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Flow of information contributing to medication incidents in home care- an analysis considering incident reporters' perspectives. | PSNet

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May 01, 2024 - Study Flow of information contributing to medication incidents in home care- an analysis considering incident reporters' perspectives. Citation Text: Vellonen M, Härkänen M, Välimäki T. Flow of information contributing to medication incidents in home care— an analysis considering inciden…

Effect of warning symbols in combination with education on the frequency of erroneously crushing medication in nursing homes: an uncontrolled before and after study. | PSNet

psnet.ahrq.gov/issue/effect-warning-symbols-combination-education-frequency-erroneously-crushing-medication

March 04, 2011 - Study Effect of warning symbols in combination with education on the frequency of erroneously crushing medication in nursing homes: an uncontrolled before and after study. Citation Text: van Welie S, Wijma L, Beerden T, et al. Effect of warning symbols in combination with education on th…

Cross-Check QA: a quality assurance workflow to prevent missed diagnoses by alerting inadvertent discordance between the radiologist and AI in the interpretation of high acuity CT scans. | PSNet

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March 04, 2015 - Study Cross-Check QA: a quality assurance workflow to prevent missed diagnoses by alerting inadvertent discordance between the radiologist and AI in the interpretation of high acuity CT scans. Citation Text: Chekmeyan M, Baccei SJ, Garwood ER. Cross-Check QA: a quality assurance workflow…

Opioid prescribing practices from 2010 through 2015 among dentists in the United States: what do claims data tell us? | PSNet

psnet.ahrq.gov/issue/opioid-prescribing-practices-2010-through-2015-among-dentists-united-states-what-do-claims

December 20, 2017 - Study Emerging Classic Opioid prescribing practices from 2010 through 2015 among dentists in the United States: what do claims data tell us? Citation Text: Gupta N, Vujicic M, Blatz A. Opioid prescribing practices from 2010 through 2015 among dentists in the Uni…

Investigating the impact of cognitive bias in nursing documentation on decision-making and judgement. | PSNet

psnet.ahrq.gov/issue/investigating-impact-cognitive-bias-nursing-documentation-decision-making-and-judgement

July 13, 2022 - Study Investigating the impact of cognitive bias in nursing documentation on decision-making and judgement. Citation Text: Martin K, Bickle K, Lok J. Investigating the impact of cognitive bias in nursing documentation on decision‐making and judgement. Int J Mental Health Nurs. 2022;31(4)…

Are bad outcomes from questionable clinical decisions preventable medical errors? A case of cascade iatrogenesis. | PSNet

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February 24, 2011 - Study Classic Are bad outcomes from questionable clinical decisions preventable medical errors? A case of cascade iatrogenesis. Citation Text: Hofer TP, Hayward RA. Are bad outcomes from questionable clinical decisions preventable medical errors? A case of cas…

Medicare's Hospital-Acquired Condition Reduction Program and community diversity in the United States: the need to account for racial and ethnic segregation. | PSNet

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May 13, 2020 - Study Medicare's Hospital-Acquired Condition Reduction Program and community diversity in the United States: the need to account for racial and ethnic segregation. Citation Text: Hamadi H, Tafili A, Apatu E, et al. Medicare' Hospital-Acquired Condition Reduction Program and Community Div…

Challenging authority and speaking up in the operating room environment: a narrative synthesis. | PSNet

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December 13, 2017 - Review Emerging Classic Challenging authority and speaking up in the operating room environment: a narrative synthesis. Citation Text: Pattni N, Arzola C, Malavade A, et al. Challenging authority and speaking up in the operating room environment: a narrative syn…

Inadequacies of physical examination as a cause of medical errors and adverse events: a collection of vignettes. | PSNet

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June 01, 1989 - Study Classic Inadequacies of physical examination as a cause of medical errors and adverse events: a collection of vignettes. Citation Text: Verghese A, Charlton B, Kassirer JP, et al. Inadequacies of Physical Examination as a Cause of Medical Errors and Advers…

Comparing the evolution of risk culture in radiation oncology, aviation, and nuclear power. | PSNet

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October 07, 2020 - Study Comparing the evolution of risk culture in radiation oncology, aviation, and nuclear power. Citation Text: Abdulla A, Schell KR, Schell MC. Comparing the evolution of risk culture in radiation oncology, aviation, and nuclear power. J Patient Saf. 2020;16(4):e352-e358. doi:10.1097/p…

Clinical handover in the trauma setting: a qualitative study of paramedics and trauma team members. | PSNet

psnet.ahrq.gov/issue/clinical-handover-trauma-setting-qualitative-study-paramedics-and-trauma-team-members

January 28, 2010 - Study Clinical handover in the trauma setting: a qualitative study of paramedics and trauma team members. Citation Text: Evans S, Murray A, Patrick I, et al. Clinical handover in the trauma setting: a qualitative study of paramedics and trauma team members. Qual Saf Health Care. 2010;1…

Risks and medication errors analysis to evaluate the impact of a chemotherapy compounding workflow management system on cancer patients' safety. | PSNet

psnet.ahrq.gov/issue/risks-and-medication-errors-analysis-evaluate-impact-chemotherapy-compounding-workflow

January 27, 2019 - Study Risks and medication errors analysis to evaluate the impact of a chemotherapy compounding workflow management system on cancer patients' safety. Citation Text: Marzal-Alfaro MB, Rodriguez-Gonzalez CG, Escudero-Vilaplana V, et al. Risks and medication errors analysis to evaluate the…

Laboratory test ordering and results management systems: a qualitative study of safety risks identified by administrators in general practice. | PSNet

psnet.ahrq.gov/issue/laboratory-test-ordering-and-results-management-systems-qualitative-study-safety-risks

March 16, 2016 - Study Laboratory test ordering and results management systems: a qualitative study of safety risks identified by administrators in general practice. Citation Text: Bowie P, Halley L, McKay J. Laboratory test ordering and results management systems: a qualitative study of safety risks id…

A qualitative study of prescribing errors among multi-professional prescribers within an e-prescribing system. | PSNet

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December 02, 2020 - Study A qualitative study of prescribing errors among multi-professional prescribers within an e-prescribing system. Citation Text: Alshahrani F, Marriott JF, Cox AR. A qualitative study of prescribing errors among multi-professional prescribers within an e-prescribing system. Int J Clin…

Mortality and morbidity meetings: an untapped resource for improving the governance of patient safety? | PSNet

psnet.ahrq.gov/issue/mortality-and-morbidity-meetings-untapped-resource-improving-governance-patient-safety

June 25, 2014 - Study Mortality and morbidity meetings: an untapped resource for improving the governance of patient safety? Citation Text: Higginson J, Walters R, Fulop NJ. Mortality and morbidity meetings: an untapped resource for improving the governance of patient safety? BMJ Qual Saf. 2012;21(7):…

Leveraging the science of teamwork to sustain handoff improvements in cardiovascular surgery. | PSNet

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November 28, 2018 - Study Leveraging the science of teamwork to sustain handoff improvements in cardiovascular surgery. Citation Text: Keebler JR, Lynch I, Ngo F, et al. Leveraging the science of teamwork to sustain handoff improvements in cardiovascular surgery. Jt Comm J Qual Patient Saf. 2023;49(8):373-3…

Applying decision science to the prioritization of healthcare-associated infection initiatives. | PSNet

psnet.ahrq.gov/issue/applying-decision-science-prioritization-healthcare-associated-infection-initiatives

October 20, 2021 - Study Applying decision science to the prioritization of healthcare-associated infection initiatives. Citation Text: Tsai TH, Gerst MD, Engineer C, et al. Applying decision science to the prioritization of healthcare-associated infection initiatives. J Patient Saf. 2021;17(7):506-512. do…

How to do no harm: empowering local leaders to make care safer in low-resource settings. | PSNet

psnet.ahrq.gov/issue/how-do-no-harm-empowering-local-leaders-make-care-safer-low-resource-settings

March 03, 2021 - Commentary How to do no harm: empowering local leaders to make care safer in low-resource settings. Citation Text: Vincent CA, Mboga M, Gathara D, et al. How to do no harm: empowering local leaders to make care safer in low-resource settings. Arch Dis Child. 2021;106(4):333-337. doi:10.1…

Integrating adverse event reporting into a free-text mobile application used in daily workflow increases adverse event reporting by physicians. | PSNet

psnet.ahrq.gov/issue/integrating-adverse-event-reporting-free-text-mobile-application-used-daily-workflow

March 17, 2021 - Study Integrating adverse event reporting into a free-text mobile application used in daily workflow increases adverse event reporting by physicians. Citation Text: Delio J, Catalanotti JS, Marko K, et al. Integrating Adverse Event Reporting Into a Free-Text Mobile Application Used in Da…

The use of medical emergency teams in medical and surgical patients: impact of patient, nurse and organisational characteristics. | PSNet

psnet.ahrq.gov/issue/use-medical-emergency-teams-medical-and-surgical-patients-impact-patient-nurse-and

November 09, 2011 - Study The use of medical emergency teams in medical and surgical patients: impact of patient, nurse and organisational characteristics. Citation Text: Schmid-Mazzoccoli A, Hoffman LA, Wolf GA, et al. The use of medical emergency teams in medical and surgical patients: impact of patient,…

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