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Treatment patterns and clinical outcomes after the introduction of the Medicare Sepsis Performance Measure (SEP-1). | PSNet

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October 02, 2019 - Study Treatment patterns and clinical outcomes after the introduction of the Medicare Sepsis Performance Measure (SEP-1). Citation Text: Barbash IJ, Davis BS, Yabes JG, et al. Treatment patterns and clinical outcomes after the introduction of the Medicare Sepsis Performance Measure (SEP-…

Applying the high reliability health care maturity model to assess hospital performance: a VA case study. | PSNet

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December 19, 2014 - Study Applying the high reliability health care maturity model to assess hospital performance: a VA case study. Citation Text: Sullivan JL, Rivard PE, Shin MH, et al. Applying the High Reliability Health Care Maturity Model to Assess Hospital Performance: A VA Case Study. Jt Comm J Qual …

Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries. | PSNet

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January 09, 2019 - Book/Report Classic Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries. Citation Text: Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries. Levinson DR. Washington, DC: US Departmen…

Analysis of clinical decision support system malfunctions: a case series and survey. | PSNet

psnet.ahrq.gov/issue/analysis-clinical-decision-support-system-malfunctions-case-series-and-survey

April 29, 2018 - Study Analysis of clinical decision support system malfunctions: a case series and survey. Citation Text: Wright A, Hickman T-TT, McEvoy D, et al. Analysis of clinical decision support system malfunctions: a case series and survey. J Am Med Inform Assoc. 2016;23(6):1068-1076. doi:10.1093…

An analysis of incident reports related to electronic medication management: how they change over time. | PSNet

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March 10, 2021 - Study An analysis of incident reports related to electronic medication management: how they change over time. Citation Text: Kinlay M, Zheng WY, Burke R, et al. An analysis of incident reports related to electronic medication management: how they change over time. J Patient Saf. 2024;20(…

Association between workarounds and medication administration errors in bar-code-assisted medication administration in hospitals. | PSNet

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August 26, 2020 - Study Classic Association between workarounds and medication administration errors in bar-code-assisted medication administration in hospitals. Citation Text: van der Veen W, van den Bemt PMLA, Wouters H, et al. Association between workarounds and medication adm…

Review of computerized physician handoff tools for improving the quality of patient care. | PSNet

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September 07, 2011 - Review Review of computerized physician handoff tools for improving the quality of patient care. Citation Text: Li P, Ali S, Tang C, et al. Review of computerized physician handoff tools for improving the quality of patient care. J Hosp Med. 2013;8(8):456-63. doi:10.1002/jhm.1988. C…

I-PASS handoff program: use of a campaign to effect transformational change. | PSNet

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April 24, 2018 - Study I-PASS handoff program: use of a campaign to effect transformational change. Citation Text: Rosenbluth G, Destino LA, Starmer AJ, et al. I-PASS Handoff Program: Use of a Campaign to Effect Transformational Change. Ped Qual Saf. 2018;3(4):e088. doi:10.1097/pq9.0000000000000088. Co…

Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle. | PSNet

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November 12, 2014 - Study Classic Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle. Citation Text: Starmer AJ, Sectish TC, Simon DW, et al. Rates of medical errors and preventable adverse events…

Designing an intervention to improve medication safety for nursing home residents based on experiential knowledge related to patient safety culture at the nursing home front line: cocreative process study. | PSNet

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February 14, 2024 - Commentary Designing an intervention to improve medication safety for nursing home residents based on experiential knowledge related to patient safety culture at the nursing home front line: cocreative process study. Citation Text: Juhl MH, Soerensen AL, Vardinghus-Nielsen H, et al. Desi…

"ChatGPT, can you help me save my child's life?" - Diagnostic accuracy and supportive capabilities to lay rescuers by ChatGPT in prehospital basic life support and paediatric advanced life support cases - an in-silico analysis. | PSNet

psnet.ahrq.gov/issue/chatgpt-can-you-help-me-save-my-childs-life-diagnostic-accuracy-and-supportive-capabilities

February 01, 2023 - Study "ChatGPT, can you help me save my child's life?" - Diagnostic accuracy and supportive capabilities to lay rescuers by ChatGPT in prehospital basic life support and paediatric advanced life support cases - an in-silico analysis. Citation Text: Bushuven S, Bentele M, Bentele S, et al…

Incorrect surgical procedures within and outside of the operating room. | PSNet

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November 21, 2011 - Study Incorrect surgical procedures within and outside of the operating room. Citation Text: Neily J, Mills PD, Eldridge N, et al. Incorrect surgical procedures within and outside of the operating room. Arch Surg. 2009;144(11):1028-34. doi:10.1001/archsurg.2009.126. Copy Citation F…

Towards safer healthcare: qualitative insights from a process view of organisational learning from failure. | PSNet

psnet.ahrq.gov/issue/towards-safer-healthcare-qualitative-insights-process-view-organisational-learning-failure

July 21, 2021 - Study Towards safer healthcare: qualitative insights from a process view of organisational learning from failure. Citation Text: Monazam Tabrizi N, Masri F. Towards safer healthcare: qualitative insights from a process view of organisational learning from failure. BMJ Open. 2021;11(8):e0…

Nature of blame in patient safety incident reports: mixed methods analysis of a national database. | PSNet

psnet.ahrq.gov/issue/nature-blame-patient-safety-incident-reports-mixed-methods-analysis-national-database

October 12, 2016 - Study Nature of blame in patient safety incident reports: mixed methods analysis of a national database. Citation Text: Cooper J, Edwards A, Williams H, et al. Nature of Blame in Patient Safety Incident Reports: Mixed Methods Analysis of a National Database. Ann Fam Med. 2017;15(5):455-4…

Sustaining reliability on accountability measures at the Johns Hopkins Hospital. | PSNet

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January 19, 2014 - Study Sustaining reliability on accountability measures at the Johns Hopkins Hospital. Citation Text: Pronovost P, Demski R, Callender T, et al. Demonstrating high reliability on accountability measures at the Johns Hopkins Hospital. Jt Comm J Qual Patient Saf. 2013;39(12):531-544. Cop…

The influence of professional identity on how the receiver receives and responds to a speaking up message: a cross-sectional study. | PSNet

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August 10, 2022 - Study The influence of professional identity on how the receiver receives and responds to a speaking up message: a cross-sectional study. Citation Text: Barlow M, Watson B, Jones EW, et al. The influence of professional identity on how the receiver receives and responds to a speaking up …

Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. | PSNet

psnet.ahrq.gov/issue/delivering-high-quality-cancer-care-charting-new-course-system-crisis

August 15, 2012 - Book/Report Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Citation Text: Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Levit L, Balogh E, Nass S, Ganz PA, eds. Committee on Improving the Quality of Cancer Care: Add…

US emergency department visits for outpatient adverse drug events, 2013–2014. | PSNet

psnet.ahrq.gov/issue/us-emergency-department-visits-outpatient-adverse-drug-events-2013-2014

February 23, 2018 - Study Classic US emergency department visits for outpatient adverse drug events, 2013–2014. Citation Text: Shehab N, Lovegrove MC, Geller AI, et al. US Emergency Department Visits for Outpatient Adverse Drug Events, 2013-2014. JAMA. 2016;316(20):2115-2125. doi:1…

Hospital-based medication reconciliation practices: a systematic review. | PSNet

psnet.ahrq.gov/issue/hospital-based-medication-reconciliation-practices-systematic-review

April 05, 2013 - Review Classic Hospital-based medication reconciliation practices: a systematic review. Citation Text: Mueller SK, Sponsler KC, Kripalani S, et al. Hospital-based medication reconciliation practices: a systematic review. Arch Intern Med. 2012;172(14):1057-69. do…

Breakdowns in the initial patient-provider encounter are a frequent source of diagnostic error among ischemic stroke cases included in a large medical malpractice claims database. | PSNet

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January 23, 2019 - Review Breakdowns in the initial patient-provider encounter are a frequent source of diagnostic error among ischemic stroke cases included in a large medical malpractice claims database. Citation Text: Liberman AL, Skillings J, Greenberg P, et al. Breakdowns in the initial patient-provid…

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