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Creation of root cause analysis and action (RCA2) standard work by a multidisciplinary team to prevent harm, reduce bias, and improve safety culture. | PSNet

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October 19, 2022 - Study Creation of root cause analysis and action (RCA2) standard work by a multidisciplinary team to prevent harm, reduce bias, and improve safety culture. Citation Text: Musheno D, Harnish M, Roberts J, et al. Creation of root cause analysis and action (RCA2) standard work by a multidis…

Understanding the factors influencing implementation of a new national patient safety policy in England: lessons from 'Learning from Deaths'. | PSNet

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August 18, 2021 - Study Understanding the factors influencing implementation of a new national patient safety policy in England: lessons from 'Learning from Deaths'. Citation Text: Lalani M, Morgan S, Basu A, et al. Understanding the factors influencing implementation of a new national patient safety pol…

Combined proactive risk assessment: unifying proactive and reactive risk assessment techniques in health care. | PSNet

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May 11, 2022 - Study Combined proactive risk assessment: unifying proactive and reactive risk assessment techniques in health care. Citation Text: Bender JA, Kulju S, Soncrant C. Combined proactive risk assessment: unifying proactive and reactive risk assessment techniques in health care. Jt Comm J Qua…

Potential biases in machine learning algorithms using electronic health record data. | PSNet

psnet.ahrq.gov/issue/potential-biases-machine-learning-algorithms-using-electronic-health-record-data

June 12, 2019 - Commentary Classic Potential biases in machine learning algorithms using electronic health record data. Citation Text: Gianfrancesco MA, Tamang S, Yazdany J, et al. Potential Biases in Machine Learning Algorithms Using Electronic Health Record Data. JAMA Intern …

Uncovering the risks of anticancer therapy through incident report analysis using a newly developed medical oncology incident taxonomy. | PSNet

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January 29, 2018 - Study Uncovering the risks of anticancer therapy through incident report analysis using a newly developed medical oncology incident taxonomy. Citation Text: Jacobson JO, Zerillo JA, Doolin J, et al. Uncovering the risks of anticancer therapy through incident report analysis using a newly…

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…

Unintended effects of a computerized physician order entry nearly hard-stop alert to prevent a drug interaction: a randomized controlled trial. | PSNet

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February 18, 2011 - Study Classic Unintended effects of a computerized physician order entry nearly hard-stop alert to prevent a drug interaction: a randomized controlled trial. Citation Text: Strom BL, Schinnar R, Aberra F, et al. Unintended effects of a computerized physician ord…

Why is learning from patient safety incidents (still) so hard? A sociocultural perspective on learning from incidents in healthcare organizations. | PSNet

psnet.ahrq.gov/issue/why-learning-patient-safety-incidents-still-so-hard-sociocultural-perspective-learning

June 29, 2011 - Study Why is learning from patient safety incidents (still) so hard? A sociocultural perspective on learning from incidents in healthcare organizations. Citation Text: Rowland P, Lan MF, Wan C, et al. Why is learning from patient safety incidents (still) so hard? A sociocultural perspect…

Comparison of methods to reduce bias from clinical prediction models of postpartum depression. | PSNet

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April 15, 2020 - Study Comparison of methods to reduce bias from clinical prediction models of postpartum depression. Citation Text: Park Y, Hu J, Singh M, et al. Comparison of methods to reduce bias from clinical prediction models of postpartum depression. JAMA Netw Open. 2021;4(4):e213909. doi:10.1001/…

Medication dosing safety for pediatric patients: recognizing gaps, safety threats, and best practices in the emergency medical services setting. A position statement and resource document from NAEMSP. | PSNet

psnet.ahrq.gov/issue/medication-dosing-safety-pediatric-patients-recognizing-gaps-safety-threats-and-best

March 01, 2023 - Organizational Policy/Guidelines Medication dosing safety for pediatric patients: recognizing gaps, safety threats, and best practices in the emergency medical services setting. A position statement and resource document from NAEMSP. Citation Text: Cicero MX, Adelgais K, Hoyle JD, et al.…

Nature of blame in patient safety incident reports: mixed methods analysis of a national database. | PSNet

psnet.ahrq.gov/issue/nature-blame-patient-safety-incident-reports-mixed-methods-analysis-national-database

October 12, 2016 - Study Nature of blame in patient safety incident reports: mixed methods analysis of a national database. Citation Text: Cooper J, Edwards A, Williams H, et al. Nature of Blame in Patient Safety Incident Reports: Mixed Methods Analysis of a National Database. Ann Fam Med. 2017;15(5):455-4…

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

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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 …

Stroke hospitalization after misdiagnosis of "benign dizziness" is lower in specialty care than general practice: a population-based cohort analysis of missed stroke using SPADE methods. | PSNet

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May 12, 2021 - Study Stroke hospitalization after misdiagnosis of "benign dizziness" is lower in specialty care than general practice: a population-based cohort analysis of missed stroke using SPADE methods. Citation Text: Chang T-P, Bery AK, Wang Z, et al. Stroke hospitalization after misdiagnosis of …

Stakeholder perspectives on contributors to delayed and inaccurate diagnosis of cardiovascular disease and their implications for digital health technologies: a UK-based qualitative study. | PSNet

psnet.ahrq.gov/issue/stakeholder-perspectives-contributors-delayed-and-inaccurate-diagnosis-cardiovascular-disease

August 18, 2021 - Study Stakeholder perspectives on contributors to delayed and inaccurate diagnosis of cardiovascular disease and their implications for digital health technologies: a UK-based qualitative study. Citation Text: Abdullayev K, Gorvett O, Sochiera A, et al. Stakeholder perspectives on contri…

Assertive communication training for nurses to speak up in cases of medical errors: a systematic review and meta-analysis. | PSNet

psnet.ahrq.gov/issue/assertive-communication-training-nurses-speak-cases-medical-errors-systematic-review-and-meta

April 15, 2020 - Review Assertive communication training for nurses to speak up in cases of medical errors: a systematic review and meta-analysis. Citation Text: Chen H-W, Wu J-C, Kang Y-N, et al. Assertive communication training for nurses to speak up in cases of medical errors: a systematic review and …

Provider-patient communication and hospital ratings: perceived gaps and forward thinking about the effects of COVID-19. | PSNet

psnet.ahrq.gov/issue/provider-patient-communication-and-hospital-ratings-perceived-gaps-and-forward-thinking-about

December 16, 2020 - Study Provider-patient communication and hospital ratings: perceived gaps and forward thinking about the effects of COVID-19. Citation Text: Belasen AT, Hertelendy AJ, Belasen AR, et al. Provider–patient communication and hospital ratings: perceived gaps and forward thinking about the ef…

The impact of computerized provider order entry on medication errors in a multispecialty group practice. | PSNet

psnet.ahrq.gov/issue/impact-computerized-provider-order-entry-medication-errors-multispecialty-group-practice

August 31, 2011 - Study The impact of computerized provider order entry on medication errors in a multispecialty group practice. Citation Text: Devine EB, Hansen RN, Wilson-Norton JL, et al. The impact of computerized provider order entry on medication errors in a multispecialty group practice. J Am Med…

Multispecialty physician online survey reveals that burnout related to adverse event involvement may be mitigated by peer support. | PSNet

psnet.ahrq.gov/issue/multispecialty-physician-online-survey-reveals-burnout-related-adverse-event-involvement-may

July 13, 2022 - Study Multispecialty physician online survey reveals that burnout related to adverse event involvement may be mitigated by peer support. Citation Text: Gupta K, Rivadeneira NA, Lisker S, et al. Multispecialty physician online survey reveals that burnout related to adverse event involveme…

Preventing pregnancy-related mental health deaths: insights from 14 US maternal mortality review committees, 2008-17. | PSNet

psnet.ahrq.gov/issue/preventing-pregnancy-related-mental-health-deaths-insights-14-us-maternal-mortality-review

November 10, 2021 - Study Preventing pregnancy-related mental health deaths: insights from 14 US maternal mortality review committees, 2008-17. Citation Text: Trost SL, Beauregard JL, Smoots AN, et al. Preventing pregnancy-related mental health deaths: insights from 14 US maternal mortality review committee…

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