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Transfusion-related errors and associated adverse reactions and blood product wastage as reported to the National Healthcare Safety Network Hemovigilance Module, 2014-2022. | PSNet

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September 23, 2020 - Study Transfusion-related errors and associated adverse reactions and blood product wastage as reported to the National Healthcare Safety Network Hemovigilance Module, 2014-2022. Citation Text: Chavez Ortiz JL, Griffin I, Kazakova SV, et al. Transfusion‐related errors and associated adve…

Unplanned return to theater: a quality of care and risk management index? | PSNet

psnet.ahrq.gov/issue/unplanned-return-theater-quality-care-and-risk-management-index

August 20, 2018 - Study Unplanned return to theater: a quality of care and risk management index? Citation Text: Pujol N, Merrer J, Lemaire B, et al. Unplanned return to theater: A quality of care and risk management index? Orthop Traumatol Surg Res. 2015;101(4):399-403. doi:10.1016/j.otsr.2015.03.013. …

Evaluation of near-miss wrong-patient events in radiology reports. | PSNet

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June 13, 2015 - Study Evaluation of near-miss wrong-patient events in radiology reports. Citation Text: Sadigh G, Loehfelm T, Applegate KE, et al. JOURNAL CLUB: Evaluation of Near-Miss Wrong-Patient Events in Radiology Reports. AJR Am J Roentgenol. 2015;205(2):337-43. doi:10.2214/AJR.14.13339. Copy Ci…

Avoiding the unintended consequences of growth in medical care: how might more be worse? | PSNet

psnet.ahrq.gov/issue/avoiding-unintended-consequences-growth-medical-care-how-might-more-be-worse

April 24, 2018 - Commentary Classic Avoiding the unintended consequences of growth in medical care: how might more be worse? Citation Text: Fisher ES, Welch HG. Avoiding the unintended consequences of growth in medical care: how might more be worse? JAMA. 1999;281(5):446-53. …

Automation of the I-PASS tool to improve transitions of care. | PSNet

psnet.ahrq.gov/issue/automation-i-pass-tool-improve-transitions-care

August 04, 2021 - Study Automation of the I-PASS tool to improve transitions of care. Citation Text: Skaret MM, Weaver TD, Humes RJ, et al. Automation of the I-PASS Tool to Improve Transitions of Care. J Healthc Qual. 2019;41(5):274-280. doi:10.1097/JHQ.0000000000000174. Copy Citation Format: …

Adverse events in patients with return emergency department visits. | PSNet

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May 31, 2017 - Study Adverse events in patients with return emergency department visits. Citation Text: Calder LA, Pozgay A, Riff S, et al. Adverse events in patients with return emergency department visits. BMJ Qual Saf. 2015;24(2):142-148. doi:10.1136/bmjqs-2014-003194. Copy Citation Format: …

Residents' numeric inputting error in computerized physician order entry prescription. | PSNet

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March 24, 2019 - Study Residents' numeric inputting error in computerized physician order entry prescription. Citation Text: Wu X, Wu C, Zhang K, et al. Residents' numeric inputting error in computerized physician order entry prescription. Int J Med Inform. 2016;88:25-33. doi:10.1016/j.ijmedinf.2016.01.0…

"Sign right here and you're good to go": a content analysis of audiotaped emergency department discharge instructions. | PSNet

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December 18, 2013 - Study "Sign right here and you're good to go": a content analysis of audiotaped emergency department discharge instructions. Citation Text: Vashi A, Rhodes K. "Sign right here and you're good to go": a content analysis of audiotaped emergency department discharge instructions. Ann Emer…

A systems approach to identify factors influencing adverse drug events in nursing homes. | PSNet

psnet.ahrq.gov/issue/systems-approach-identify-factors-influencing-adverse-drug-events-nursing-homes

March 18, 2020 - Study A systems approach to identify factors influencing adverse drug events in nursing homes. Citation Text: Al-Jumaili AA, Doucette WR. A Systems Approach to Identify Factors Influencing Adverse Drug Events in Nursing Homes. J Am Geriatr Soc. 2018;66(7):1420-1427. doi:10.1111/jgs.15389…

Evolving quality improvement support strategies to improve Plan–Do–Study–Act cycle fidelity: a retrospective mixed-methods study. | PSNet

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March 17, 2014 - Study Emerging Classic Evolving quality improvement support strategies to improve Plan–Do–Study–Act cycle fidelity: a retrospective mixed-methods study. Citation Text: McNicholas C, Lennox L, Woodcock T, et al. Evolving quality improvement support strategies to …

Race differences in reported harmful patient safety events in healthcare system high reliability organizations. | PSNet

psnet.ahrq.gov/issue/race-differences-reported-harmful-patient-safety-events-healthcare-system-high-reliability

March 01, 2023 - Study Race differences in reported harmful patient safety events in healthcare system high reliability organizations. Citation Text: Thomas AD, Pandit C, Krevat SA. Race Differences in Reported Harmful Patient Safety Events in Healthcare System High Reliability Organizations. J Patient S…

Medical misadventures as errors and mistakes and motor vehicular accidents in the disproportionate burden of childhood mortality among Blacks/African Americans in the United States: CDC Dataset, 1968-2015. | PSNet

psnet.ahrq.gov/issue/medical-misadventures-errors-and-mistakes-and-motor-vehicular-accidents-disproportionate

March 05, 2025 - Study Medical misadventures as errors and mistakes and motor vehicular accidents in the disproportionate burden of childhood mortality among Blacks/African Americans in the United States: CDC Dataset, 1968-2015. Citation Text: Holmes L, Enwere M, Mason R, et al. Medical misadventures as …

Patient safety in external beam radiotherapy—guidelines on risk assessment and analysis of adverse error-events and near misses: introducing the ACCIRAD project. | PSNet

psnet.ahrq.gov/issue/patient-safety-external-beam-radiotherapy-guidelines-risk-assessment-and-analysis-adverse

March 15, 2017 - Study Patient safety in external beam radiotherapy—guidelines on risk assessment and analysis of adverse error-events and near misses: introducing the ACCIRAD project. Citation Text: Malicki J, Bly R, Bulot M, et al. Patient safety in external beam radiotherapy - guidelines on risk asses…

Designing a critical care nurse–led rapid response team using only available resources: 6 years later. | PSNet

psnet.ahrq.gov/issue/designing-critical-care-nurse-led-rapid-response-team-using-only-available-resources-6-years

December 21, 2014 - Study Designing a critical care nurse–led rapid response team using only available resources: 6 years later. Citation Text: Mitchell A, Schatz M, Francis H. Designing a critical care nurse-led rapid response team using only available resources: 6 years later. Crit Care Nurse. 2014;34(3):…

The Harvard Medical Practice Study trigger system performance in deceased patients. | PSNet

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March 02, 2022 - Study The Harvard Medical Practice Study trigger system performance in deceased patients. Citation Text: Klein DO, Rennenberg RJMW, Koopmans RP, et al. The Harvard medical practice study trigger system performance in deceased patients. BMC Health Serv Res. 2019;19(1):16. doi:10.1186/s129…

Barriers to the implementation of checklists in the office-based procedural setting. | PSNet

psnet.ahrq.gov/issue/barriers-implementation-checklists-office-based-procedural-setting

February 18, 2019 - Study Barriers to the implementation of checklists in the office-based procedural setting. Citation Text: Shapiro FE, Fernando RJ, Urman RD. Barriers to the implementation of checklists in the office-based procedural setting. J Healthc Risk Manag. 2014;33(4):35-43. doi:10.1002/jhrm.21141…

Physician knowledge, attitudes, and behavior related to reporting adverse drug events. | PSNet

psnet.ahrq.gov/issue/physician-knowledge-attitudes-and-behavior-related-reporting-adverse-drug-events

September 23, 2020 - Study Classic Physician knowledge, attitudes, and behavior related to reporting adverse drug events. Citation Text: Rogers AS, Israel E, Smith CR, et al. Physician Knowledge, Attitudes, and Behavior Related to Reporting Adverse Drug Events. Arch Intern Med. 201…

Ten years later, alarm fatigue is still a safety concern. | PSNet

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October 25, 2023 - Commentary Ten years later, alarm fatigue is still a safety concern. Citation Text: Albanowski K, Burdick KJ, Bonafide CP, et al. Ten years later, alarm fatigue is still a safety concern. AACN Adv Crit Care. 2023;34(3):189-197. doi:10.4037/aacnacc2023662. Copy Citation Format: …

BONE break: a hot debrief tool to reduce second victim syndrome for nurses. | PSNet

psnet.ahrq.gov/issue/bone-break-hot-debrief-tool-reduce-second-victim-syndrome-nurses

August 02, 2015 - Study BONE break: a hot debrief tool to reduce second victim syndrome for nurses. Citation Text: Hess A, Flicek T, Watral AT, et al. BONE break: a hot debrief tool to reduce second victim syndrome for nurses. Jt Comm J Qual Patient Saf. 2024;50(9):673-677. doi:10.1016/j.jcjq.2024.05.005.…

A new category of "never events"-ending harmful hospital policies. | PSNet

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September 07, 2022 - Commentary A new category of "never events"-ending harmful hospital policies. Citation Text: Chokshi DA, Beckman AL. A new category of "never events"-ending harmful hospital policies. JAMA Health Forum. 2022;3(10):e224703. doi:10.1001/jamahealthforum.2022.4703. Copy Citation Format…

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