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psnet.ahrq.gov/issue/effect-central-call-center-employee-perceptions-safety-culture-within-community-pharmacies
June 15, 2022 - Study
Effect of a central call center on employee perceptions of safety culture within community pharmacies in an academic health system.
Citation Text:
Bowden A, Mullin S, Tak C, et al. Effect of a central call center on employee perceptions of safety culture within community pharmacies…
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psnet.ahrq.gov/issue/changing-work-environment-icus-achieve-patient-focused-care-time-has-come
April 05, 2023 - Commentary
Changing the work environment in ICUs to achieve patient-focused care: the time has come.
Citation Text:
McCauley K, Irwin RS. Changing the work environment in ICUs to achieve patient-focused care: the time has come. Chest. 2006;130(5):1571-8.
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psnet.ahrq.gov/issue/organizational-perspectives-nurse-executives-15-hospitals-impact-and-effectiveness-rapid
August 03, 2022 - Study
Organizational perspectives of nurse executives in 15 hospitals on the impact and effectiveness of rapid response teams.
Citation Text:
Smith PL, McSweeney J. Organizational Perspectives of Nurse Executives in 15 Hospitals on the Impact and Effectiveness of Rapid Response Teams. Jt…
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psnet.ahrq.gov/issue/vestibular-syndromes-diagnosis-and-diagnostic-errors-patients-dizziness-presenting-emergency
May 17, 2023 - Study
Vestibular syndromes, diagnosis and diagnostic errors in patients with dizziness presenting to the emergency department: a cross-sectional study.
Citation Text:
Comolli L, Korda A, Zamaro E, et al. Vestibular syndromes, diagnosis and diagnostic errors in patients with dizziness pre…
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psnet.ahrq.gov/issue/workarounds-electronic-health-record-systems-and-revised-sociotechnical-electronic-health
October 05, 2022 - Review
Workarounds in electronic health record systems and the revised Sociotechnical Electronic Health Record Workaround Analysis Framework: scoping review.
Citation Text:
Blijleven V, Hoxha F, Jaspers MWM. Workarounds in electronic health record systems and the revised sociotechnical E…
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psnet.ahrq.gov/issue/assessing-use-google-translate-spanish-and-chinese-translations-emergency-department
March 16, 2016 - Study
Assessing the use of Google Translate for Spanish and Chinese translations of emergency department discharge instructions.
Citation Text:
Khoong EC, Steinbrook E, Brown C, et al. Assessing the Use of Google Translate for Spanish and Chinese Translations of Emergency Department Disc…
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psnet.ahrq.gov/issue/fda-safety-communication-caution-when-using-robotically-assisted-surgical-devices-womens
September 01, 2021 - Press Release/Announcement
FDA Safety Communication: update--robotically-assisted surgical devices in mastectomy.
Citation Text:
FDA Safety Communication: update--robotically-assisted surgical devices in mastectomy. MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administratio…
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psnet.ahrq.gov/issue/effect-day-week-short-and-long-term-mortality-after-emergency-general-surgery
January 23, 2019 - Study
Effect of day of the week on short- and long-term mortality after emergency general surgery.
Citation Text:
Gillies MA, Lone NI, Pearse RM, et al. Effect of day of the week on short- and long-term mortality after emergency general surgery. Br J Surg. 2017;104(7):936-945. doi:10.100…
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psnet.ahrq.gov/issue/connecting-patients-and-clinicians-anticipated-effects-open-notes-patient-safety-and-quality
March 20, 2017 - Commentary
Connecting patients and clinicians: the anticipated effects of Open Notes on patient safety and quality of care.
Citation Text:
Bell SK, Folcarelli PH, Anselmo MK, et al. Connecting patients and clinicians: the anticipated effects of Open Notes on patient safety and quality of…
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psnet.ahrq.gov/issue/prescribing-patterns-heart-failure-exacerbating-medications-following-heart-failure
January 26, 2022 - Study
Prescribing patterns of heart failure-exacerbating medications following a heart failure hospitalization.
Citation Text:
Goyal P, Kneifati-Hayek J, Archambault A, et al. Prescribing patterns of heart failure-exacerbating medications following a heart failure hospitalization. JACC H…
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psnet.ahrq.gov/issue/relationship-between-job-burnout-psychosocial-factors-and-health-care-associated-infections
January 12, 2022 - Study
Relationship between job burnout, psychosocial factors and health care–associated infections in critical care units.
Citation Text:
Galletta M, Portoghese I, D'Aloja E, et al. Relationship between job burnout, psychosocial factors and health care-associated infections in critical c…
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psnet.ahrq.gov/issue/effect-electronic-sbar-communication-tool-documentation-acute-events-pediatric-intensive-care
August 12, 2015 - Study
The effect of an electronic SBAR communication tool on documentation of acute events in the pediatric intensive care unit.
Citation Text:
Panesar RS, Albert B, Messina C, et al. The Effect of an Electronic SBAR Communication Tool on Documentation of Acute Events in the Pediatric In…
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psnet.ahrq.gov/issue/application-global-trigger-tool-systematic-review
December 06, 2023 - Review
The application of the Global Trigger Tool: a systematic review.
Citation Text:
Hibbert PD, Molloy CJ, Hooper TD, et al. The application of the Global Trigger Tool: a systematic review. Int J Qual Health Care. 2016;28(6):640-649. doi:10.1093/intqhc/mzw115.
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psnet.ahrq.gov/issue/family-safety-reporting-hospitalized-children-medical-complexity
September 18, 2024 - Study
Family safety reporting in hospitalized children with medical complexity.
Citation Text:
Mercer AN, Mauskar S, Baird JD, et al. Family safety reporting in hospitalized children with medical complexity. Pediatrics. 2022;150(2):e2021055098. doi:10.1542/peds.2021-055098.
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psnet.ahrq.gov/issue/what-evidence-supports-use-computerized-alerts-and-prompts-improve-clinicians-prescribing
August 04, 2021 - Computerized provider order entry (CPOE) systems have been hailed as a solution to prevent medication … errors and improve patient outcomes , particularly when combined with clinical decision support systems
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psnet.ahrq.gov/node/836978/psn-pdf
May 16, 2022 - Check Twice, Transport Once
May 16, 2022
DePew A, Rice J, Chou J. Check Twice, Transport Once. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/check-twice-transport-once
The Case
Case #1: A 26-year-old woman (Patient A) presented to the Emergency Department (ED) with abdominal
pain and was diagnosed with “s…
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psnet.ahrq.gov/node/60152/psn-pdf
March 25, 2020 - Errors during resuscitation: the impact of perceived
authority on delivery of care.
March 25, 2020
Delaloye NJ, Tobler K, O?Neill T, et al. Errors during resuscitation: the impact of perceived authority on
delivery of care. J Patient Saf. 2020;16(1). doi:10.1097/pts.0000000000000359.
https://psnet.ahrq.gov/issue/e…
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psnet.ahrq.gov/issue/stop-silent-misdiagnosis-patients-preferences-matter
February 02, 2020 - August 5, 2020
Medication errors associated with transition from insulin pens to insulin
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psnet.ahrq.gov/issue/profiles-patient-safety-authority-gradients-medical-error
August 28, 2019 - July 31, 2013
Profiles in patient safety: medication errors in the emergency department
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psnet.ahrq.gov/issue/forgive-and-forget-recognition-error-and-use-apology-preemptive-steps-adr-or-litigation
July 24, 2018 - December 16, 2020
Analysis of iatrogenic and in-hospital medication errors reported to