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Are bad outcomes from questionable clinical decisions preventable medical errors? A case of cascade iatrogenesis. | PSNet

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February 24, 2011 - Study Classic Are bad outcomes from questionable clinical decisions preventable medical errors? A case of cascade iatrogenesis. Citation Text: Hofer TP, Hayward RA. Are bad outcomes from questionable clinical decisions preventable medical errors? A case of cas…

A multifaceted approach to safety: the synergistic detection of adverse drug events in adult inpatients. | PSNet

psnet.ahrq.gov/issue/multifaceted-approach-safety-synergistic-detection-adverse-drug-events-adult-inpatients

April 11, 2011 - Study A multifaceted approach to safety: the synergistic detection of adverse drug events in adult inpatients. Citation Text: Ferranti JM, Horvath MM, Cozart H, et al. A Multifaceted Approach to Safety. J Patient Saf. 2008;4(3):184-190. doi:10.1097/pts.0b013e318184a9d5. Copy Citation…

Comparing process- and outcome-oriented approaches to voluntary incident reporting in two hospitals. | PSNet

psnet.ahrq.gov/issue/comparing-process-and-outcome-oriented-approaches-voluntary-incident-reporting-two-hospitals

June 15, 2011 - Study Comparing process- and outcome-oriented approaches to voluntary incident reporting in two hospitals. Citation Text: Nuckols TK, Bell D, Paddock SM, et al. Comparing process- and outcome-oriented approaches to voluntary incident reporting in two hospitals. Jt Comm J Qual Patient Saf…

Programmable infusion pumps in ICUs: an analysis of corresponding adverse drug events. | PSNet

psnet.ahrq.gov/issue/programmable-infusion-pumps-icus-analysis-corresponding-adverse-drug-events

January 16, 2008 - Study Programmable infusion pumps in ICUs: an analysis of corresponding adverse drug events. Citation Text: Nuckols TK, Bower AG, Paddock SM, et al. Programmable infusion pumps in ICUs: an analysis of corresponding adverse drug events. J Gen Intern Med. 2008;23 Suppl 1:41-5. doi:10.100…

"Good catch, Kiddo"--enhancing patient safety in the pediatric emergency department through simulation. | PSNet

psnet.ahrq.gov/issue/good-catch-kiddo-enhancing-patient-safety-pediatric-emergency-department-through-simulation

January 03, 2017 - Study "Good catch, Kiddo"--enhancing patient safety in the pediatric emergency department through simulation. Citation Text: Shaikh U, Natale JAE, Till DA, et al. "Good catch, Kiddo"--enhancing patient safety in the pediatric emergency department through simulation. Pediatr Emerg Care. 2…

Detection of adverse events in surgical patients using the Trigger Tool approach. | PSNet

psnet.ahrq.gov/issue/detection-adverse-events-surgical-patients-using-trigger-tool-approach

February 15, 2011 - Study Detection of adverse events in surgical patients using the Trigger Tool approach. Citation Text: Griffin FA, Classen DC. Detection of adverse events in surgical patients using the Trigger Tool approach. Qual Saf Health Care. 2008;17(4):253-258. doi:10.1136/qshc.2007.025080. Cop…

Lessons learnt from incidents reported by postgraduate trainees in Dutch general practice. A prospective cohort study. | PSNet

psnet.ahrq.gov/issue/lessons-learnt-incidents-reported-postgraduate-trainees-dutch-general-practice-prospective

February 23, 2011 - Study Lessons learnt from incidents reported by postgraduate trainees in Dutch general practice. A prospective cohort study. Citation Text: Zwart DLM, Heddema WS, Vermeulen MI, et al. Lessons learnt from incidents reported by postgraduate trainees in Dutch general practice. A prospecti…

Assisting beginners in root cause analysis operations: analysis and recommendations regarding the spread of COVID-19 in nursing facilities for the elderly. | PSNet

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June 08, 2022 - Commentary Assisting beginners in root cause analysis operations: analysis and recommendations regarding the spread of COVID-19 in nursing facilities for the elderly. Citation Text: Tsuchiya H. Assisting beginners in root cause analysis operations: analysis and recommendations regarding …

The postpartum hemorrhage patient safety bundle implementation at a single institution: successes, failures, and lessons learned, | PSNet

psnet.ahrq.gov/issue/postpartum-hemorrhage-patient-safety-bundle-implementation-single-institution-successes

February 01, 2023 - Study The postpartum hemorrhage patient safety bundle implementation at a single institution: successes, failures, and lessons learned, Citation Text: Duzyj CM, Boyle C, Mahoney K, et al. The postpartum hemorrhage patient safety bundle implementation at a single institution: successes, f…

Supporting the emotional well-being of health care workers during the COVID-19 pandemic. | PSNet

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October 14, 2020 - Commentary Emerging Classic Supporting the emotional well-being of health care workers during the COVID-19 pandemic. Citation Text: Wu AW, Buckle P, Haut ER, et al. Supporting the emotional well-being of health care workers during the COVID-19 pandemic. J Patien…

Cybersecurity in health is an urgent patient safety concern: we can learn from existing patient safety improvement strategies to address it. | PSNet

psnet.ahrq.gov/issue/cybersecurity-health-urgent-patient-safety-concern-we-can-learn-existing-patient-safety

October 28, 2020 - Commentary Cybersecurity in health is an urgent patient safety concern: we can learn from existing patient safety improvement strategies to address it. Citation Text: O’Brien N, Ghafur S, Durkin M. Cybersecurity in health is an urgent patient safety concern: we can learn from existing pa…

Identifying electronic health record contributions to diagnostic error in ambulatory settings through legal claims analysis. | PSNet

psnet.ahrq.gov/issue/identifying-electronic-health-record-contributions-diagnostic-error-ambulatory-settings

January 25, 2023 - Study Identifying electronic health record contributions to diagnostic error in ambulatory settings through legal claims analysis. Citation Text: Krevat S, Samuel S, Boxley C, et al. Identifying electronic health record contributions to diagnostic error in ambulatory settings through leg…

Machine learning models outperform manual result review for the identification of wrong blood in tube errors in complete blood count results. | PSNet

psnet.ahrq.gov/issue/machine-learning-models-outperform-manual-result-review-identification-wrong-blood-tube

May 13, 2020 - Study Machine learning models outperform manual result review for the identification of wrong blood in tube errors in complete blood count results. Citation Text: Farrell C‐JL, Giannoutsos J. Machine learning models outperform manual result review for the identification of wrong blood in…

The potential for leveraging machine learning to filter medication alerts. | PSNet

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July 22, 2020 - Study The potential for leveraging machine learning to filter medication alerts. Citation Text: Liu S, Kawamoto K, Del Fiol G, et al. The potential for leveraging machine learning to filter medication alerts. J Am Med Inform Assoc. 2022;29(5):891-899. doi:10.1093/jamia/ocab292. Copy Ci…

Helping healthcare teams save lives during COVID-19: insights and countermeasures from team science. | PSNet

psnet.ahrq.gov/issue/helping-healthcare-teams-save-lives-during-covid-19-insights-and-countermeasures-team-science

June 24, 2020 - Commentary Emerging Classic Helping healthcare teams save lives during COVID-19: insights and countermeasures from team science. Citation Text: Traylor AM. Helping healthcare teams save lives during COVID-19: insights and countermeasures from team science. Am Ps…

Physician engagement in organisational patient safety through the implementation of a Medical Safety Huddle initiative: a qualitative study. | PSNet

psnet.ahrq.gov/issue/physician-engagement-organisational-patient-safety-through-implementation-medical-safety

February 22, 2011 - Study Physician engagement in organisational patient safety through the implementation of a Medical Safety Huddle initiative: a qualitative study. Citation Text: Rotteau L, Othman D, Dunbar-Yaffe R, et al. Physician engagement in organisational patient safety through the implementation o…

Enhancing surgical safety using digital multimedia technology. | PSNet

psnet.ahrq.gov/issue/enhancing-surgical-safety-using-digital-multimedia-technology

October 09, 2013 - Study Enhancing surgical safety using digital multimedia technology. Citation Text: Dixon JL, Mukhopadhyay D, Hunt J, et al. Enhancing surgical safety using digital multimedia technology. Am J Surg. 2016;211(6):1095-8. doi:10.1016/j.amjsurg.2015.08.023. Copy Citation Format: …

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

psnet.ahrq.gov/issue/advancing-health-equity-patient-safety-reckoning-challenge-and-opportunity

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…

Nurse judgements of hospitalized patients' safety concerns are affected by patient, nurse and event characteristics: a factorial survey experiment. | PSNet

psnet.ahrq.gov/issue/nurse-judgements-hospitalized-patients-safety-concerns-are-affected-patient-nurse-and-event

May 13, 2020 - Study Nurse judgements of hospitalized patients' safety concerns are affected by patient, nurse and event characteristics: a factorial survey experiment. Citation Text: Groves PS, Farag A, Perkhounkova Y, et al. Nurse judgements of hospitalized patients' safety concerns are affected by p…

From the flight deck to the operating room: an initial pilot study of the feasibility and potential impact of true interdisciplinary team training using high-fidelity simulation. | PSNet

psnet.ahrq.gov/issue/flight-deck-operating-room-initial-pilot-study-feasibility-and-potential-impact-true

February 25, 2009 - Study From the flight deck to the operating room: an initial pilot study of the feasibility and potential impact of true interdisciplinary team training using high-fidelity simulation. Citation Text: Paige JT, Kozmenko V, Morgan B, et al. From the Flight Deck to the Operating Room: A…

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