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Showing results for "occurring".

  1. Wrong-site nerve blocks: a systematic literature review to guide principles for prevention. | PSNet

    psnet.ahrq.gov/issue/wrong-site-nerve-blocks-systematic-literature-review-guide-principles-prevention
    July 22, 2020 - Review Wrong-site nerve blocks: a systematic literature review to guide principles for prevention. Citation Text: Deutsch ES, Yonash RA, Martin DE, et al. Wrong-site nerve blocks: A systematic literature review to guide principles for prevention. J Clin Anesth. 2018;46:101-111. doi:10.10…

  2. Hospital readmissions: physician awareness and communication practices. | PSNet

    psnet.ahrq.gov/issue/hospital-readmissions-physician-awareness-and-communication-practices
    December 19, 2009 - Study Classic Hospital readmissions: physician awareness and communication practices. Citation Text: Roy CL, Kachalia A, Woolf S, et al. Hospital readmissions: physician awareness and communication practices. J Gen Intern Med. 2009;24(3):374-80. doi:10.1007/s1…

  3. When doing wrong feels so right: normalization of deviance. | PSNet

    psnet.ahrq.gov/issue/when-doing-wrong-feels-so-right-normalization-deviance
    September 03, 2011 - Review When doing wrong feels so right: normalization of deviance. Citation Text: Price MR, Williams TC. When Doing Wrong Feels So Right: Normalization of Deviance. J Patient Saf. 2018;14(1):1-2. doi:10.1097/PTS.0000000000000157. Copy Citation Format: DOI Google Scholar Pub…

  4. 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…

  5. Safety of inpatient care in surgical settings: cohort study. | PSNet

    psnet.ahrq.gov/issue/safety-inpatient-care-surgical-settings-cohort-study
    May 15, 2024 - Study Safety of inpatient care in surgical settings: cohort study. Citation Text: Duclos A, Frits ML, Iannaccone C, et al. Safety of inpatient care in surgical settings: cohort study. BMJ. 2024;387:e080480. doi:10.1136/bmj-2024-080480. Copy Citation Format: DOI Google Schol…

  6. 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…

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

    psnet.ahrq.gov/issue/developing-and-pilot-testing-practical-measures-preanalytic-surgical-specimen-identification
    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…

  8. 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…

  9. Review of alternatives to root cause analysis: developing a robust system for incident report analysis. | PSNet

    psnet.ahrq.gov/issue/review-alternatives-root-cause-analysis-developing-robust-system-incident-report-analysis
    November 14, 2018 - Review Review of alternatives to root cause analysis: developing a robust system for incident report analysis. Citation Text: Hagley G, Mills PD, Watts B, et al. Review of alternatives to root cause analysis: developing a robust system for incident report analysis. BMJ Open Qual. 2019;8(…

  10. Specimen labeling errors in surgical pathology: an 18-month experience. | PSNet

    psnet.ahrq.gov/issue/specimen-labeling-errors-surgical-pathology-18-month-experience
    January 04, 2012 - Study Specimen labeling errors in surgical pathology: an 18-month experience. Citation Text: Layfield LJ, Anderson GM. Specimen labeling errors in surgical pathology: an 18-month experience. Am J Clin Pathol. 2010;134(3):466-70. doi:10.1309/AJCPHLQHJ0S3DFJK. Copy Citation Format:…

  11. Violations of behavioral practices revealed in closed claims reviews. | PSNet

    psnet.ahrq.gov/issue/violations-behavioral-practices-revealed-closed-claims-reviews
    August 26, 2011 - Study Violations of behavioral practices revealed in closed claims reviews. Citation Text: Griffen FD, Stephens LS, Alexander JB, et al. Violations of behavioral practices revealed in closed claims reviews. Ann Surg. 2008;248(3):468-474. doi:10.1097/sla.0b013e318185e196. Copy Citatio…

  12. Improving surgical complications and patient safety at the nation's largest military hospital: an analysis of National Surgical Quality Improvement Program data. | PSNet

    psnet.ahrq.gov/issue/improving-surgical-complications-and-patient-safety-nations-largest-military-hospital
    November 09, 2022 - Study Improving surgical complications and patient safety at the nation's largest military hospital: an analysis of National Surgical Quality Improvement Program data. Citation Text: Maturo S, Hughes C, Kallingal G, et al. Improving Surgical Complications and Patient Safety at the Nation…

  13. Integrating patient safety education into early medical education utilizing cadaver, sponges, and an inter-professional team. | PSNet

    psnet.ahrq.gov/issue/integrating-patient-safety-education-early-medical-education-utilizing-cadaver-sponges-and
    September 23, 2020 - Commentary Integrating patient safety education into early medical education utilizing cadaver, sponges, and an inter-professional team. Citation Text: Kutaimy R, Zhang L, Blok D, et al. Integrating patient safety education into early medical education utilizing cadaver, sponges, and an …

  14. Preventing central line–associated bloodstream infections in the intensive care unit: application of high-reliability principles. | PSNet

    psnet.ahrq.gov/issue/preventing-central-line-associated-bloodstream-infections-intensive-care-unit-application
    March 10, 2010 - Commentary Preventing central line–associated bloodstream infections in the intensive care unit: application of high-reliability principles. Citation Text: McCraw B, Crutcher T, Polancich S, et al. Preventing Central Line-Associated Bloodstream Infections in the Intensive Care Unit: Appl…

  15. Hospital commitments to address diagnostic errors: an assessment of 95 US hospitals. | PSNet

    psnet.ahrq.gov/issue/hospital-commitments-address-diagnostic-errors-assessment-95-us-hospitals
    September 18, 2024 - Study Hospital commitments to address diagnostic errors: an assessment of 95 US hospitals. Citation Text: Campione Russo A, Tilly J‐L, Kaufman L, et al. Hospital commitments to address diagnostic errors: an assessment of 95 US hospitals. J Hosp Med. 2025;20(2):120-134. doi:10.1002/jhm.13…

  16. Mitigating errors caused by interruptions during medication verification and administration: interventions in a simulated ambulatory chemotherapy setting. | PSNet

    psnet.ahrq.gov/issue/mitigating-errors-caused-interruptions-during-medication-verification-and-administration
    September 24, 2016 - Study Mitigating errors caused by interruptions during medication verification and administration: interventions in a simulated ambulatory chemotherapy setting. Citation Text: Prakash V, Koczmara C, Savage P, et al. Mitigating errors caused by interruptions during medication verification…

  17. Beyond the medical record: other modes of error acknowledgment. | PSNet

    psnet.ahrq.gov/issue/beyond-medical-record-other-modes-error-acknowledgment
    August 03, 2009 - Study Beyond the medical record: other modes of error acknowledgment. Citation Text: Rosenthal M, Cornett PL, Sutcliffe K, et al. Beyond the medical record: other modes of error acknowledgment. J Gen Intern Med. 2005;20(5):404-9. Copy Citation Format: Google Scholar PubMe…

  18. Surgical fire in the United States: 2000-2020. | PSNet

    psnet.ahrq.gov/issue/surgical-fire-united-states-2000-2020
    March 03, 2021 - Study Surgical fire in the United States: 2000-2020. Citation Text: Grauer JS, Kana LA, Alzouhayli SJ, et al. Surgical fire in the United States: 2000–2020. Surgery. 2022;173(2):357-364. doi:10.1016/j.surg.2022.10.015. Copy Citation Format: DOI Google Scholar BibTeX EndNote…

  19. “Those found responsible have been sacked”: some observations on the usefulness of error. | PSNet

    psnet.ahrq.gov/issue/those-found-responsible-have-been-sacked-some-observations-usefulness-error
    September 28, 2010 - Commentary “Those found responsible have been sacked”: some observations on the usefulness of error. Citation Text: Cook RI, Nemeth CP. “Those found responsible have been sacked”: some observations on the usefulness of error. Cogn Tech Work. 2010;12(2):87-93. doi:10.1007/s10111-010-0149-…

  20. Defining patient safety events in inpatient psychiatry. | PSNet

    psnet.ahrq.gov/issue/defining-patient-safety-events-inpatient-psychiatry
    January 30, 2019 - Study Defining patient safety events in inpatient psychiatry. Citation Text: Marcus SC, Hermann R, Cullen SW. Defining Patient Safety Events in Inpatient Psychiatry. J Patient Saf. 2018;17(8):e1452-e1457. doi:10.1097/PTS.0000000000000520. Copy Citation Format: DOI Google Sc…
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