.1097/PTS.0b013e3…

Disclosure of harmful medical errors in out-of-hospital care. | PSNet

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June 18, 2014 - Review Disclosure of harmful medical errors in out-of-hospital care. Citation Text: Lu DW, Guenther E, Wesley AK, et al. Disclosure of harmful medical errors in out-of-hospital care. Ann Emerg Med. 2013;61(2):215-21. doi:10.1016/j.annemergmed.2012.07.004. Copy Citation Format: …

Some unintended effects of teamwork in healthcare. | PSNet

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July 02, 2008 - Study Some unintended effects of teamwork in healthcare. Citation Text: Finn R, Learmonth M, Reedy P. Some unintended effects of teamwork in healthcare. Soc Sci Med. 2010;70(8):1148-54. doi:10.1016/j.socscimed.2009.12.025. Copy Citation Format: DOI Google Scholar PubMed B…

Standardized sign-out reduces intern perception of medical errors on the general internal medicine ward. | PSNet

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August 04, 2021 - Study Standardized sign-out reduces intern perception of medical errors on the general internal medicine ward. Citation Text: Salerno SM, Arnett M, Domanski JP. Standardized sign-out reduces intern perception of medical errors on the general internal medicine ward. Teach Learn Med. 200…

Building capacity and capability for patient safety education: a train-the-trainers programme for senior doctors. | PSNet

psnet.ahrq.gov/issue/building-capacity-and-capability-patient-safety-education-train-trainers-programme-senior

January 15, 2014 - Study Building capacity and capability for patient safety education: a train-the-trainers programme for senior doctors. Citation Text: Ahmed M, Arora S, Baker P, et al. Building capacity and capability for patient safety education: a train-the-trainers programme for senior doctors. BMJ…

Radiation protection and dose monitoring in medical imaging: a journey from awareness, through accountability, ability and action … but where will we arrive? | PSNet

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May 18, 2022 - Review Radiation protection and dose monitoring in medical imaging: a journey from awareness, through accountability, ability and action … but where will we arrive? Citation Text: Frush DP, Denham CR, Goske MJ, et al. Radiation Protection and Dose Monitoring in Medical Imaging. J Patien…

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