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Error or "act of God"? A study of patients' and operating room team members' perceptions of error definition, reporting, and disclosure. | PSNet

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August 10, 2011 - Study Error or "act of God"? A study of patients' and operating room team members' perceptions of error definition, reporting, and disclosure. Citation Text: Espin S, Levinson W, Regehr G, et al. Error or "act of God"? A study of patients' and operating room team members' perceptions o…

Patient safety and the problem of many hands. | PSNet

psnet.ahrq.gov/issue/patient-safety-and-problem-many-hands

June 16, 2021 - Commentary Patient safety and the problem of many hands. Citation Text: Dixon-Woods M, Pronovost P. Patient safety and the problem of many hands. BMJ Qual Saf. 2016;25(7):485-488. doi:10.1136/bmjqs-2016-005232. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote …

Effects of a night-team system on resident sleep and work hours. | PSNet

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November 16, 2022 - Study Effects of a night-team system on resident sleep and work hours. Citation Text: Chua K-P, Gordon M, Sectish TC, et al. Effects of a night-team system on resident sleep and work hours. Pediatrics. 2011;128(6):1142-7. doi:10.1542/peds.2011-1049. Copy Citation Format: DO…

The effects of computerized provider order entry implementation on communication in intensive care units. | PSNet

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March 15, 2017 - Study The effects of computerized provider order entry implementation on communication in intensive care units. Citation Text: Hoonakker P, Carayon P, Walker JM, et al. The effects of Computerized Provider Order Entry implementation on communication in Intensive Care Units. Int J Med I…

The next step in learning from sentinel events in healthcare. | PSNet

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June 12, 2024 - Commentary The next step in learning from sentinel events in healthcare. Citation Text: Bos K, Dongelmans DA, Greuters S, et al. The next step in learning from sentinel events in healthcare. BMJ Open Qual. 2020;9(1):e000739. doi:10.1136/bmjoq-2019-000739. Copy Citation Format: …

Ensuring access to medications in the US during the COVID-19 pandemic. | PSNet

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May 08, 2017 - Commentary Ensuring access to medications in the US during the COVID-19 pandemic. Citation Text: Alexander GC, Qato DM. Ensuring access to medications in the US during the COVID-19 pandemic. JAMA. 2020;324(1):31-32. doi:10.1001/jama.2020.6016. Copy Citation Format: DOI Goog…

Clinical oversight: conceptualizing the relationship between supervision and safety. | PSNet

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June 23, 2010 - Study Clinical oversight: conceptualizing the relationship between supervision and safety. Citation Text: Kennedy TJT, Lingard LA, Baker R, et al. Clinical oversight: conceptualizing the relationship between supervision and safety. J Gen Intern Med. 2007;22(8):1080-5. Copy Citation …

We need to talk: primary care provider communication at discharge in the era of a shared electronic medical record. | PSNet

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October 13, 2018 - Study We need to talk: primary care provider communication at discharge in the era of a shared electronic medical record. Citation Text: Sheu L, Fung K, Mourad M, et al. We need to talk: Primary care provider communication at discharge in the era of a shared electronic medical record. J …

Updating Eindhoven: clarifying the features of a patient safety near miss. | PSNet

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March 13, 2024 - Study Updating Eindhoven: clarifying the features of a patient safety near miss. Citation Text: Woodier N, Burnett C, Sampson P, et al. Updating Eindhoven: clarifying the features of a patient safety near miss. J Patient Saf Risk Manag. 2024;29(4):195-201. doi:10.1177/25160435241247096. …

Implementing online medication reconciliation at a large academic medical center. | PSNet

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January 23, 2019 - Commentary Implementing online medication reconciliation at a large academic medical center. Citation Text: Bails D, Clayton K, Roy K, et al. Implementing online medication reconciliation at a large academic medical center. Jt Comm J Qual Patient Saf. 2008;34(9):499-508. Copy Citatio…

Prescribing for the elderly. Part I: Sensitivity of the elderly to adverse drug reactions. | PSNet

psnet.ahrq.gov/issue/prescribing-elderly-part-i-sensitivity-elderly-adverse-drug-reactions

January 11, 2017 - Review Classic Prescribing for the elderly. Part I: Sensitivity of the elderly to adverse drug reactions. Citation Text: Nolan L, O'Malley K. Prescribing for the Elderly Part I: Sensitivity of the Elderly to Adverse Drug Reactions*. J Am Geriatr Soc. 2015;36(2…

Analysis of adverse events in pediatric surgery using criteria validated from the adult population: justifying the need for pediatric-focused outcome measures. | PSNet

psnet.ahrq.gov/issue/analysis-adverse-events-pediatric-surgery-using-criteria-validated-adult-population

May 06, 2009 - Study Analysis of adverse events in pediatric surgery using criteria validated from the adult population: justifying the need for pediatric-focused outcome measures. Citation Text: Rice-Townsend S, Hall M, Jenkins KJ, et al. Analysis of adverse events in pediatric surgery using criteri…

Managing competing organizational priorities in clinical handover across organizational boundaries. | PSNet

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February 07, 2024 - Study Managing competing organizational priorities in clinical handover across organizational boundaries. Citation Text: Sujan MA, Chessum P, Rudd M, et al. Managing competing organizational priorities in clinical handover across organizational boundaries. J Health Serv Res Policy. 2015;…

Do crowdsourced hospital ratings coincide with Hospital Compare measures of clinical and nonclinical quality? | PSNet

psnet.ahrq.gov/issue/do-crowdsourced-hospital-ratings-coincide-hospital-compare-measures-clinical-and-nonclinical

June 23, 2021 - Study Do crowdsourced hospital ratings coincide with Hospital Compare measures of clinical and nonclinical quality? Citation Text: Perez V, Freedman S. Do Crowdsourced Hospital Ratings Coincide with Hospital Compare Measures of Clinical and Nonclinical Quality? Health Serv Res. 2018;53(6…

Costs of adverse events in intensive care units. | PSNet

psnet.ahrq.gov/issue/costs-adverse-events-intensive-care-units

July 23, 2008 - Study Classic Costs of adverse events in intensive care units. Citation Text: Kaushal R, Bates DW, Franz C, et al. Costs of adverse events in intensive care units. Crit Care Med. 2007;35(11):2479-83. Copy Citation Format: Google Scholar PubMed Bi…

Medication administration errors in nursing homes using an automated medication dispensing system. | PSNet

psnet.ahrq.gov/issue/medication-administration-errors-nursing-homes-using-automated-medication-dispensing-system

January 23, 2019 - Study Medication administration errors in nursing homes using an automated medication dispensing system. Citation Text: van den Bemt PMLA, Idzinga JC, Robertz H, et al. Medication administration errors in nursing homes using an automated medication dispensing system. J Am Med Inform As…

Multicenter development, implementation, and patient safety impacts of a simulation-based module to teach handovers to pediatric residents. | PSNet

psnet.ahrq.gov/issue/multicenter-development-implementation-and-patient-safety-impacts-simulation-based-module

June 03, 2013 - Study Multicenter development, implementation, and patient safety impacts of a simulation-based module to teach handovers to pediatric residents. Citation Text: Johnson DP, Zimmerman K, Staples B, et al. Multicenter development, implementation, and patient safety impacts of a simulation-…

Hospitalization and death associated with potentially inappropriate medication prescriptions among elderly nursing home residents. | PSNet

psnet.ahrq.gov/issue/hospitalization-and-death-associated-potentially-inappropriate-medication-prescriptions-among

August 04, 2021 - Study Hospitalization and death associated with potentially inappropriate medication prescriptions among elderly nursing home residents. Citation Text: Lau DT, Kasper JD, Potter DEB, et al. Hospitalization and death associated with potentially inappropriate medication prescriptions among…

Disclosing medical errors to patients: attitudes and practices of physicians and trainees. | PSNet

psnet.ahrq.gov/issue/disclosing-medical-errors-patients-attitudes-and-practices-physicians-and-trainees

February 15, 2011 - Study Disclosing medical errors to patients: attitudes and practices of physicians and trainees. Citation Text: Kaldjian LC, Jones EW, Wu BJ, et al. Disclosing medical errors to patients: attitudes and practices of physicians and trainees. J Gen Intern Med. 2007;22(7):988-96. Copy Ci…

Sustainable, effective implementation of a surgical preprocedural checklist: an "attestation" format for all operating team members. | PSNet

psnet.ahrq.gov/issue/sustainable-effective-implementation-surgical-preprocedural-checklist-attestation-format-all

July 31, 2013 - Study Sustainable, effective implementation of a surgical preprocedural checklist: an "attestation" format for all operating team members. Citation Text: Porter AJ, Narimasu JY, Mulroy MF, et al. Sustainable, effective implementation of a surgical preprocedural checklist: an "attestati…

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