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Human factors analysis of latent safety threats in a pediatric critical care unit. | PSNet

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April 28, 2021 - Study Human factors analysis of latent safety threats in a pediatric critical care unit. Citation Text: Trbovich PL, Tomasi JN, Kolodzey L, et al. Human factors analysis of latent safety threats in a pediatric critical care unit. Pediatr Crit Care Med. 2022;23(3):151-159. doi:10.1097/pcc…

Where trust flourishes: perceptions of clinicians who trust their organizations and are trusted by their patients. | PSNet

psnet.ahrq.gov/issue/where-trust-flourishes-perceptions-clinicians-who-trust-their-organizations-and-are-trusted

March 15, 2023 - Study Where trust flourishes: perceptions of clinicians who trust their organizations and are trusted by their patients. Citation Text: Linzer M, Neprash HT, Brown RL, et al. Where trust flourishes: perceptions of clinicians who trust their organizations and are trusted by their patients…

Polypharmacy in hospitalized older adult cancer patients: experience from a prospective, observational study of an oncology-acute care for elders unit. | PSNet

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July 19, 2023 - Study Polypharmacy in hospitalized older adult cancer patients: experience from a prospective, observational study of an oncology-acute care for elders unit. Citation Text: Flood KL, Carroll MB, Le C, et al. Polypharmacy in hospitalized older adult cancer patients: experience from a …

Patterns of opioid administration among opioid-naive inpatients and associations with postdischarge opioid use: a cohort study. | PSNet

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November 05, 2008 - Study Patterns of opioid administration among opioid-naive inpatients and associations with postdischarge opioid use: a cohort study. Citation Text: Donohue JM, Kennedy JN, Seymour CW, et al. Patterns of Opioid Administration Among Opioid-Naive Inpatients and Associations With Postdischa…

The relationship between hospital systems load and patient harm. | PSNet

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November 12, 2008 - Study The relationship between hospital systems load and patient harm. Citation Text: Pedroja AT, Blegen MA, Abravanel R, et al. The relationship between hospital systems load and patient harm. J Patient Saf. 2014;10(3):168-75. doi:10.1097/PTS.0b013e31829e4f82. Copy Citation Format…

Why studying human behavior is a critical component of patient safety. | PSNet

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January 15, 2020 - Commentary Why studying human behavior is a critical component of patient safety. Citation Text: Su L. Why Studying Human Behavior is a Critical Component of Patient Safety. Curr Probl Pediatr Adolesc Health Care. 2015;45(12):367-9. doi:10.1016/j.cppeds.2015.10.004. Copy Citation F…

Inequities in quality and safety outcomes for hospitalized children with intellectual disability. | PSNet

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June 15, 2022 - Study Inequities in quality and safety outcomes for hospitalized children with intellectual disability. Citation Text: Mimmo L, Harrison R, Travaglia J, et al. Inequities in quality and safety outcomes for hospitalized children with intellectual disability. Dev Med Child Neurol. 2022;64(…

Responsibility for quality improvement and patient safety: hospital board and medical staff leadership challenges. | PSNet

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April 27, 2010 - Review Responsibility for quality improvement and patient safety: hospital board and medical staff leadership challenges. Citation Text: Goeschel CA, Wachter R, Pronovost P. Responsibility for quality improvement and patient safety: hospital board and medical staff leadership challeng…

Advancing health equity in patient safety: a reckoning, challenge and opportunity. | PSNet

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February 23, 2022 - Commentary Advancing health equity in patient safety: a reckoning, challenge and opportunity. Citation Text: Chin MH. Advancing health equity in patient safety: a reckoning, challenge and opportunity. BMJ Qual Saf. 2021;30(5):356-361. doi:10.1136/bmjqs-2020-012599. Copy Citation Fo…

Delivery of optimized inpatient anticoagulation therapy: consensus statement from the Anticoagulation Forum. | PSNet

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March 04, 2020 - Commentary Delivery of optimized inpatient anticoagulation therapy: consensus statement from the Anticoagulation Forum. Citation Text: Nutescu EA, Wittkowsky AK, Burnett A, et al. Delivery of optimized inpatient anticoagulation therapy: consensus statement from the anticoagulation forum…

A data-driven approach to evaluate barcode-assisted medication preparation alerts at a large academic medical center. | PSNet

psnet.ahrq.gov/issue/data-driven-approach-evaluate-barcode-assisted-medication-preparation-alerts-large-academic

October 19, 2022 - Study A data-driven approach to evaluate barcode-assisted medication preparation alerts at a large academic medical center. Citation Text: Joshi RN, Kalaminsky S, Feemster A-A, et al. A data-driven approach to evaluate barcode-assisted medication preparation alerts at a large academic me…

Surgical glove perforation and the risk of surgical site infection. | PSNet

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March 02, 2011 - Study Surgical glove perforation and the risk of surgical site infection. Citation Text: Misteli H, Weber WP, Reck S, et al. Surgical glove perforation and the risk of surgical site infection. Arch Surg. 2009;144(6):553-8; discussion 558. doi:10.1001/archsurg.2009.60. Copy Citation …

Standards for patient monitoring during general anesthesia at Harvard Medical School. | PSNet

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February 10, 2011 - Clinical Guideline Standards for patient monitoring during general anesthesia at Harvard Medical School. Citation Text: Eichhorn JH, Cooper JB, Cullen DJ, et al. Standards for patient monitoring during anesthesia at Harvard Medical School. JAMA. 1986;256(8):1017-20. Copy Citation F…

Failure mode and effects analysis to reduce risk of heparin use. | PSNet

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July 19, 2023 - Study Failure mode and effects analysis to reduce risk of heparin use. Citation Text: Pino FA, Weidemann DK, Schroeder LL, et al. Failure mode and effects analysis to reduce risk of heparin use. Am J Health Syst Pharm. 2019;76(23):1972-1979. doi:10.1093/ajhp/zxz229. Copy Citation F…

Practice and quality improvement: successful implementation of TeamSTEPPS tools into an academic interventional ultrasound practice. | PSNet

psnet.ahrq.gov/issue/practice-and-quality-improvement-successful-implementation-teamstepps-tools-academic

April 17, 2019 - Study Practice and quality improvement: successful implementation of TeamSTEPPS tools into an academic interventional ultrasound practice. Citation Text: Gupta RT, Sexton B, Milne J, et al. Practice and quality improvement: successful implementation of TeamSTEPPS tools into an academic i…

Race differences in reported "near miss" patient safety events in health care system high reliability organizations. | PSNet

psnet.ahrq.gov/issue/race-differences-reported-near-miss-patient-safety-events-health-care-system-high-reliability

March 01, 2023 - Study Race differences in reported "near miss" patient safety events in health care system high reliability organizations. Citation Text: Thomas AD, Pandit C, Krevat S. Race differences in reported "near miss" patient safety events in health care system high reliability organizations. J …

Getting doctors to report medical errors: project DISCLOSE. | PSNet

psnet.ahrq.gov/issue/getting-doctors-report-medical-errors-project-disclose

January 07, 2011 - Study Getting doctors to report medical errors: project DISCLOSE. Citation Text: King ES, Moyer D, Couturie MJ, et al. Getting doctors to report medical errors: project DISCLOSE. Jt Comm J Qual Patient Saf. 2006;32(7):382-392. Copy Citation Format: Google Scholar PubMed B…

Risk factors for retained instruments and sponges after surgery. | PSNet

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February 17, 2011 - Study Classic Risk factors for retained instruments and sponges after surgery. Citation Text: Gawande AA, Studdert DM, Orav J, et al. Risk factors for retained instruments and sponges after surgery. N Engl J Med. 2003;348(3):229-35. Copy Citation Format:…

Examining the relationship between nurse fatigue, alertness, and medication errors. | PSNet

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October 10, 2015 - Study Examining the relationship between nurse fatigue, alertness, and medication errors. Citation Text: Farag A, Gallagher J, Carr L. Examining the relationship between nurse fatigue, alertness, and medication errors. West J Nurs Res. 2024;46(4):288-295. doi:10.1177/01939459241236631. …

An examination of opportunities for the active patient in improving patient safety. | PSNet

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October 04, 2011 - Review An examination of opportunities for the active patient in improving patient safety. Citation Text: Davis R, Sevdalis N, Jacklin R, et al. An examination of opportunities for the active patient in improving patient safety. J Patient Saf. 2012;8(1):36-43. doi:10.1097/PTS.0b013e318…

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