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Disclosing adverse events in clinical practice: the delicate act of being open. | PSNet

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April 14, 2021 - Review Disclosing adverse events in clinical practice: the delicate act of being open. Citation Text: Myren BJ, de Hullu JA, Bastiaans S, et al. Disclosing adverse events in clinical practice: the delicate act of being open. Health Commun. 2022;37(2):191-201. doi:10.1080/10410236.2020.18…

Making soft intelligence hard: a multi-site qualitative study of challenges relating to voice about safety concerns. | PSNet

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June 16, 2021 - Study Emerging Classic Making soft intelligence hard: a multi-site qualitative study of challenges relating to voice about safety concerns. Citation Text: Martin G, Aveling E-L, Campbell A, et al. Making soft intelligence hard: a multi-site qualitative study of …

Shaping systems for better behavioral choices: lessons learned from a fatal medication error. | PSNet

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February 12, 2020 - Commentary Shaping systems for better behavioral choices: lessons learned from a fatal medication error. Citation Text: Smetzer JL, Baker C, Byrne FD, et al. Shaping systems for better behavioral choices: lessons learned from a fatal medication error. Jt Comm J Qual Patient Saf. 2010;36(…

Incorrect surgical procedures within and outside of the operating room: a follow-up report. | PSNet

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April 30, 2014 - Study Incorrect surgical procedures within and outside of the operating room: a follow-up report. Citation Text: Neily J, Mills PD, Eldridge N, et al. Incorrect surgical procedures within and outside of the operating room: a follow-up report. Arch Surg. 2011;146(11):1235-9. doi:10.1001…

Validity of the Agency for Healthcare Research and Quality Patient Safety Indicators and the Centers for Medicare and Medicaid Hospital-acquired Conditions: a systematic review and meta-analysis. | PSNet

psnet.ahrq.gov/issue/validity-agency-healthcare-research-and-quality-patient-safety-indicators-and-centers

June 14, 2017 - Review Classic Validity of the Agency for Healthcare Research and Quality Patient Safety Indicators and the Centers for Medicare and Medicaid Hospital-acquired Conditions: a systematic review and meta-analysis. Citation Text: Winters BD, Bharmal A, Wilson RF, et…

To make or buy patient safety solutions: a resource dependence and transaction cost economics perspective. | PSNet

psnet.ahrq.gov/issue/make-or-buy-patient-safety-solutions-resource-dependence-and-transaction-cost-economics

April 08, 2008 - Study To make or buy patient safety solutions: a resource dependence and transaction cost economics perspective. Citation Text: Fareed N, Mick SS. To make or buy patient safety solutions: a resource dependence and transaction cost economics perspective. Health Care Manage Rev. 2011;36(…

Association of open communication and the emotional and behavioural impact of medical error on patients and families: state-wide cross-sectional survey. | PSNet

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February 16, 2022 - Study Association of open communication and the emotional and behavioural impact of medical error on patients and families: state-wide cross-sectional survey. Citation Text: Prentice JC, Bell SK, Thomas EJ, et al. Association of open communication and the emotional and behavioural impact…

Review of computerized physician handoff tools for improving the quality of patient care. | PSNet

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September 07, 2011 - Review Review of computerized physician handoff tools for improving the quality of patient care. Citation Text: Li P, Ali S, Tang C, et al. Review of computerized physician handoff tools for improving the quality of patient care. J Hosp Med. 2013;8(8):456-63. doi:10.1002/jhm.1988. C…

When order sets do not align with clinician workflow: assessing practice patterns in the electronic health record. | PSNet

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March 24, 2019 - Study When order sets do not align with clinician workflow: assessing practice patterns in the electronic health record. Citation Text: Li RC, Wang JK, Sharp C, et al. When order sets do not align with clinician workflow: assessing practice patterns in the electronic health record. BMJ Q…

Electronic health record-based surveillance of diagnostic errors in primary care. | PSNet

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April 09, 2013 - Study Electronic health record-based surveillance of diagnostic errors in primary care. Citation Text: Singh H, Giardina TD, Forjuoh SN, et al. Electronic health record-based surveillance of diagnostic errors in primary care. BMJ Qual Saf. 2012;21(2):93-100. doi:10.1136/bmjqs-2011-0003…

Communication-and-resolution programs: the challenges and lessons learned from six early adopters. | PSNet

psnet.ahrq.gov/issue/communication-and-resolution-programs-challenges-and-lessons-learned-six-early-adopters

September 29, 2017 - Study Classic Communication-and-resolution programs: the challenges and lessons learned from six early adopters. Citation Text: Mello MM, Boothman RC, McDonald TB, et al. Communication-and-resolution programs: the challenges and lessons learned from six early ad…

Adverse events in Italian nursing homes during the COVID-19 epidemic: a national survey. | PSNet

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December 16, 2020 - Study Adverse events in Italian nursing homes during the COVID-19 epidemic: a national survey. Citation Text: Lombardo FL, Salvi E, Lacorte E, et al. Adverse events in Italian nursing homes during the COVID-19 epidemic: a national survey. Front Psychiatry. 2020;11:578465. Copy Citation…

Incorrect surgical procedures within and outside of the operating room. | PSNet

psnet.ahrq.gov/issue/incorrect-surgical-procedures-within-and-outside-operating-room

November 21, 2011 - Study Incorrect surgical procedures within and outside of the operating room. Citation Text: Neily J, Mills PD, Eldridge N, et al. Incorrect surgical procedures within and outside of the operating room. Arch Surg. 2009;144(11):1028-34. doi:10.1001/archsurg.2009.126. Copy Citation F…

Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. | PSNet

psnet.ahrq.gov/issue/delivering-high-quality-cancer-care-charting-new-course-system-crisis

August 15, 2012 - Book/Report Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Citation Text: Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Levit L, Balogh E, Nass S, Ganz PA, eds. Committee on Improving the Quality of Cancer Care: Add…

US emergency department visits for outpatient adverse drug events, 2013–2014. | PSNet

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February 23, 2018 - Study Classic US emergency department visits for outpatient adverse drug events, 2013–2014. Citation Text: Shehab N, Lovegrove MC, Geller AI, et al. US Emergency Department Visits for Outpatient Adverse Drug Events, 2013-2014. JAMA. 2016;316(20):2115-2125. doi:1…

Characterising the nature of primary care patient safety incident reports in the England and Wales National Reporting and Learning System: a mixed-methods agenda-setting study for general practice. | PSNet

psnet.ahrq.gov/issue/characterising-nature-primary-care-patient-safety-incident-reports-england-and-wales-national

December 16, 2015 - Book/Report Characterising the nature of primary care patient safety incident reports in the England and Wales National Reporting and Learning System: a mixed-methods agenda-setting study for general practice. Citation Text: Carson-Stevens A, Hibbert P, Williams H, et al. Characterising …

Outcomes in two Massachusetts hospital systems give reason for optimism about communication-and-resolution programs. | PSNet

psnet.ahrq.gov/issue/outcomes-two-massachusetts-hospital-systems-give-reason-optimism-about-communication-and

December 19, 2018 - Study Outcomes in two Massachusetts hospital systems give reason for optimism about communication-and-resolution programs. Citation Text: Mello MM, Kachalia A, Roche S, et al. Outcomes In Two Massachusetts Hospital Systems Give Reason For Optimism About Communication-And-Resolution Progr…

Association between mobile telephone interruptions and medication administration errors in a pediatric intensive care unit. | PSNet

psnet.ahrq.gov/issue/association-between-mobile-telephone-interruptions-and-medication-administration-errors

June 29, 2009 - Study Association between mobile telephone interruptions and medication administration errors in a pediatric intensive care unit. Citation Text: Bonafide CP, Miller JM, Localio AR, et al. Association between mobile telephone interruptions and medication administration errors in a pediatr…

Inadequate hand-off communication. | PSNet

psnet.ahrq.gov/issue/inadequate-hand-communication

April 02, 2015 - Sentinel Event Alerts Inadequate hand-off communication. Citation Text: Inadequate hand-off communication. Sentinel event alert. 2017;58(58):1-6. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download C…

Patient harm resulting from medication reconciliation process failures: a study of serious events reported by Pennsylvania hospitals. | PSNet

psnet.ahrq.gov/issue/patient-harm-resulting-medication-reconciliation-process-failures-study-serious-events

October 07, 2020 - Study Patient harm resulting from medication reconciliation process failures: a study of serious events reported by Pennsylvania hospitals. Citation Text: Harper A, Kukielka E, Jones RM. Patient harm resulting from medication reconciliation process failures: a study of serious events rep…

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