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Near-misses are an opportunity to improve patient safety: adapting strategies of high reliability organizations to healthcare. | PSNet

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July 01, 2011 - Review Near-misses are an opportunity to improve patient safety: adapting strategies of high reliability organizations to healthcare. Citation Text: Van Spall H, Kassam A, Tollefson TT. Near-misses are an opportunity to improve patient safety: adapting strategies of high reliability orga…

Adverse drug event–related emergency department visits associated with complex chronic conditions. | PSNet

psnet.ahrq.gov/issue/adverse-drug-event-related-emergency-department-visits-associated-complex-chronic-conditions

August 20, 2016 - Study Adverse drug event–related emergency department visits associated with complex chronic conditions. Citation Text: Feinstein JA, Feudtner C, Kempe A. Adverse drug event-related emergency department visits associated with complex chronic conditions. Pediatrics. 2014;133(6):e1575-85. …

Misdiagnosis of heart failure: a systematic review of the literature. | PSNet

psnet.ahrq.gov/issue/misdiagnosis-heart-failure-systematic-review-literature

October 06, 2021 - Review Misdiagnosis of heart failure: a systematic review of the literature. Citation Text: Wong CW, Tafuro J, Azam Z, et al. Misdiagnosis of heart failure: a systematic review of the literature. J Cardiac Failure. 2021;27(9):925-933. doi:10.1016/j.cardfail.2021.05.014. Copy Citation …

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…

Design and trial of a new ambulance-to-emergency department handover protocol: 'IMIST-AMBO.' | PSNet

psnet.ahrq.gov/issue/design-and-trial-new-ambulance-emergency-department-handover-protocol-imist-ambo

March 14, 2022 - Study Design and trial of a new ambulance-to-emergency department handover protocol: 'IMIST-AMBO.' Citation Text: Iedema R, Ball C, Daly B, et al. Design and trial of a new ambulance-to-emergency department handover protocol: 'IMIST-AMBO'. BMJ Qual Saf. 2012;21(8):627-33. doi:10.1136/b…

Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. | PSNet

psnet.ahrq.gov/issue/do-professional-interpreters-improve-clinical-care-patients-limited-english-proficiency

November 30, 2016 - Review Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Citation Text: Karliner LS, Jacobs EA, Chen AH, et al. Do professional interpreters improve clinical care for patients with limited English pr…

Nurses and nursing students as second victims: a scoping review. | PSNet

psnet.ahrq.gov/issue/nurses-and-nursing-students-second-victims-scoping-review

March 08, 2023 - Review Nurses and nursing students as second victims: a scoping review. Citation Text: Sahay A, McKenna L. Nurses and nursing students as second victims: a scoping review. Nurs Outlook. 2023;71(4):101992. doi:10.1016/j.outlook.2023.101992. Copy Citation Format: DOI Google S…

Risk managers' descriptions of programs to support second victims after adverse events. | PSNet

psnet.ahrq.gov/issue/risk-managers-descriptions-programs-support-second-victims-after-adverse-events

May 11, 2016 - Study Risk managers' descriptions of programs to support second victims after adverse events. Citation Text: White AA, Brock DM, McCotter PI, et al. Risk managers' descriptions of programs to support second victims after adverse events. J Healthc Risk Manag. 2015;34(4):30-40. doi:10.1002…

Use of the Second Victim Experience and Support Tool (SVEST) to assess the impact of a departmental peer support program on anesthesia professionals' second victim experiences (SVEs) and perceptions of support two years after implementation. | PSNet

psnet.ahrq.gov/issue/use-second-victim-experience-and-support-tool-svest-assess-impact-departmental-peer-support

December 23, 2020 - Study Use of the Second Victim Experience and Support Tool (SVEST) to assess the impact of a departmental peer support program on anesthesia professionals' second victim experiences (SVEs) and perceptions of support two years after implementation. Citation Text: Use of the Second Victim …

The opioid crisis: origins, trends, policies, and the roles of pharmacists. | PSNet

psnet.ahrq.gov/issue/opioid-crisis-origins-trends-policies-and-roles-pharmacists

December 14, 2022 - Review The opioid crisis: origins, trends, policies, and the roles of pharmacists. Citation Text: Chisholm-Burns MA, Spivey CA, Sherwin E, et al. The opioid crisis: Origins, trends, policies, and the roles of pharmacists. Am J Health-Syst Pharm. 2019;76(7):424-435. doi:10.1093/ajhp/zxy08…

Patient safety in inpatient psychiatry: a remaining frontier for health policy. | PSNet

psnet.ahrq.gov/issue/patient-safety-inpatient-psychiatry-remaining-frontier-health-policy

October 19, 2022 - Commentary Patient safety in inpatient psychiatry: a remaining frontier for health policy. Citation Text: Shields MC, Stewart MT, Delaney KR. Patient Safety In Inpatient Psychiatry: A Remaining Frontier For Health Policy. Health Aff (Millwood). 2018;37(11):1853-1861. doi:10.1377/hlthaff.…

Missed opportunities in the primary care management of early acute ischemic heart disease. | PSNet

psnet.ahrq.gov/issue/missed-opportunities-primary-care-management-early-acute-ischemic-heart-disease

January 08, 2016 - Study Missed opportunities in the primary care management of early acute ischemic heart disease. Citation Text: Sequist TD, Marshall R, Lampert S, et al. Missed opportunities in the primary care management of early acute ischemic heart disease. Arch Intern Med. 2006;166(20):2237-43. …

Automated identification of diagnostic labelling errors in medicine. | PSNet

psnet.ahrq.gov/issue/automated-identification-diagnostic-labelling-errors-medicine

September 23, 2020 - Study Automated identification of diagnostic labelling errors in medicine. Citation Text: Hautz WE, Kündig MM, Tschanz R, et al. Automated identification of diagnostic labelling errors in medicine. Diagnosis. 2021;9(2):241-249. doi:10.1515/dx-2021-0039. Copy Citation Format: …

The gap in electronic drug information resources: a systematic review. | PSNet

psnet.ahrq.gov/issue/gap-electronic-drug-information-resources-systematic-review

January 24, 2024 - Review The gap in electronic drug information resources: a systematic review. Citation Text: Rambaran KA, Huynh HA, Zhang Z, et al. The Gap in Electronic Drug Information Resources: A Systematic Review. Cureus. 2018;10(6):e2860. doi:10.7759/cureus.2860. Copy Citation Format: …

Clinical and financial implications of second-opinion surgical pathology review. | PSNet

psnet.ahrq.gov/issue/clinical-and-financial-implications-second-opinion-surgical-pathology-review

August 04, 2021 - Study Clinical and financial implications of second-opinion surgical pathology review. Citation Text: Johnson SM, Samulski TD, O’Connor SM, et al. Clinical and financial implications of second-opinion surgical pathology review. Am J Clin Pathol. 2021;156(4):559-568. doi:10.1093/ajcp/aqaa…

Paediatric dosing errors before and after electronic prescribing. | PSNet

psnet.ahrq.gov/issue/paediatric-dosing-errors-and-after-electronic-prescribing

February 13, 2008 - Study Paediatric dosing errors before and after electronic prescribing. Citation Text: Jani Y, Barber N, Wong ICK. Paediatric dosing errors before and after electronic prescribing. Qual Saf Health Care. 2010;19(4):337-40. doi:10.1136/qshc.2009.033068. Copy Citation Format: …

Comparison of adverse events during procedural sedation between specially trained pediatric residents and pediatric emergency physicians in Israel. | PSNet

psnet.ahrq.gov/issue/comparison-adverse-events-during-procedural-sedation-between-specially-trained-pediatric

August 21, 2008 - Study Comparison of adverse events during procedural sedation between specially trained pediatric residents and pediatric emergency physicians in Israel. Citation Text: Shavit I, Steiner IP, Idelman S, et al. Comparison of adverse events during procedural sedation between specially tra…

Making an infusion error: the second victims of infusion therapy-related medication errors. | PSNet

psnet.ahrq.gov/issue/making-infusion-error-second-victims-infusion-therapy-related-medication-errors

June 27, 2018 - Study Making an infusion error: the second victims of infusion therapy-related medication errors. Citation Text: Treiber LA, Jones JH. Making an Infusion Error: The Second Victims of Infusion Therapy-Related Medication Errors. J Infus Nurs. 2018;41(3):156-163. doi:10.1097/NAN.00000000000…

Prospective observational study on the incidence of medication errors during simulated resuscitation in a paediatric emergency department. | PSNet

psnet.ahrq.gov/issue/prospective-observational-study-incidence-medication-errors-during-simulated-resuscitation

April 22, 2011 - Study Prospective observational study on the incidence of medication errors during simulated resuscitation in a paediatric emergency department. Citation Text: Kozer E, Seto W, Verjee Z, et al. Prospective observational study on the incidence of medication errors during simulated resus…

Giving up learning from failures? An examination of learning from one's own failures in the context of heart surgeons. | PSNet

psnet.ahrq.gov/issue/giving-learning-failures-examination-learning-ones-own-failures-context-heart-surgeons

April 03, 2013 - Study Giving up learning from failures? An examination of learning from one's own failures in the context of heart surgeons. Citation Text: Lee S, Park J. Giving up learning from failures? An examination of learning from one's own failures in the context of heart surgeons. Strat Manage J…

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