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A systems approach to analyzing and preventing hospital adverse events. | PSNet

psnet.ahrq.gov/issue/systems-approach-analyzing-and-preventing-hospital-adverse-events

March 30, 2022 - Study Emerging Classic A systems approach to analyzing and preventing hospital adverse events. Citation Text: Leveson N, Samost A, Dekker SWA, et al. A systems approach to analyzing and preventing hospital adverse events. J Patient Saf. 2020;16(2):162-167. doi:1…

Learning from incident reporting? Analysis of incidents resulting in patient injuries in a web-based system in Swedish health care. | PSNet

psnet.ahrq.gov/issue/learning-incident-reporting-analysis-incidents-resulting-patient-injuries-web-based-system

August 04, 2021 - Study Learning from incident reporting? Analysis of incidents resulting in patient injuries in a web-based system in Swedish health care. Citation Text: Ahlberg E-L, Elfström J, Borgstedt MR, et al. Learning from incident reporting? Analysis of incidents resulting in patient injuries in …

Hierarchy and medical error: speaking up when witnessing an error. | PSNet

psnet.ahrq.gov/issue/hierarchy-and-medical-error-speaking-when-witnessing-error

April 14, 2011 - Review Emerging Classic Hierarchy and medical error: speaking up when witnessing an error. Citation Text: Peadon R (R), Hurley J, Hutchinson M. Hierarchy and medical error: speaking up when witnessing an error. Safety Sci. 2020;125:104648. doi:10.1016/j.ssci.202…

Does teamwork improve performance in the operating room? A multilevel evaluation. | PSNet

psnet.ahrq.gov/issue/does-teamwork-improve-performance-operating-room-multilevel-evaluation

July 02, 2014 - Study Does teamwork improve performance in the operating room? A multilevel evaluation. Citation Text: Weaver SJ, Rosen MA, DiazGranados D, et al. Does teamwork improve performance in the operating room? A multilevel evaluation. Jt Comm J Qual Patient Saf. 2010;36(3):133-42. Copy Citat…

Are interventions to reduce interruptions and errors during medication administration effective?: a systematic review. | PSNet

psnet.ahrq.gov/issue/are-interventions-reduce-interruptions-and-errors-during-medication-administration-effective

August 28, 2024 - Review Are interventions to reduce interruptions and errors during medication administration effective?: a systematic review. Citation Text: Raban MZ, Westbrook JI. Are interventions to reduce interruptions and errors during medication administration effective?: a systematic review. BMJ …

Nurses' attitudes to a medical emergency team service in a teaching hospital. | PSNet

psnet.ahrq.gov/issue/nurses-attitudes-medical-emergency-team-service-teaching-hospital

November 16, 2022 - Study Nurses' attitudes to a medical emergency team service in a teaching hospital. Citation Text: Jones D, Baldwin I, McIntyre T, et al. Nurses' attitudes to a medical emergency team service in a teaching hospital. Qual Saf Health Care. 2006;15(6):427-32. Copy Citation Format: …

Differences in medication reconciliation interventions between six hospitals: a mixed method study. | PSNet

psnet.ahrq.gov/issue/differences-medication-reconciliation-interventions-between-six-hospitals-mixed-method-study

September 08, 2021 - Study Differences in medication reconciliation interventions between six hospitals: a mixed method study. Citation Text: Stuijt CCM, van den Bemt BJF, Boerlage VE, et al. Differences in medication reconciliation interventions between six hospitals: a mixed method study. BMC Health Serv R…

Patient harm resulting from medication reconciliation process failures: a study of serious events reported by Pennsylvania hospitals. | PSNet

psnet.ahrq.gov/issue/patient-harm-resulting-medication-reconciliation-process-failures-study-serious-events

October 07, 2020 - Study Patient harm resulting from medication reconciliation process failures: a study of serious events reported by Pennsylvania hospitals. Citation Text: Harper A, Kukielka E, Jones RM. Patient harm resulting from medication reconciliation process failures: a study of serious events rep…

How incident reporting systems can stimulate social and participative learning: a mixed-methods study. | PSNet

psnet.ahrq.gov/issue/how-incident-reporting-systems-can-stimulate-social-and-participative-learning-mixed-methods

November 04, 2020 - Study How incident reporting systems can stimulate social and participative learning: a mixed-methods study. Citation Text: de Kam D, Kok J, Grit K, et al. How incident reporting systems can stimulate social and participative learning: a mixed-methods study. Health Policy (New York). 202…

Association of nurse workload with missed nursing care in the neonatal intensive care unit. | PSNet

psnet.ahrq.gov/issue/association-nurse-workload-missed-nursing-care-neonatal-intensive-care-unit

September 27, 2017 - Study Emerging Classic Association of nurse workload with missed nursing care in the neonatal intensive care unit. Citation Text: Tubbs-Cooley HL, Mara CA, Carle AC, et al. Association of Nurse Workload With Missed Nursing Care in the Neonatal Intensive Care Uni…

Standardized assessment of medication reconciliation in post-acute care. | PSNet

psnet.ahrq.gov/issue/standardized-assessment-medication-reconciliation-post-acute-care

December 16, 2020 - Study Standardized assessment of medication reconciliation in post-acute care. Citation Text: Fischer SH, Shih RA, McMullen TL, et al. Standardized assessment of medication reconciliation in post‐acute care. J Am Geriatr Soc. 2022;70(4):1047-1056. doi:10.1111/jgs.17655. Copy Citation …

Publicly available hospital comparison web sites: determination of useful, valid, and appropriate information for comparing surgical quality. | PSNet

psnet.ahrq.gov/issue/publicly-available-hospital-comparison-web-sites-determination-useful-valid-and-appropriate

December 21, 2014 - Study Classic Publicly available hospital comparison web sites: determination of useful, valid, and appropriate information for comparing surgical quality. Citation Text: Leonardi MJ, McGory ML, Ko CY. Publicly available hospital comparison web sites: determin…

Review of medication error sources associated with inpatient subcutaneous insulin: recommendations for safe and cost-effective dispensing practices. | PSNet

psnet.ahrq.gov/issue/review-medication-error-sources-associated-inpatient-subcutaneous-insulin-recommendations

June 17, 2020 - Review Review of medication error sources associated with inpatient subcutaneous insulin: recommendations for safe and cost-effective dispensing practices. Citation Text: McKay C, Schenkat D, Murphy K, et al. Review of medication error sources associated with inpatient subcutaneous insul…

Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety. | PSNet

psnet.ahrq.gov/issue/workarounds-barcode-medication-administration-systems-their-occurrences-causes-and-threats

November 30, 2011 - Study Classic Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety. Citation Text: Koppel R, Wetterneck TB, Telles JL, et al. Workarounds to barcode medication administration systems: their occurren…

Systemic causes of in-hospital intravenous medication errors: a systematic review. | PSNet

psnet.ahrq.gov/issue/systemic-causes-hospital-intravenous-medication-errors-systematic-review

July 01, 2020 - Review Systemic causes of in-hospital intravenous medication errors: a systematic review. Citation Text: Kuitunen S, Niittynen I, Airaksinen M, et al. Systemic causes of in-hospital intravenous medication errors: a systematic review. J Patient Saf. 2021;17(8):e1660-e1668. doi:10.1097/pts…

Computerised physician order entry-related medication errors: analysis of reported errors and vulnerability testing of current systems. | PSNet

psnet.ahrq.gov/issue/computerised-physician-order-entry-related-medication-errors-analysis-reported-errors-and

May 08, 2017 - Study Classic Computerised physician order entry-related medication errors: analysis of reported errors and vulnerability testing of current systems. Citation Text: Schiff GD, Amato MG, Eguale T, et al. Computerised physician order entry-related medication error…

The impact of rudeness on medical team performance: a randomized trial. | PSNet

psnet.ahrq.gov/issue/impact-rudeness-medical-team-performance-randomized-trial

April 24, 2018 - Study Classic The impact of rudeness on medical team performance: a randomized trial. Citation Text: Riskin A, Erez A, Foulk T, et al. The impact of rudeness on medical team performance: a randomized trial. Pediatrics. 2015;136(3):487-495. doi:10.1542/peds.2015-…

Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. | PSNet

psnet.ahrq.gov/issue/making-health-care-safer-ii-updated-critical-analysis-evidence-patient-safety-practices

March 13, 2013 - Book/Report Classic Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Citation Text: Shekelle PG, Wachter RM, Pronovost PJ, et al. Making Health Care Safer Ii: An Updated Critical Analysis Of The Evidence For…

Caring for our own: deploying a systemwide second victim rapid response team. | PSNet

psnet.ahrq.gov/issue/caring-our-own-deploying-systemwide-second-victim-rapid-response-team

September 19, 2016 - Study Classic Caring for our own: deploying a systemwide second victim rapid response team. Citation Text: Scott SD, Hirschinger LE, Cox KR, et al. Caring for our own: deploying a systemwide second victim rapid response team. Jt Comm J Qual Saf. 2010;36(5):233-2…

Effects of a multimodal transitional care intervention in patients at high risk of readmission: the TARGET-READ randomized clinical trial. | PSNet

psnet.ahrq.gov/issue/effects-multimodal-transitional-care-intervention-patients-high-risk-readmission-target-read

August 18, 2021 - Study Effects of a multimodal transitional care intervention in patients at high risk of readmission: the TARGET-READ randomized clinical trial. Citation Text: Donzé JD, John G, Genné D, et al. Effects of a multimodal transitional care intervention in patients at high risk of readmission…

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