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An evidence-based toolkit for the development of effective and sustainable root cause analysis system safety solutions. | PSNet

psnet.ahrq.gov/issue/evidence-based-toolkit-development-effective-and-sustainable-root-cause-analysis-system

June 01, 2019 - Study An evidence-based toolkit for the development of effective and sustainable root cause analysis system safety solutions. Citation Text: Hettinger Z, Fairbanks RJ, Hegde S, et al. An evidence-based toolkit for the development of effective and sustainable root cause analysis syste…

Medication errors involving nursing students: a systematic review. | PSNet

psnet.ahrq.gov/issue/medication-errors-involving-nursing-students-systematic-review

March 09, 2022 - Review Medication errors involving nursing students: a systematic review. Citation Text: Asensi-Vicente J, Jiménez-Ruiz I, Vizcaya-Moreno F. Medication Errors Involving Nursing Students: A Systematic Review. Nurse Educ. 2018;43(5):E1-E5. doi:10.1097/NNE.0000000000000481. Copy Citation …

Payment innovations to improve diagnostic accuracy and reduce diagnostic error. | PSNet

psnet.ahrq.gov/issue/payment-innovations-improve-diagnostic-accuracy-and-reduce-diagnostic-error

December 16, 2020 - Commentary Payment innovations to improve diagnostic accuracy and reduce diagnostic error. Citation Text: Berenson R, Singh H. Payment Innovations To Improve Diagnostic Accuracy And Reduce Diagnostic Error. Health Aff (Millwood). 2018;37(11):1828-1835. doi:10.1377/hlthaff.2018.0714. Co…

Identifying contributing factors associated with dental adverse events through a pragmatic electronic health record-based root cause analysis. | PSNet

psnet.ahrq.gov/issue/identifying-contributing-factors-associated-dental-adverse-events-through-pragmatic

May 23, 2018 - Study Identifying contributing factors associated with dental adverse events through a pragmatic electronic health record-based root cause analysis. Citation Text: Kalenderian E, Bangar S, Yansane A, et al. Identifying contributing factors associated with dental adverse events through a …

Diagnostic reasoning: an endangered competency in internal medicine training. | PSNet

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September 04, 2019 - Commentary Diagnostic reasoning: an endangered competency in internal medicine training. Citation Text: Simpkin AL, Vyas JM, Armstrong KA. Diagnostic Reasoning: An Endangered Competency in Internal Medicine Training. Ann Intern Med. 2017;167(7):507-508. doi:10.7326/M17-0163. Copy Citat…

Crisis management on surgical wards: a simulation-based approach to enhancing technical, teamwork, and patient interaction skills. | PSNet

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January 27, 2012 - Study Crisis management on surgical wards: a simulation-based approach to enhancing technical, teamwork, and patient interaction skills. Citation Text: Arora S, Hull L, Fitzpatrick M, et al. Crisis management on surgical wards: a simulation-based approach to enhancing technical, teamwork…

Computerized Prescriber Order Entry Medication Safety (CPOEMS): Uncovering and Learning From Issues and Errors. | PSNet

psnet.ahrq.gov/issue/computerized-prescriber-order-entry-medication-safety-cpoems-uncovering-and-learning-issues

February 05, 2014 - Book/Report Computerized Prescriber Order Entry Medication Safety (CPOEMS): Uncovering and Learning From Issues and Errors. Citation Text: Computerized Prescriber Order Entry Medication Safety (CPOEMS): Uncovering and Learning From Issues and Errors. Brigham and Women's Hospital, Harvard…

Diet order entry by registered dietitians results in a reduction in error rates and time delays compared with other health professionals. | PSNet

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September 23, 2020 - Study Diet order entry by registered dietitians results in a reduction in error rates and time delays compared with other health professionals. Citation Text: Imfeld K, Keith M, Stoyanoff L, et al. Diet order entry by registered dietitians results in a reduction in error rates and time …

Root cause analysis of reported patient falls in ORs in the Veterans Health Administration. | PSNet

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January 17, 2019 - Commentary Root cause analysis of reported patient falls in ORs in the Veterans Health Administration. Citation Text: Soncrant CM, Warner LJ, Neily J, et al. Root Cause Analysis of Reported Patient Falls in ORs in the Veterans Health Administration. AORN J. 2018;108(4):386-397. doi:10.10…

Surgical programs in the Veterans Health Administration maintain briefing and debriefing following medical team training. | PSNet

psnet.ahrq.gov/issue/surgical-programs-veterans-health-administration-maintain-briefing-and-debriefing-following

October 24, 2018 - Study Surgical programs in the Veterans Health Administration maintain briefing and debriefing following medical team training. Citation Text: West P, Neily J, Warner L, et al. Surgical programs in the Veterans Health Administration maintain briefing and debriefing following medical team…

A 5-year analysis of rapid response system activation at an in-hospital haemodialysis unit. | PSNet

psnet.ahrq.gov/issue/5-year-analysis-rapid-response-system-activation-hospital-haemodialysis-unit

March 24, 2011 - Study A 5-year analysis of rapid response system activation at an in-hospital haemodialysis unit. Citation Text: Galhotra S, Devita MA, Dew MA, et al. A 5-year analysis of rapid response system activation at an in-hospital haemodialysis unit. Qual Saf Health Care. 2010;19(6):e38. doi:1…

Improving diagnostic performance through feedback: the Diagnosis Learning Cycle. | PSNet

psnet.ahrq.gov/issue/improving-diagnostic-performance-through-feedback-diagnosis-learning-cycle

December 16, 2020 - Commentary Improving diagnostic performance through feedback: the Diagnosis Learning Cycle. Citation Text: Fernandez Branson C, Williams M, Chan TM, et al. Improving diagnostic performance through feedback: the Diagnosis Learning Cycle. BMJ Qual Saf. 2021;30(12):1002-1009. doi:10.1136/bm…

The girl who cried pain: a bias against women in the treatment of pain. | PSNet

psnet.ahrq.gov/issue/girl-who-cried-pain-bias-against-women-treatment-pain

February 08, 2023 - Review Classic The girl who cried pain: a bias against women in the treatment of pain. Citation Text: Hoffmann DE, Tarzian AJ. The girl who cried pain: a bias against women in the treatment of pain. J Law Med Ethics. 2001;29(1):13-27. doi:10.1111/j.1748-720x.200…

Structured handover in general surgery: an audit of current practice. | PSNet

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August 08, 2018 - Study Structured handover in general surgery: an audit of current practice. Citation Text: Jones HG, Watt B, Lewis L, et al. Structured Handover in General Surgery: An Audit of Current Practice. J Patient Saf. 2019;15(1):7-10. doi:10.1097/PTS.0000000000000201. Copy Citation Format:…

Reducing medical error in the Military Health System: how can team training help? | PSNet

psnet.ahrq.gov/issue/reducing-medical-error-military-health-system-how-can-team-training-help

March 29, 2007 - Commentary Reducing medical error in the Military Health System: how can team training help? Citation Text: Alonso A, Baker DP, Holtzman A, et al. Reducing medical error in the Military Health System: How can team training help? Human Resource Management Review. 2006;16(3). doi:10.101…

Addressing safety concerns about U-500 insulin in a hospital setting. | PSNet

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March 15, 2017 - Commentary Addressing safety concerns about U-500 insulin in a hospital setting. Citation Text: Samaan KH, Dahlke M, Stover J. Addressing safety concerns about U-500 insulin in a hospital setting. Am J Health Syst Pharm. 2011;68(1):63-8. doi:10.2146/ajhp100224. Copy Citation Form…

Patient participation in patient safety and nursing input—a systematic review. | PSNet

psnet.ahrq.gov/issue/patient-participation-patient-safety-and-nursing-input-systematic-review

June 10, 2020 - Review Patient participation in patient safety and nursing input—a systematic review. Citation Text: Vaismoradi M, Jordan S, Kangasniemi M. Patient participation in patient safety and nursing input - a systematic review. J Clin Nurs. 2015;24(5-6):627-39. doi:10.1111/jocn.12664. Copy Ci…

Identifying and measuring administrative harms experienced by hospitalists and administrative leaders. | PSNet

psnet.ahrq.gov/issue/identifying-and-measuring-administrative-harms-experienced-hospitalists-and-administrative

April 12, 2023 - Study Identifying and measuring administrative harms experienced by hospitalists and administrative leaders. Citation Text: Burden M, Astik GJ, Auerbach AD, et al. Identifying and measuring administrative harms experienced by hospitalists and administrative leaders. JAMA Intern Med. 2024…

Effect of communication errors during calls to an antimicrobial stewardship program. | PSNet

psnet.ahrq.gov/issue/effect-communication-errors-during-calls-antimicrobial-stewardship-program

June 22, 2022 - Study Effect of communication errors during calls to an antimicrobial stewardship program. Citation Text: Linkin DR, Fishman NO, Landis R, et al. Effect of communication errors during calls to an antimicrobial stewardship program. Infect Control Hosp Epidemiol. 2007;28(12):1374-1381. …

Nursing home residents with dementia: association between place of death and patient safety culture. | PSNet

psnet.ahrq.gov/issue/nursing-home-residents-dementia-association-between-place-death-and-patient-safety-culture

November 04, 2020 - Study Nursing home residents with dementia: association between place of death and patient safety culture. Citation Text: Orth J, Li Y, Simning A, et al. Nursing Home Residents With Dementia: Association Between Place of Death and Patient Safety Culture. Gerontologist. 2021;61(8):1296-1…

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