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Equipment-related incidents in the operating room: an analysis of occurrence, underlying causes and consequences for the clinical process. | PSNet

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February 14, 2024 - Study Equipment-related incidents in the operating room: an analysis of occurrence, underlying causes and consequences for the clinical process. Citation Text: Wubben I, van Manen JG, van den Akker BJ, et al. Equipment-related incidents in the operating room: an analysis of occurrence,…

Root cause analysis of transfusion error: identifying causes to implement changes. | PSNet

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August 15, 2018 - Commentary Root cause analysis of transfusion error: identifying causes to implement changes. Citation Text: Elhence P, Veena S, Sharma RK, et al. Root cause analysis of transfusion error: identifying causes to implement changes. Transfusion (Paris). 2010;50(12 Pt 2):2772-2777. doi:10.…

FOCUS: The Society of Cardiovascular Anesthesiologists' initiative to improve quality and safety in the cardiovascular operating room. | PSNet

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January 03, 2017 - Commentary FOCUS: The Society of Cardiovascular Anesthesiologists' initiative to improve quality and safety in the cardiovascular operating room. Citation Text: Barbeito A, Lau WT, Weitzel N, et al. FOCUS: the Society of Cardiovascular Anesthesiologists' initiative to improve quality and…

Understanding ultrarare adverse events - lessons learned from a twelve-year review of intraoperative deaths at an academic medical center. | PSNet

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March 29, 2023 - Review Understanding ultrarare adverse events - lessons learned from a twelve-year review of intraoperative deaths at an academic medical center. Citation Text: Cohen TN, Kanji FF, Wang AS, et al. Understanding ultrarare adverse events - lessons learned from a twelve-year review of intra…

Incidence of prescription errors in patients discharged from the emergency department. | PSNet

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March 30, 2022 - Study Incidence of prescription errors in patients discharged from the emergency department. Citation Text: Gregory H, Cantley M, Calhoun C, et al. Incidence of prescription errors in patients discharged from the emergency department. Am J Emerg Med. 2021;46:266-270. doi:10.1016/j.ajem.2…

Measuring communication in the surgical ICU: better communication equals better care. | PSNet

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April 03, 2005 - Study Measuring communication in the surgical ICU: better communication equals better care. Citation Text: Williams M, Hevelone N, Alban RF, et al. Measuring communication in the surgical ICU: better communication equals better care. J Am Coll Surg. 2010;210(1):17-22. doi:10.1016/j.jamc…

A decade of health information technology usability challenges and the path forward. | PSNet

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January 16, 2019 - Commentary Emerging Classic A decade of health information technology usability challenges and the path forward. Citation Text: Ratwani RM, Reider J, Singh H. A Decade of Health Information Technology Usability Challenges and the Path Forward. JAMA. 2019;321(8):…

Compliance to technical guidelines for radiotherapy treatment in relation to patient safety. | PSNet

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December 10, 2014 - Study Compliance to technical guidelines for radiotherapy treatment in relation to patient safety. Citation Text: Simons PAM, Houben RMA, Backes HH, et al. Compliance to technical guidelines for radiotherapy treatment in relation to patient safety. Int J Qual Health Care. 2010;22(3):18…

A multiple-drawer medication layout problem in automated dispensing cabinets. | PSNet

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December 21, 2017 - Study A multiple-drawer medication layout problem in automated dispensing cabinets. Citation Text: Pazour JA, Meller RD. A multiple-drawer medication layout problem in automated dispensing cabinets. Health Care Manag Sci. 2012;15(4). doi:10.1007/s10729-012-9197-8. Copy Citation Fo…

Errors prevented by and associated with bar-code medication administration systems. | PSNet

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October 16, 2019 - Study Errors prevented by and associated with bar-code medication administration systems. Citation Text: Cochran GL, Jones KJ, Brockman J, et al. Errors prevented by and associated with bar-code medication administration systems. Jt Comm J Qual Patient Saf. 2007;33(5):293-301, 245. Cop…

Continuous monitoring of adverse events: influence on the quality of care and the incidence of errors in general surgery. | PSNet

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March 09, 2022 - Study Continuous monitoring of adverse events: influence on the quality of care and the incidence of errors in general surgery. Citation Text: Rebasa P, Mora L, Luna A, et al. Continuous monitoring of adverse events: influence on the quality of care and the incidence of errors in gener…

Teaching medical students about medical errors and patient safety: evaluation of a required curriculum. | PSNet

psnet.ahrq.gov/issue/teaching-medical-students-about-medical-errors-and-patient-safety-evaluation-required

June 08, 2022 - Study Teaching medical students about medical errors and patient safety: evaluation of a required curriculum. Citation Text: Halbach JL, Sullivan LL. Teaching medical students about medical errors and patient safety: evaluation of a required curriculum. Acad Med. 2005;80(6):600-6. Co…

The interpretability of doctor identification badges in UK hospitals: a survey of nurses and patients. | PSNet

psnet.ahrq.gov/issue/interpretability-doctor-identification-badges-uk-hospitals-survey-nurses-and-patients

October 07, 2013 - Study The interpretability of doctor identification badges in UK hospitals: a survey of nurses and patients. Citation Text: Hickerton BC, Fitzgerald DJ, Perry E, et al. The interpretability of doctor identification badges in UK hospitals: a survey of nurses and patients. BMJ Qual Saf. 20…

Improving patient safety using the sterile cockpit principle during medication administration: a collaborative, unit-based project. | PSNet

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September 12, 2016 - Study Improving patient safety using the sterile cockpit principle during medication administration: a collaborative, unit-based project. Citation Text: Fore AM, Sculli GL, Albee D, et al. Improving patient safety using the sterile cockpit principle during medication administration: a…

Between choice and chance: the role of human factors in acute care equipment decisions. | PSNet

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February 22, 2023 - Study Between choice and chance: the role of human factors in acute care equipment decisions. Citation Text: Nemeth CP, Nunnally M, Bitan Y, et al. Between choice and chance: the role of human factors in acute care equipment decisions. J Patient Saf. 2009;5(2):114-21. doi:10.1097/PTS.0…

What 'just culture' doesn't understand about just punishment. | PSNet

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December 30, 2014 - Commentary What 'just culture' doesn't understand about just punishment. Citation Text: Reis-Dennis S. What 'Just Culture' doesn't understand about just punishment. J Med Ethics. 2018;44(11):739-742. doi:10.1136/medethics-2018-104911. Copy Citation Format: DOI Google Schola…

Long-term effects of an e-learning course on patient safety: a controlled longitudinal study with medical students. | PSNet

psnet.ahrq.gov/issue/long-term-effects-e-learning-course-patient-safety-controlled-longitudinal-study-medical

March 16, 2016 - Study Long-term effects of an e-learning course on patient safety: a controlled longitudinal study with medical students. Citation Text: Gaupp R, Dinius J, Drazic I, et al. Long-term effects of an e-learning course on patient safety: A controlled longitudinal study with medical students.…

Detection, classification, and correction of defective chemotherapy orders through nursing and pharmacy oversight. | PSNet

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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…

Use of an electronic information system to identify adverse events resulting in an emergency department visit. | PSNet

psnet.ahrq.gov/issue/use-electronic-information-system-identify-adverse-events-resulting-emergency-department

March 13, 2015 - Study Use of an electronic information system to identify adverse events resulting in an emergency department visit. Citation Text: Ackroyd-Stolarz S, MacKinnon NJ, Zed PJ, et al. Use of an electronic information system to identify adverse events resulting in an emergency department vi…

The role of safety culture in influencing provider perceptions of patient safety. | PSNet

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November 09, 2016 - Study The role of safety culture in influencing provider perceptions of patient safety. Citation Text: Bishop A, Boyle TA. The Role of Safety Culture in Influencing Provider Perceptions of Patient Safety. J Patient Saf. 2016;12(4):204-209. Copy Citation Format: Google Schol…

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