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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: …

Organizational learning: health care leaders need to design structures and processes that enhance collective learning. | PSNet

psnet.ahrq.gov/issue/organizational-learning-health-care-leaders-need-design-structures-and-processes-enhance

November 18, 2020 - Commentary Organizational learning: health care leaders need to design structures and processes that enhance collective learning. Citation Text: Bohmer RM, Edmondson AC. Organizational learning in health care. Health Forum J. 2001;44(2):32-35. Copy Citation Format: Google…

Patients' concerns about medical errors during hospitalization. | PSNet

psnet.ahrq.gov/issue/patients-concerns-about-medical-errors-during-hospitalization

December 22, 2008 - Study Classic Patients' concerns about medical errors during hospitalization. Citation Text: Burroughs TE, Waterman AD, Gallagher TH, et al. Patients' concerns about medical errors during hospitalization. Jt Comm J Qual Patient Saf. 2007;33(1):5-14. Copy Citat…

Surveillance of medical device-related hazards and adverse events in hospitalized patients. | PSNet

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March 11, 2011 - Study Classic Surveillance of medical device-related hazards and adverse events in hospitalized patients. Citation Text: Samore MH, Evans S, Lassen A, et al. Surveillance of medical device-related hazards and adverse events in hospitalized patients. JAMA. 2004;2…

Team cognition in handoffs: relating system factors, team cognition functions and outcomes in two handoff processes. | PSNet

psnet.ahrq.gov/issue/team-cognition-handoffs-relating-system-factors-team-cognition-functions-and-outcomes-two

February 16, 2022 - Study Team cognition in handoffs: relating system factors, team cognition functions and outcomes in two handoff processes. Citation Text: Wooldridge AR, Carayon P, Hoonakker PLT, et al. Team cognition in handoffs: relating system factors, team cognition functions and outcomes in two hand…

Using Lean to improve medication administration safety: in search of the "perfect dose." | PSNet

psnet.ahrq.gov/issue/using-lean-improve-medication-administration-safety-search-perfect-dose

September 16, 2015 - Study Using Lean to improve medication administration safety: in search of the "perfect dose." Citation Text: Ching JM, Long C, Williams BL, et al. Using lean to improve medication administration safety: in search of the "perfect dose". Jt Comm J Qual Patient Saf. 2013;39(5):195-204. C…

COVID-19 Pandemic Impact on Healthcare Associated Conditions | PSNet

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July 21, 2025 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed COVID-19 Pandemic Impact on Healthcare Associated Conditions Download Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Sam W…

Adherence to black box warnings for prescription medications in outpatients. | PSNet

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September 29, 2017 - Study Adherence to black box warnings for prescription medications in outpatients. Citation Text: Lasser KE, Seger DL, Yu T, et al. Adherence to black box warnings for prescription medications in outpatients. Arch Intern Med. 2006;166(3):338-44. Copy Citation Format: Goog…

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 …

Misleading one detail: a preventable mode of diagnostic error? | PSNet

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February 10, 2016 - Study Misleading one detail: a preventable mode of diagnostic error? Citation Text: Arzy S, Brezis M, Khoury S, et al. Misleading one detail: a preventable mode of diagnostic error? J Eval Clin Pract. 2009;15(5):804-6. doi:10.1111/j.1365-2753.2008.01098.x. Copy Citation Format: …

"Mr Smith's been our problem child today...": anticipatory management communication (AMC) in VA end-of-shift medicine and nursing handoffs. | PSNet

psnet.ahrq.gov/issue/mr-smiths-been-our-problem-child-today-anticipatory-management-communication-amc-va-end-shift

January 22, 2016 - Study "Mr Smith's been our problem child today...": anticipatory management communication (AMC) in VA end-of-shift medicine and nursing handoffs. Citation Text: Bergman AA, Flanagan ME, Ebright PR, et al. "Mr Smith's been our problem child today…": anticipatory management communication (…

Direct oral anticoagulant-related medication incidents and pharmacists' interventions in hospital in-patients: evaluation using Reason's accident causation theory. | PSNet

psnet.ahrq.gov/issue/direct-oral-anticoagulant-related-medication-incidents-and-pharmacists-interventions-hospital

January 12, 2022 - Study Direct oral anticoagulant-related medication incidents and pharmacists' interventions in hospital in-patients: evaluation using Reason's accident causation theory. Citation Text: Haque H, Alrowily A, Jalal Z, et al. Direct oral anticoagulant-related medication incidents and pharmac…

Nurse managers' leadership, patient safety, and quality of care: a systematic review. | PSNet

psnet.ahrq.gov/issue/nurse-managers-leadership-patient-safety-and-quality-care-systematic-review

September 09, 2020 - Review Nurse managers' leadership, patient safety, and quality of care: a systematic review. Citation Text: Lee SE, Hyunjie L, Sang S. Nurse managers' leadership, patient safety, and quality of care: a systematic review. West J Nurs Res. 2023;45(2):176-185. doi:10.1177/01939459221114079.…

A visual medication schedule to improve anticoagulation control: a randomized, controlled trial. | PSNet

psnet.ahrq.gov/issue/visual-medication-schedule-improve-anticoagulation-control-randomized-controlled-trial

October 21, 2010 - Study A visual medication schedule to improve anticoagulation control: a randomized, controlled trial. Citation Text: Machtinger EL, Wang F, Chen L-L, et al. A visual medication schedule to improve anticoagulation control: a randomized, controlled trial. Jt Comm J Qual Patient Saf. 2007;…

Predictors and triggers of incivility within healthcare teams: a systematic review of the literature. | PSNet

psnet.ahrq.gov/issue/predictors-and-triggers-incivility-within-healthcare-teams-systematic-review-literature

July 21, 2011 - Review Predictors and triggers of incivility within healthcare teams: a systematic review of the literature. Citation Text: Keller S, Yule S, Zagarese V, et al. Predictors and triggers of incivility within healthcare teams: a systematic review of the literature. BMJ Open. 2020;10(6):e035…

Types of diagnostic errors reported by paediatric emergency providers in a global paediatric emergency care research network. | PSNet

psnet.ahrq.gov/issue/types-diagnostic-errors-reported-paediatric-emergency-providers-global-paediatric-emergency

December 16, 2020 - Study Types of diagnostic errors reported by paediatric emergency providers in a global paediatric emergency care research network. Citation Text: Mahajan P, Grubenhoff JA, Cranford J, et al. Types of diagnostic errors reported by paediatric emergency providers in a global paediatric eme…

Adverse event and error of unexpected life-threatening events within 24h of emergency department admission. | PSNet

psnet.ahrq.gov/issue/adverse-event-and-error-unexpected-life-threatening-events-within-24h-emergency-department

October 27, 2016 - Study Adverse event and error of unexpected life-threatening events within 24h of emergency department admission. Citation Text: Zhang E, Hung S-C, Wu C-H, et al. Adverse event and error of unexpected life-threatening events within 24hours of ED admission. Am J Emerg Med. 2017;35(3):479-…

Grading recommendations for enhanced patient safety in sentinel event analysis: the recommendation improvement matrix. | PSNet

psnet.ahrq.gov/issue/grading-recommendations-enhanced-patient-safety-sentinel-event-analysis-recommendation

April 15, 2020 - Study Grading recommendations for enhanced patient safety in sentinel event analysis: the recommendation improvement matrix. Citation Text: Bos K, van der Laan MJ, Groeneweg J, et al. Grading recommendations for enhanced patient safety in sentinel event analysis: the recommendation impro…

Identifying electronic health record contributions to diagnostic error in ambulatory settings through legal claims analysis. | PSNet

psnet.ahrq.gov/issue/identifying-electronic-health-record-contributions-diagnostic-error-ambulatory-settings

January 25, 2023 - Study Identifying electronic health record contributions to diagnostic error in ambulatory settings through legal claims analysis. Citation Text: Krevat S, Samuel S, Boxley C, et al. Identifying electronic health record contributions to diagnostic error in ambulatory settings through leg…

Misuse, abuse and medication errors' adverse events associated with opioids--a systematic review. | PSNet

psnet.ahrq.gov/issue/misuse-abuse-and-medication-errors-adverse-events-associated-opioids-systematic-review

January 15, 2025 - Review Misuse, abuse and medication errors' adverse events associated with opioids--a systematic review. Citation Text: Gustafsson M, Silva V, Valeiro C, et al. Misuse, abuse and medication errors' adverse events associated with opioids--a systematic review. Pharmaceuticals (Basel). 2024…

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