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Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression | PSNet

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May 26, 2021 - SPOTLIGHT CASE Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression Citation Text: Fazio S, Firestone R. Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depar…

Responding to unprofessional behavior by trainees - a "just culture" framework. | PSNet

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June 24, 2020 - Commentary Responding to unprofessional behavior by trainees - a "just culture" framework. Citation Text: Wasserman JA, Redinger M, Gibb T. Responding to Unprofessional Behavior by Trainees — A “Just Culture” Framework. New England Journal of Medicine. 2020;382(8). doi:10.1056/nejmms191…

Child-specific risk factors and patient safety. | PSNet

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February 02, 2022 - Study Child-specific risk factors and patient safety. Citation Text: Child-specific risk factors and patient safety. Woods DM, Holl JL, Shonkoff JP, et al. J Patient Saf. 2005;1(1):17-22. Copy Citation Save Save to your library Print Download PDF …

What do family physicians consider an error? A comparison of definitions and physician perception. | PSNet

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February 15, 2011 - Study What do family physicians consider an error? A comparison of definitions and physician perception. Citation Text: Elder NC, Pallerla H, Regan S. What do family physicians consider an error? A comparison of definitions and physician perception. BMC Fam Pract. 2006;7:73. Copy Cit…

Assessment of a safety enhancement to the hospital medication reconciliation process for elderly patients. | PSNet

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August 04, 2021 - Study Assessment of a safety enhancement to the hospital medication reconciliation process for elderly patients. Citation Text: Gizzi LA, Slain D, Hare JT, et al. Assessment of a safety enhancement to the hospital medication reconciliation process for elderly patients. Am J Geriatr Phar…

Honest communication and social asymmetries inside a hospital: pitfalls for clinicians. | PSNet

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March 02, 2022 - Commentary Honest communication and social asymmetries inside a hospital: pitfalls for clinicians. Citation Text: Redelmeier DA, Etchells EE, Najeeb U. Honest communication and social asymmetries inside a hospital: pitfalls for clinicians. J Hosp Med. 2022;17(5):405-409. doi:10.1002/jhm.…

Linking Joint Commission inpatient core measures and National Patient Safety Goals with evidence. | PSNet

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October 19, 2022 - Commentary Linking Joint Commission inpatient core measures and National Patient Safety Goals with evidence. Citation Text: Masica AL, Richter KM, Convery P, et al. Linking joint commission inpatient core measures and national patient safety goals with evidence. Proc (Bayl Univ Med Cen…

Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. | PSNet

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April 12, 2011 - Study Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. Citation Text: Solet DJ, Norvell M, Rutan GH, et al. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoff…

Medication reconciliation campaign in a clinic for homeless patients. | PSNet

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November 16, 2022 - Commentary Medication reconciliation campaign in a clinic for homeless patients. Citation Text: Moczygemba LR, Gatewood SBS, Kennedy AK, et al. Medication reconciliation campaign in a clinic for homeless patients. Am J Health Syst Pharm. 2012;69(7):558, 560-2. doi:10.2146/ajhp110334. …

Long-term effects of an e-learning course on patient safety: a controlled longitudinal study with medical students. | PSNet

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March 16, 2016 - Study Long-term effects of an e-learning course on patient safety: a controlled longitudinal study with medical students. Citation Text: Gaupp R, Dinius J, Drazic I, et al. Long-term effects of an e-learning course on patient safety: A controlled longitudinal study with medical students.…

Antimicrobial prescription errors in hospitalized children: role of antimicrobial stewardship program in detection and intervention. | PSNet

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April 07, 2021 - Study Antimicrobial prescription errors in hospitalized children: role of antimicrobial stewardship program in detection and intervention. Citation Text: Di Pentima C, Chan S, Eppes SC, et al. Antimicrobial prescription errors in hospitalized children: role of antimicrobial stewardship…

The rising frequency of IT blackouts indicates the increasing relevance of IT emergency concepts to ensure patient safety. | PSNet

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October 12, 2022 - Review The rising frequency of IT blackouts indicates the increasing relevance of IT emergency concepts to ensure patient safety. Citation Text: Sax U, Lipprandt M, Röhrig R. The Rising Frequency of IT Blackouts Indicates the Increasing Relevance of IT Emergency Concepts to Ensure Patien…

Rapid response team implementation and in-hospital mortality. | PSNet

psnet.ahrq.gov/issue/rapid-response-team-implementation-and-hospital-mortality

December 03, 2014 - Study Rapid response team implementation and in-hospital mortality. Citation Text: Salvatierra G, Bindler RC, Corbett CF, et al. Rapid response team implementation and in-hospital mortality*. Crit Care Med. 2014;42(9):2001-6. doi:10.1097/CCM.0000000000000347. Copy Citation Format: …

Impact of proactive rounding by a rapid response team on patient outcomes at an academic medical center. | PSNet

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January 19, 2012 - Study Impact of proactive rounding by a rapid response team on patient outcomes at an academic medical center. Citation Text: Butcher BW, Vittinghoff E, Maselli J, et al. Impact of proactive rounding by a rapid response team on patient outcomes at an academic medical center. J Hosp Med…

Diagnostic error in pediatric cancer. | PSNet

psnet.ahrq.gov/issue/diagnostic-error-pediatric-cancer

November 16, 2022 - Study Diagnostic error in pediatric cancer. Citation Text: Carberry AR, Hanson K, Flannery A, et al. Diagnostic Error in Pediatric Cancer. Clin Pediatr (Phila). 2017;57*1((1):11-18. doi:10.1177/0009922816687325. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML…

Implementing an electronic root cause analysis reporting system to decrease hospital-acquired pressure injuries. | PSNet

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December 22, 2021 - Study Implementing an electronic root cause analysis reporting system to decrease hospital-acquired pressure injuries. Citation Text: Armstrong AA. Implementing an electronic root cause analysis reporting system to decrease hospital-acquired pressure injuries. J Healthc Qual. 2023;45(3):…

Managing alarm systems for quality and safety in the hospital setting. | PSNet

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August 13, 2014 - Review Managing alarm systems for quality and safety in the hospital setting. Citation Text: Bach TA, Berglund L-M, Turk E. Managing alarm systems for quality and safety in the hospital setting. BMJ Open Qual. 2018;7(3):e000202. doi:10.1136/bmjoq-2017-000202. Copy Citation Format: …

A case of adverse drug reaction induced by dispensing error. | PSNet

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August 17, 2022 - Commentary A case of adverse drug reaction induced by dispensing error. Citation Text: Gallelli L, Staltari O, Palleria C, et al. A case of adverse drug reaction induced by dispensing error. J Forensic Leg Med. 2012;19(8):497-8. doi:10.1016/j.jflm.2012.04.026. Copy Citation Format…

Case-control analysis of the financial cost of medication errors in hospitalized patients. | PSNet

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January 15, 2025 - Study Case-control analysis of the financial cost of medication errors in hospitalized patients. Citation Text: Pinilla J, Murillo C, Carrasco G, et al. Case-control analysis of the financial cost of medication errors in hospitalized patients. Eur J Health Econ. 2006;7(1):66-71. Copy…

Communication gaps and readmissions to hospital for patients aged 75 years and older: observational study. | PSNet

psnet.ahrq.gov/issue/communication-gaps-and-readmissions-hospital-patients-aged-75-years-and-older-observational

July 19, 2023 - Study Communication gaps and readmissions to hospital for patients aged 75 years and older: observational study. Citation Text: Witherington EMA, Pirzada OM, Avery A. Communication gaps and readmissions to hospital for patients aged 75 years and older: observational study. Qual Saf Hea…

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