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Unintentionally retained guidewires: a descriptive study of 73 sentinel events. | PSNet

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April 27, 2019 - Study Unintentionally retained guidewires: a descriptive study of 73 sentinel events. Citation Text: Steelman VM, Thenuwara K, Shaw C, et al. Unintentionally Retained Guidewires: A Descriptive Study of 73 Sentinel Events. Jt Comm J Qual Saf. 2019;45(2):81-90. doi:10.1016/j.jcjq.2018.08.0…

The human factor. To improve patients safety, hospitals urged to adjust for how staff use new technology. | PSNet

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April 22, 2016 - Newspaper/Magazine Article The human factor. To improve patients safety, hospitals urged to adjust for how staff use new technology. Citation Text: Rice S, Tahir D. The human factor. To improve patients safety, hospitals urged to adjust for how staff use new technology. Modern healthcare…

Navigating towards improved surgical safety using aviation-based strategies. | PSNet

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January 04, 2011 - Review Navigating towards improved surgical safety using aviation-based strategies. Citation Text: Kao LS, Thomas EJ. Navigating towards improved surgical safety using aviation-based strategies. J Surg Res. 2008;145(2):327-35. Copy Citation Format: Google Scholar PubMed B…

Mortality rate after nonelective hospital admission. | PSNet

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January 22, 2016 - Study Mortality rate after nonelective hospital admission. Citation Text: Ricciardi R, Roberts PL, Read TE, et al. Mortality rate after nonelective hospital admission. Arch Surg. 2011;146(5):545-51. doi:10.1001/archsurg.2011.106. Copy Citation Format: DOI Google Scholar P…

Building capacity and capability for patient safety education: a train-the-trainers programme for senior doctors. | PSNet

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January 15, 2014 - Study Building capacity and capability for patient safety education: a train-the-trainers programme for senior doctors. Citation Text: Ahmed M, Arora S, Baker P, et al. Building capacity and capability for patient safety education: a train-the-trainers programme for senior doctors. BMJ…

Parenteral nutrition errors and potential errors reported over the past 10 years. | PSNet

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June 20, 2018 - Study Parenteral nutrition errors and potential errors reported over the past 10 years. Citation Text: Guenter P, Ayers P, Boullata JI, et al. Parenteral Nutrition Errors and Potential Errors Reported Over the Past 10 Years. Nutr Clin Pract. 2017;32(6):826-830. doi:10.1177/08845336177158…

Improving the safety of intravenous admixtures: lessons learned from a Pentostam® overdose. | PSNet

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January 04, 2017 - Commentary Improving the safety of intravenous admixtures: lessons learned from a Pentostam® overdose. Citation Text: Just S, Schepers G, Piotrowski MM, et al. Improving the safety of intravenous admixtures: lessons learned from a Pentostam overdose. Jt Comm J Qual Patient Saf. 2006;32(7…

Can positivity promote safety? Psychological capital development combats cynicism and unsafe behavior. | PSNet

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June 09, 2011 - Study Can positivity promote safety? Psychological capital development combats cynicism and unsafe behavior. Citation Text: Stratman JL, Youssef-Morgan CM. Can positivity promote safety? Psychological capital development combats cynicism and unsafe behavior. Safety Sci. 2019;116:13-25. d…

Inpatient notes: just what the doctor ordered—checklists to improve diagnosis. | PSNet

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August 14, 2019 - Commentary Inpatient notes: just what the doctor ordered—checklists to improve diagnosis. Citation Text: Gupta A, Graber ML. Web Exclusive. Annals for Hospitalists Inpatient Notes - Just What the Doctor Ordered-Checklists to Improve Diagnosis. Ann Intern Med. 2019;170(8):HO2-HO3. doi:10.…

What stands in the way of technology-mediated patient safety improvements? A study of facilitators and barriers to physicians' use of electronic health records. | PSNet

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May 16, 2012 - Study What stands in the way of technology-mediated patient safety improvements? A study of facilitators and barriers to physicians' use of electronic health records. Citation Text: Holden RJ. What stands in the way of technology-mediated patient safety improvements?: a study of facili…

Her husband died by suicide. She sued his pain doctors—a rare challenge over an opioid dose reduction. | PSNet

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September 15, 2021 - Newspaper/Magazine Article Her husband died by suicide. She sued his pain doctors—a rare challenge over an opioid dose reduction. Citation Text: Her husband died by suicide. She sued his pain doctors—a rare challenge over an opioid dose reduction. Joseph A. STAT. November 22, 2021 Co…

Diagnostic delays and errors in head and neck cancer patients: opportunities for improvement. | PSNet

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March 14, 2022 - Study Diagnostic delays and errors in head and neck cancer patients: opportunities for improvement. Citation Text: Franco J, Elghouche AN, Harris MS, et al. Diagnostic Delays and Errors in Head and Neck Cancer Patients: Opportunities for Improvement. Am J Med Qual. 2017;32(3):330-335. do…

Adverse events associated with procedural sedation and analgesia in a pediatric emergency department: a comparison of common parenteral drugs. | PSNet

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June 12, 2019 - Study Adverse events associated with procedural sedation and analgesia in a pediatric emergency department: a comparison of common parenteral drugs. Citation Text: Roback MG, Wathen JE, Bajaj L, et al. Adverse events associated with procedural sedation and analgesia in a pediatric emer…

Effects of critical care nurses' work hours on vigilance and patients' safety. | PSNet

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February 19, 2010 - Study Effects of critical care nurses' work hours on vigilance and patients' safety. Citation Text: Scott LD, Rogers AE, Hwang W-T, et al. Effects of critical care nurses' work hours on vigilance and patients' safety. Am J Crit Care. 2006;15(1):30-7. Copy Citation Format: …

Meaningful use and certification of health information technology: what about safety? | PSNet

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September 07, 2022 - Commentary Meaningful use and certification of health information technology: what about safety? Citation Text: Hoffman S, Podgurski A. Meaningful use and certification of health information technology: what about safety? J Law Med Ethics. 2011;39(suppl 1):77-80. doi:10.1111/j.1748-720…

Rates of new or missed colorectal cancers after colonoscopy and their risk factors: a population-based analysis. | PSNet

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August 28, 2024 - Study Rates of new or missed colorectal cancers after colonoscopy and their risk factors: a population-based analysis. Citation Text: Bressler B, Paszat LF, Chen Z, et al. Rates of new or missed colorectal cancers after colonoscopy and their risk factors: a population-based analysis. G…

Potential medical adverse events associated with death: a forensic pathology perspective. | PSNet

psnet.ahrq.gov/issue/potential-medical-adverse-events-associated-death-forensic-pathology-perspective

July 31, 2019 - Study Potential medical adverse events associated with death: a forensic pathology perspective. Citation Text: Sakai K, Takatsu A, Shigeta A, et al. Potential medical adverse events associated with death: a forensic pathology perspective. International Journal for Quality in Health Car…

A method for prioritizing interventions following root cause analysis (RCA): lessons from philosophy. | PSNet

psnet.ahrq.gov/issue/method-prioritizing-interventions-following-root-cause-analysis-rca-lessons-philosophy

March 11, 2015 - Commentary A method for prioritizing interventions following root cause analysis (RCA): lessons from philosophy. Citation Text: Boyd M. A method for prioritizing interventions following root cause analysis (RCA): lessons from philosophy. J Eval Clin Pract. 2015;21(3):461-9. doi:10.1111/j…

Prompting physicians to address a daily checklist for antibiotics: do we need a co-pilot in the ICU? | PSNet

psnet.ahrq.gov/issue/prompting-physicians-address-daily-checklist-antibiotics-do-we-need-co-pilot-icu

September 23, 2020 - Review Prompting physicians to address a daily checklist for antibiotics: do we need a co-pilot in the ICU? Citation Text: Weiss CH, Wunderink RG. Prompting physicians to address a daily checklist for antibiotics: do we need a co-pilot in the ICU? Curr Opin Crit Care. 2013;19(5):448-52.…

Interprofessional learning for medication safety. | PSNet

psnet.ahrq.gov/issue/interprofessional-learning-medication-safety

September 23, 2020 - Commentary Interprofessional learning for medication safety. Citation Text: Hardisty J, Scott L, Chandler S, et al. Interprofessional learning for medication safety. Clin Teach. 2014;11(4):290-6. doi:10.1111/tct.12148. Copy Citation Format: DOI Google Scholar PubMed BibTeX …

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