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Detection, classification, and correction of defective chemotherapy orders through nursing and pharmacy oversight. | PSNet

psnet.ahrq.gov/issue/detection-classification-and-correction-defective-chemotherapy-orders-through-nursing-and

May 27, 2011 - Study Detection, classification, and correction of defective chemotherapy orders through nursing and pharmacy oversight. Citation Text: Mertens WC, Brown DE, Parisi R, et al. Detection, Classification, and Correction of Defective Chemotherapy Orders Through Nursing and Pharmacy Oversig…

The spectrum of hospitalization-associated harm in the elderly. | PSNet

psnet.ahrq.gov/issue/spectrum-hospitalization-associated-harm-elderly

April 06, 2022 - Commentary The spectrum of hospitalization-associated harm in the elderly. Citation Text: Schattner A. The spectrum of hospitalization-associated harm in the elderly. Eur J Intern Med. 2023;115(Sept):29-33. doi:10.1016/j.ejim.2023.05.025. Copy Citation Format: DOI Google Sc…

Towards international consensus on patient harm: perspectives on pressure injury policy. | PSNet

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September 27, 2016 - Review Towards international consensus on patient harm: perspectives on pressure injury policy. Citation Text: Jackson D, Hutchinson M, Barnason S, et al. Towards international consensus on patient harm: perspectives on pressure injury policy. J Nurs Manag. 2016;24(7):902-914. doi:10.111…

The influence of bullying on nursing practice errors: a systematic review. | PSNet

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January 30, 2019 - Review The influence of bullying on nursing practice errors: a systematic review. Citation Text: Johnson AH, Benham‐Hutchins M. The Influence of Bullying on Nursing Practice Errors: A Systematic Review. AORN J. 2020;111(2). doi:10.1002/aorn.12923. Copy Citation Format: DOI …

The occurrence of wrong-site surgery self-reported by candidates for certification by the American Board of Orthopaedic Surgery. | PSNet

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June 03, 2020 - Study The occurrence of wrong-site surgery self-reported by candidates for certification by the American Board of Orthopaedic Surgery. Citation Text: James MA, Seiler JG, Harrast JJ, et al. The occurrence of wrong-site surgery self-reported by candidates for certification by the Americ…

Registered nurses' judgments of the classification and risk level of patient care errors. | PSNet

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August 24, 2022 - Study Registered nurses' judgments of the classification and risk level of patient care errors. Citation Text: Chipps E, Wills CE, Tanda R, et al. Registered nurses' judgments of the classification and risk level of patient care errors. J Nurs Care Qual. 2011;26(4):302-310. doi:10.1097…

Prevention of a wrong-location misadministration through the use of an intradepartmental incident learning system. | PSNet

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January 22, 2017 - Study Prevention of a wrong-location misadministration through the use of an intradepartmental incident learning system. Citation Text: Ford E, Smith K, Harris K, et al. Prevention of a wrong-location misadministration through the use of an intradepartmental incident learning system. M…

Developing and pilot testing practical measures of preanalytic surgical specimen identification defects. | PSNet

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June 16, 2011 - Study Developing and pilot testing practical measures of preanalytic surgical specimen identification defects. Citation Text: Bixenstine PJ, Zarbo RJ, Holzmueller CG, et al. Developing and pilot testing practical measures of preanalytic surgical specimen identification defects. Am J M…

Patient safety incidents associated with airway devices in critical care: a review of reports to the UK National Patient Safety Agency. | PSNet

psnet.ahrq.gov/issue/patient-safety-incidents-associated-airway-devices-critical-care-review-reports-uk-national

March 12, 2025 - Study Patient safety incidents associated with airway devices in critical care: a review of reports to the UK National Patient Safety Agency. Citation Text: Thomas AN, McGrath BA. Patient safety incidents associated with airway devices in critical care: a review of reports to the UK Na…

Improving resident education and patient safety: a method to balance initial caseloads at academic year-end transfer. | PSNet

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January 27, 2016 - Study Improving resident education and patient safety: a method to balance initial caseloads at academic year-end transfer. Citation Text: Young JQ, Niehaus B, Lieu SC, et al. Improving resident education and patient safety: a method to balance initial caseloads at academic year-end tran…

Feedback loop failure modes in medical diagnosis: how biases can emerge and be reinforced. | PSNet

psnet.ahrq.gov/issue/feedback-loop-failure-modes-medical-diagnosis-how-biases-can-emerge-and-be-reinforced

November 01, 2023 - Study Feedback loop failure modes in medical diagnosis: how biases can emerge and be reinforced. Citation Text: Aikens RC, Chen JH, Baiocchi M, et al. Feedback loop failure modes in medical diagnosis: how biases can emerge and be reinforced. Med Decis Making. 2024;44(5):481-496. doi:10.1…

Controlled substance drug diversion by healthcare workers as a threat to patient safety. | PSNet

psnet.ahrq.gov/issue/controlled-substance-drug-diversion-healthcare-workers-threat-patient-safety

April 05, 2023 - Special or Theme Issue Controlled substance drug diversion by healthcare workers as a threat to patient safety. Citation Text: Controlled substance drug diversion by healthcare workers as a threat to patient safety. ISMP Medication Safety Alert! Acute care edition. February 23, 2023;28(4…

Surgical never events in the United States. | PSNet

psnet.ahrq.gov/issue/surgical-never-events-united-states

September 10, 2014 - Study Surgical never events in the United States. Citation Text: Mehtsun WT, Ibrahim AM, Diener-West M, et al. Surgical never events in the United States. Surgery. 2013;153(4):465-472. doi:10.1016/j.surg.2012.10.005. Copy Citation Format: DOI Google Scholar PubMed BibTeX …

An intervention to enhance nursing staff teamwork and engagement. | PSNet

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June 21, 2010 - Study An intervention to enhance nursing staff teamwork and engagement. Citation Text: Kalisch BJ, Curley M, Stefanov S. An intervention to enhance nursing staff teamwork and engagement. J Nurs Adm. 2007;37(2):77-84. Copy Citation Format: Google Scholar PubMed BibTeX EndN…

Developing an intervention to reduce harm in hospitalized patients: patients and families in research. | PSNet

psnet.ahrq.gov/issue/developing-intervention-reduce-harm-hospitalized-patients-patients-and-families-research

December 21, 2018 - Study Developing an intervention to reduce harm in hospitalized patients: patients and families in research. Citation Text: Schenk EC, Bryant RA, Van Son CR, et al. Developing an Intervention to Reduce Harm in Hospitalized Patients: Patients and Families in Research. J Nurs Care Qual. 20…

The 2018 Gosport Independent Panel report into deaths at the National Health Service's Gosport War Memorial Hospital. Does the culture of the medical profession influence health outcomes? | PSNet

psnet.ahrq.gov/issue/2018-gosport-independent-panel-report-deaths-national-health-services-gosport-war-memorial

March 25, 2020 - Commentary The 2018 Gosport Independent Panel report into deaths at the National Health Service's Gosport War Memorial Hospital. Does the culture of the medical profession influence health outcomes? Citation Text: Bennett S. The 2018 Gosport Independent Panel report into deaths at the Na…

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

psnet.ahrq.gov/issue/rising-frequency-it-blackouts-indicates-increasing-relevance-it-emergency-concepts-ensure

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…

Oral outpatient chemotherapy medication errors in children with acute lymphoblastic leukemia. | PSNet

psnet.ahrq.gov/issue/oral-outpatient-chemotherapy-medication-errors-children-acute-lymphoblastic-leukemia

August 12, 2020 - Study Oral outpatient chemotherapy medication errors in children with acute lymphoblastic leukemia. Citation Text: Taylor JA, Winter L, Geyer LJ, et al. Oral outpatient chemotherapy medication errors in children with acute lymphoblastic leukemia. Cancer. 2006;107(6):1400-6. Copy Cita…

Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis reports in the Veterans Health Administration. | PSNet

psnet.ahrq.gov/issue/patient-misidentification-laboratory-medicine-qualitative-analysis-227-root-cause-analysis

August 28, 2024 - Study Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis reports in the Veterans Health Administration. Citation Text: Dunn EJ, Moga PJ. Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis …

Medication errors and error chains involving high-alert medications in a paediatric hospital setting: a qualitative analysis of self-reported medication safety incidents. | PSNet

psnet.ahrq.gov/issue/medication-errors-and-error-chains-involving-high-alert-medications-paediatric-hospital

March 27, 2024 - Study Medication errors and error chains involving high-alert medications in a paediatric hospital setting: a qualitative analysis of self-reported medication safety incidents. Citation Text: Kuitunen S, Saksa M, Holmström A-R. Medication errors and error chains involving high-alert medi…

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