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psnet.ahrq.gov/node/49678/psn-pdf
March 01, 2013 - The resident and attending physician diagnosed an
uncomplicated periorbital cellulitis and prescribed … The mother, a medical student,
realized the potential implications of such an error and asked the resident
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psnet.ahrq.gov/web-mm/real-heartache
October 01, 2018 - November 16, 2022
Effects on resident work hours, sleep duration and work experience … in a Randomized Order Safety Trial Evaluating Resident-physician Schedules (ROSTERS).
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psnet.ahrq.gov/web-mm/are-you-mrs-issue-identification-over-telephone
January 01, 2016 - Had the resident seen a picture of Mr. B instead of Mr. … completed within the electronic record, additional safety guards could be used, such as verifying the resident
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psnet.ahrq.gov/issue/learning-through-experience-influence-formal-and-informal-training-medical-error-disclosure
March 16, 2022 - Study
Learning through experience: influence of formal and informal training on medical error disclosure skills in residents.
Citation Text:
Wong BM, Coffey M, Nousiainen MT, et al. Learning through experience: influence of formal and informal training on medical error disclosure skills …
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psnet.ahrq.gov/node/850361/psn-pdf
June 14, 2023 - The results were sent to the inbox of the ordering
resident, who was not on the primary service taking … The resident did not check his
inbox. … communication;
2. none of the primary providers on the team followed up the echocardiogram results;
3. the resident
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psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow
July 31, 2023 - The results were sent to the inbox of the ordering resident, who was not on the primary service taking … The resident did not check his inbox. … communication; none of the primary providers on the team followed up the echocardiogram results; the resident
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psnet.ahrq.gov/web-mm/falling-through-crack-bedrails
February 19, 2020 - The intern and resident on the team worked together to prepare the patient for the procedure. … The intern and resident cleaned up the materials from the procedure and left the room. … The resident and intern did not communicate with the nurses after the procedure, and they failed to replace
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psnet.ahrq.gov/perspective/ensuring-patient-and-workforce-safety-culture-healthcare
March 27, 2024 - The most recent AHRQ SOPS Nursing Home Survey found that 54% of nursing home employees rated resident … The main themes that emerged were communication about resident safety, particularly the important role … of physician and manager accessibility, and leadership support for and responsiveness to resident safety
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psnet.ahrq.gov/sites/default/files/2023-04/april_2023_spotlight_the_dose_makes_the_poison.pdf
January 01, 2023 - • Following the ED’s standard protocol for procedural sedation, the ED
resident physician then called … • The resident administered the medication and called out “10 of propofol”. … • Subsequent case review confirmed that the resident administered 10 mL
of a 10 mg/mL solution of … • The resident physician’s assumed use of milliliter units did not align with the
nurse’s assumption
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psnet.ahrq.gov/node/38801/psn-pdf
March 04, 2011 - Computerized clinical decision support during medication
ordering for long-term care residents with renal
insufficiency.
March 4, 2011
Field T, Rochon P, Lee M, et al. Computerized clinical decision support during medication ordering for long-
term care residents with renal insufficiency. J Am Med Inform Assoc. 20…
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psnet.ahrq.gov/node/46430/psn-pdf
September 27, 2017 - Can residents detect errors in technique while observing
central line insertions?
September 27, 2017
Pei K, Merola J, Davis KA, et al. Can residents detect errors in technique while observing central line
insertions? Am J Surg. 2017;213(6):1166-1170.e1. doi:10.1016/j.amjsurg.2016.08.026.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/46548/psn-pdf
April 16, 2018 - Nurses' communication of safety events to nursing home
residents and families.
April 16, 2018
Wagner LM, Driscoll L, Darlington JL, et al. Nurses' Communication of Safety Events to Nursing Home
Residents and Families. J Gerontol Nurs. 2018;44(2):25-32. doi:10.3928/00989134-20171002-01.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/867757/psn-pdf
March 12, 2025 - Improving medication-related safety for residents in
nursing homes: a qualitative study.
March 12, 2025
Shieu B, Lee Y-W, Epps F, et al. Improving medication-related safety for residents in nursing homes: a
qualitative study. J Gerontol Nurs. 2025;51(3):38-43. doi:10.3928/00989134-20250102-03.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/48130/psn-pdf
August 07, 2019 - Adverse events in long-term care residents transitioning
from hospital back to nursing home.
August 7, 2019
Kapoor A, Field T, Handler S, et al. Adverse Events in Long-term Care Residents Transitioning From
Hospital Back to Nursing Home. JAMA Intern Med. 2019;179(9):1254-1261.
doi:10.1001/jamainternmed.2019.2005.
…
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psnet.ahrq.gov/node/44996/psn-pdf
June 29, 2016 - Residents' numeric inputting error in computerized
physician order entry prescription.
June 29, 2016
Wu X, Wu C, Zhang K, et al. Residents' numeric inputting error in computerized physician order entry
prescription. Int J Med Inform. 2016;88:25-33. doi:10.1016/j.ijmedinf.2016.01.002.
https://psnet.ahrq.gov/issue/r…
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psnet.ahrq.gov/node/46002/psn-pdf
October 13, 2018 - Exploring physician perspectives of residency holdover
handoffs: a qualitative study to understand an
increasingly important type of handoff.
October 13, 2018
Duong JA, Jensen TP, Morduchowicz S, et al. Exploring Physician Perspectives of Residency Holdover
Handoffs: A Qualitative Study to Understand an Increasing…
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psnet.ahrq.gov/issue/comprehensive-collaborative-patient-safety-residency-curriculum-address-acgme-core
October 06, 2011 - Commentary
A comprehensive collaborative patient safety residency curriculum to address the ACGME core competencies.
Citation Text:
Singh R, Naughton B, Taylor JS, et al. A comprehensive collaborative patient safety residency curriculum to address the ACGME core competencies. Med Educ.…
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psnet.ahrq.gov/node/844770/psn-pdf
September 11, 2019 - Use of "Doctor" badges for physician role identification
during clinical training.
September 11, 2019
Foote MB, DeFilippis EM, Rome BN, et al. Use of "Doctor" Badges for Physician Role Identification During
Clinical Training. JAMA Intern Med. 2019. doi:10.1001/jamainternmed.2019.2416.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/43722/psn-pdf
November 26, 2014 - Reporting medication errors: residents with diabetes.
November 26, 2014
Milligan F, Gadsby R, Ghaleb MA, et al. Reporting medication errors: residents with diabetes. Nursing and
Residential Care. 2014;16(11). doi:10.12968/nrec.2014.16.11.617.
https://psnet.ahrq.gov/issue/reporting-medication-errors-residents-diabet…
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psnet.ahrq.gov/node/47541/psn-pdf
March 04, 2019 - Health outcomes of deprescribing interventions among
older residents in nursing homes: a systematic review
and meta-analysis.
March 4, 2019
Kua C-H, Mak VSL, Lee SWH. Health Outcomes of Deprescribing Interventions Among Older Residents in
Nursing Homes: A Systematic Review and Meta-analysis. J Amer Med Direct Asso…