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Showing results for "reviews".

  1. Root cause analyses of reported adverse events occurring during gastrointestinal scope and tube placement procedures in the Veterans Health Association. | PSNet

    psnet.ahrq.gov/issue/root-cause-analyses-reported-adverse-events-occurring-during-gastrointestinal-scope-and-tube
    November 17, 2021 - Study Root cause analyses of reported adverse events occurring during gastrointestinal scope and tube placement procedures in the Veterans Health Association. Citation Text: Soncrant C, Mills PD, Neily J, et al. Root cause analyses of reported adverse events occurring during gastrointest…

  2. System issues leading to "found-on-floor" incidents: a multi-incident analysis. | PSNet

    psnet.ahrq.gov/issue/system-issues-leading-found-floor-incidents-multi-incident-analysis
    August 04, 2021 - Study System issues leading to "found-on-floor" incidents: a multi-incident analysis. Citation Text: Shaw J, Bastawrous M, Burns S, et al. System Issues Leading to “Found-on-Floor” Incidents: A Multi-Incident Analysis. J Patient Saf. 2021;17(1):30-35. doi:10.1097/pts.0000000000000294. …

  3. Enhancing patient safety: a national standard for cyber resiliency in healthcare. | PSNet

    psnet.ahrq.gov/issue/enhancing-patient-safety-national-standard-cyber-resiliency-healthcare
    September 23, 2020 - Commentary Enhancing patient safety: a national standard for cyber resiliency in healthcare. Citation Text: Samuelson-Kiraly C, Mitchell JI, Kingston D, et al. Enhancing patient safety: A national standard for cyber resiliency in healthcare. Healthc Manage Forum. 2024;37(1):9-12. doi:10.…

  4. Critical errors in infrequently performed trauma procedures after training. | PSNet

    psnet.ahrq.gov/issue/critical-errors-infrequently-performed-trauma-procedures-after-training
    June 27, 2018 - Study Critical errors in infrequently performed trauma procedures after training. Citation Text: Mackenzie CF, Shackelford SA, Tisherman SA, et al. Critical errors in infrequently performed trauma procedures after training. Surgery. 2019;166(5):835-843. doi:10.1016/j.surg.2019.05.031. …

  5. 'It's all about patient safety': an ethnographic study of how pharmacy staff construct medicines safety in the context of polypharmacy. | PSNet

    psnet.ahrq.gov/issue/its-all-about-patient-safety-ethnographic-study-how-pharmacy-staff-construct-medicines-safety
    October 06, 2021 - Study 'It's all about patient safety': an ethnographic study of how pharmacy staff construct medicines safety in the context of polypharmacy. Citation Text: Fudge N, Swinglehurst D. ‘It's all about patient safety’: an ethnographic study of how pharmacy staff construct medicines safety in…

  6. Preserving organizational resilience, patient safety, and staff retention during COVID-19 requires a holistic consideration of the psychological safety of healthcare workers | PSNet

    psnet.ahrq.gov/issue/preserving-organizational-resilience-patient-safety-and-staff-retention-during-covid-19
    May 08, 2019 - Commentary Classic Preserving organizational resilience, patient safety, and staff retention during COVID-19 requires a holistic consideration of the psychological safety of healthcare workers Citation Text: Rangachari P, L. Woods J. Preserving organizational re…

  7. A text mining approach to categorize patient safety event reports by medication error type. | PSNet

    psnet.ahrq.gov/issue/text-mining-approach-categorize-patient-safety-event-reports-medication-error-type
    December 07, 2022 - Study A text mining approach to categorize patient safety event reports by medication error type. Citation Text: Boxley C, Fujimoto M, Ratwani RM, et al. A text mining approach to categorize patient safety event reports by medication error type. Sci Rep. 2023;13(1):18354. doi:10.1038/s41…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43571/psn-pdf
    October 01, 2014 - The evolving literature on safety WalkRounds: emerging themes and practical messages. October 1, 2014 Singer SJ, Tucker AL. The evolving literature on safety WalkRounds: emerging themes and practical messages: Table 1. BMJ Qual Saf. 2014;23(10). doi:10.1136/bmjqs-2014-003416. https://psnet.ahrq.gov/issue/evolving-…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39523/psn-pdf
    September 26, 2016 - Association of interruptions with an increased risk and severity of medication administration errors. September 26, 2016 Westbrook JI, Woods A, Rob MI, et al. Association of interruptions with an increased risk and severity of medication administration errors. Arch Intern Med. 2010;170(8):683-690. doi:10.1001/arch…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/840141/psn-pdf
    November 16, 2022 - Toward zero harm: Mackenzie Health's journey toward becoming a high reliability organization and eliminating avoidable harm. November 16, 2022 Wilson M-A, Sinno M, Hacker Teper M, et al. Toward zero harm: Mackenzie Health's journey toward becoming a high reliability organization and eliminating avoidable harm. J P…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37257/psn-pdf
    April 19, 2011 - Validation of a diagnostic reminder system in emergency medicine: a multi-centre study. April 19, 2011 Ramnarayan P, Cronje N, Brown R, et al. Validation of a diagnostic reminder system in emergency medicine: a multi-centre study. Emerg Med J. 2007;24(9):619-24. https://psnet.ahrq.gov/issue/validation-diagnostic-r…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46615/psn-pdf
    January 23, 2019 - The surgical safety checklist and patient outcomes after surgery: a prospective observational cohort study, systematic review and meta-analysis. January 23, 2019 Abbott TEF, Ahmad T, Phull MK, et al. The surgical safety checklist and patient outcomes after surgery: a prospective observational cohort study, systema…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43711/psn-pdf
    November 26, 2014 - The impact of hospital-acquired conditions on Medicare program payments. November 26, 2014 Kandilov AMG, Coomer NM, Dalton K. The impact of hospital-acquired conditions on Medicare program payments. Medicare Medicaid Res Rev. 2014;4(4). doi:10.5600/mmrr.004.04.a01. https://psnet.ahrq.gov/issue/impact-hospital-acqu…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45471/psn-pdf
    September 21, 2016 - Vital signs: epidemiology of sepsis: prevalence of health care factors and opportunities for prevention. September 21, 2016 Novosad SA, Sapiano MRP, Grigg C, et al. Vital Signs: Epidemiology of Sepsis: Prevalence of Health Care Factors and Opportunities for Prevention. MMWR Morb Mortal Wkly Rep. 2016;65(33):864-869…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44315/psn-pdf
    November 20, 2015 - Expanding the scope of Critical Care Rapid Response Teams: a feasible approach to identify adverse events. A prospective observational cohort. November 20, 2015 Amaral ACK-B, McDonald A, Coburn NG, et al. Expanding the scope of Critical Care Rapid Response Teams: a feasible approach to identify adverse events. A p…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42458/psn-pdf
    February 13, 2014 - Human factors and ergonomics as a patient safety practice. February 13, 2014 Carayon P, Xie A, Kianfar S. Human factors and ergonomics as a patient safety practice. BMJ Qual Saf. 2014;23(3):196-205. doi:10.1136/bmjqs-2013-001812. https://psnet.ahrq.gov/issue/human-factors-and-ergonomics-patient-safety-practice As…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44376/psn-pdf
    October 08, 2016 - Avoidability of hospital deaths and association with hospital-wide mortality ratios: retrospective case record review and regression analysis. October 8, 2016 Hogan H, Zipfel R, Neuburger J, et al. Avoidability of hospital deaths and association with hospital-wide mortality ratios: retrospective case record review…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44915/psn-pdf
    January 01, 2020 - Electronic health record adoption and rates of in-hospital adverse events. February 24, 2016 Furukawa MF, Eldridge N, Wang Y, et al. Electronic Health Record Adoption and Rates of In-hospital Adverse Events. J Patient Saf. 2020;16(2):137-142. doi:10.1097/pts.0000000000000257. https://psnet.ahrq.gov/issue/electroni…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45435/psn-pdf
    August 24, 2016 - Pharmacist–physician communications in a highly computerised hospital: sign-off and action of electronic review messages. August 24, 2016 Pontefract SK, Hodson J, Marriott JF, et al. Pharmacist-Physician Communications in a Highly Computerised Hospital: Sign-Off and Action of Electronic Review Messages. PLoS One. …

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/844549/psn-pdf
    February 15, 2023 - Preventable harm because of outpatient medication errors among children with leukemia and lymphoma: a multisite longitudinal assessment. February 15, 2023 Wong CI, Vannatta K, Gilleland Marchak J, et al. Preventable harm because of outpatient medication errors among children with leukemia and lymphoma: a multisite…
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