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

psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-reduce-risk-heparin-use

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. …

Improving patient safety by identifying side effects from introducing bar coding in medication administration. | PSNet

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March 11, 2011 - Study Classic Improving patient safety by identifying side effects from introducing bar coding in medication administration. Citation Text: Patterson ES, Cook RI, Render ML. Improving patient safety by identifying side effects from introducing bar coding in me…

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…

Development of a theoretical framework of factors affecting patient safety incident reporting: a theoretical review of the literature. | PSNet

psnet.ahrq.gov/issue/development-theoretical-framework-factors-affecting-patient-safety-incident-reporting

January 19, 2016 - Review Development of a theoretical framework of factors affecting patient safety incident reporting: a theoretical review of the literature. Citation Text: Archer S, Hull L, Soukup T, et al. Development of a theoretical framework of factors affecting patient safety incident reporting: a…

Widespread misinterpretation of advance directives and Portable Orders for Life-Sustaining Treatments threatens patient safety and causes undertreatment and overtreatment. | PSNet

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December 18, 2019 - Commentary Widespread misinterpretation of advance directives and Portable Orders for Life-Sustaining Treatments threatens patient safety and causes undertreatment and overtreatment. Citation Text: Mirarchi FL, Pope TM. Widespread misinterpretation of advance directives and Portable Orde…

Toward improving patient safety through voluntary peer-to-peer assessment. | PSNet

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August 25, 2015 - Commentary Toward improving patient safety through voluntary peer-to-peer assessment. Citation Text: Hudson DW, Holzmueller CG, Pronovost P, et al. Toward improving patient safety through voluntary peer-to-peer assessment. Am J Med Qual. 2012;27(3):201-9. doi:10.1177/1062860611421981. …

Paying the piper: investing in infrastructure for patient safety. | PSNet

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July 01, 2017 - Commentary Classic Paying the piper: investing in infrastructure for patient safety. Citation Text: Pronovost P, Rosenstein BJ, Paine LA, et al. Paying the piper: investing in infrastructure for patient safety. Jt Comm J Qual Patient Saf. 2008;34(6):342-8. Co…

Transforming team performance through reimplementation of the surgical safety checklist. | PSNet

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March 09, 2022 - Study Transforming team performance through reimplementation of the surgical safety checklist. Citation Text: Etheridge JC, Moyal-Smith R, Yong TT, et al. Transforming team performance through reimplementation of the surgical safety checklist. JAMA Surg. 2024;159(1):78-86. doi:10.1001/ja…

Interventions to improve safe and effective medicines use by consumers: an overview of systematic reviews. | PSNet

psnet.ahrq.gov/issue/interventions-improve-safe-and-effective-medicines-use-consumers-overview-systematic-reviews

July 19, 2023 - Review Interventions to improve safe and effective medicines use by consumers: an overview of systematic reviews. Citation Text: Ryan R, Santesso N, Lowe D, et al. Interventions to improve safe and effective medicines use by consumers: an overview of systematic reviews. Cochrane Database…

Exploring pharmacist experiences of delivering individualised prescribing error feedback in an acute hospital setting. | PSNet

psnet.ahrq.gov/issue/exploring-pharmacist-experiences-delivering-individualised-prescribing-error-feedback-acute

May 30, 2016 - Study Exploring pharmacist experiences of delivering individualised prescribing error feedback in an acute hospital setting. Citation Text: Lloyd M, Watmough SD, O'Brien S, et al. Exploring pharmacist experiences of delivering individualised prescribing error feedback in an acute hospita…

Patient Safety Leadership WalkRounds™ at Partners HealthCare: learning from implementation. | PSNet

psnet.ahrq.gov/issue/patient-safety-leadership-walkroundstm-partners-healthcare-learning-implementation

January 04, 2017 - Study Patient Safety Leadership WalkRounds™ at Partners HealthCare: learning from implementation. Citation Text: Frankel A, Grillo SP, Baker EG, et al. Patient Safety Leadership WalkRounds at Partners Healthcare: learning from implementation. Jt Comm J Qual Patient Saf. 2005;31(8):423-37…

'Whatever you cut, I can fix it': clinical supervisors' interview accounts of allowing trainee failure while guarding patient safety. | PSNet

psnet.ahrq.gov/issue/whatever-you-cut-i-can-fix-it-clinical-supervisors-interview-accounts-allowing-trainee

November 24, 2021 - Study 'Whatever you cut, I can fix it': clinical supervisors' interview accounts of allowing trainee failure while guarding patient safety. Citation Text: Klasen JM, Driessen E, Teunissen PW, et al. ‘Whatever you cut, I can fix it’: clinical supervisors’ interview accounts of allowing t…

The relationship between culture of safety and rate of adverse events in long-term care facilities. | PSNet

psnet.ahrq.gov/issue/relationship-between-culture-safety-and-rate-adverse-events-long-term-care-facilities

June 09, 2021 - Study The relationship between culture of safety and rate of adverse events in long-term care facilities. Citation Text: Abusalem S, Polivka B, Coty M-B, et al. The Relationship Between Culture of Safety and Rate of Adverse Events in Long-Term Care Facilities. J Patient Saf. 2021;17(4):2…

Autopsy as a quality control measure for radiology, and vice versa. | PSNet

psnet.ahrq.gov/issue/autopsy-quality-control-measure-radiology-and-vice-versa

April 24, 2018 - Study Autopsy as a quality control measure for radiology, and vice versa. Citation Text: Murken DR, Ding M, Branstetter BF, et al. Autopsy as a quality control measure for radiology, and vice versa. AJR Am J Roentgenol. 2012;199(2):394-401. doi:10.2214/AJR.11.8386. Copy Citation Fo…

Less is more: a project to reduce the number of PIMs (potentially inappropriate medications) on an elderly care ward. | PSNet

psnet.ahrq.gov/issue/less-more-project-reduce-number-pims-potentially-inappropriate-medications-elderly-care-ward

September 27, 2017 - Commentary Less is more: a project to reduce the number of PIMs (potentially inappropriate medications) on an elderly care ward. Citation Text: Aung TH, Beck AJ, Siese T, et al. Less is more: a project to reduce the number of PIMs (potentially inappropriate medications) on an elderly car…

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