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Mortality and morbidity rounds (MMR) in pathology: relative contribution of cognitive bias vs. systems failures to diagnostic error. | PSNet

psnet.ahrq.gov/issue/mortality-and-morbidity-rounds-mmr-pathology-relative-contribution-cognitive-bias-vs-systems

May 18, 2022 - Study Mortality and morbidity rounds (MMR) in pathology: relative contribution of cognitive bias vs. systems failures to diagnostic error. Citation Text: Eichbaum Q, Adkins B, Craig-Owens L, et al. Mortality and morbidity rounds (MMR) in pathology: relative contribution of cognitive bias…

The end of the beginning: patient safety five years after 'To Err Is Human.' | PSNet

psnet.ahrq.gov/issue/end-beginning-patient-safety-five-years-after-err-human

March 02, 2011 - Commentary Classic The end of the beginning: patient safety five years after 'To Err Is Human.' Citation Text: Wachter RM. The End Of The Beginning: Patient Safety Five Years After ‘To Err Is Human’. Health Aff. 2004;23(Suppl1). doi:10.1377/hlthaff.w4.534. C…

Work hour rules and contributors to patient care mistakes: a focus group study with internal medicine residents. | PSNet

psnet.ahrq.gov/issue/work-hour-rules-and-contributors-patient-care-mistakes-focus-group-study-internal-medicine

February 22, 2011 - Study Work hour rules and contributors to patient care mistakes: a focus group study with internal medicine residents. Citation Text: Fletcher KE, Parekh V, Halasyamani L, et al. Work hour rules and contributors to patient care mistakes: a focus group study with internal medicine resid…

Complexity of medication-related verbal orders. | PSNet

psnet.ahrq.gov/issue/complexity-medication-related-verbal-orders

November 17, 2010 - Study Complexity of medication-related verbal orders. Citation Text: Wakefield DS, Ward MM, Groath D, et al. Complexity of medication-related verbal orders. Am J Med Qual. 2008;23(1):7-17. doi:10.1177/1062860607310922. Copy Citation Format: DOI Google Scholar PubMed BibTe…

Quality and patient safety improvement is never finished. | PSNet

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September 18, 2024 - Study Quality and patient safety improvement is never finished. Citation Text: Kachalia A, Vanhaecht K. Quality and patient safety improvement is never finished. NEJM Catalyst. 2024;5(9). doi:10.1056/cat.24.0316. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XM…

Effect of alerts for drug dosage adjustment in inpatients with renal insufficiency. | PSNet

psnet.ahrq.gov/issue/effect-alerts-drug-dosage-adjustment-inpatients-renal-insufficiency

September 01, 2016 - Study Effect of alerts for drug dosage adjustment in inpatients with renal insufficiency. Citation Text: Sellier E, Colombet I, Sabatier B, et al. Effect of alerts for drug dosage adjustment in inpatients with renal insufficiency. J Am Med Inform Assoc. 2009;16(2):203-10. doi:10.1197/j…

Lack of patient knowledge regarding hospital medications. | PSNet

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September 20, 2006 - Study Lack of patient knowledge regarding hospital medications. Citation Text: Lack of patient knowledge regarding hospital medications. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Citation …

Patient involvement in patient safety: the health-care professional's perspective. | PSNet

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July 06, 2012 - Study Patient involvement in patient safety: the health-care professional's perspective. Citation Text: Davis R, Sevdalis N, Vincent CA. Patient involvement in patient safety: the health-care professional's perspective. J Patient Saf. 2012;8(4):182-8. doi:10.1097/PTS.0b013e318267c4aa. …

Implementing a perioperative handoff tool to improve postprocedural patient transfers. | PSNet

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February 29, 2012 - Commentary Implementing a perioperative handoff tool to improve postprocedural patient transfers. Citation Text: Petrovic MA, Martinez EA, Aboumatar HJ. Implementing a perioperative handoff tool to improve postprocedural patient transfers. Jt Comm J Qual Patient Saf. 2012;38(3):135-42. …

Increasing vigilance on the medical/surgical floor to improve patient safety. | PSNet

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January 18, 2011 - Study Increasing vigilance on the medical/surgical floor to improve patient safety. Citation Text: Jacobs JL, Apatov N, Glei M. Increasing vigilance on the medical/surgical floor to improve patient safety. J Adv Nurs. 2007;57(5). doi:10.1111/j.1365-2648.2006.04161.x. Copy Citation …

Physicians' beliefs about using EMR and CPOE: in pursuit of a contextualized understanding of health IT use behavior. | PSNet

psnet.ahrq.gov/issue/physicians-beliefs-about-using-emr-and-cpoe-pursuit-contextualized-understanding-health-it

May 16, 2012 - Study Physicians' beliefs about using EMR and CPOE: in pursuit of a contextualized understanding of health IT use behavior. Citation Text: Holden RJ. Physicians' beliefs about using EMR and CPOE: in pursuit of a contextualized understanding of health IT use behavior. Int J Med Inform. …

Experiences with Lean Six Sigma as improvement strategy to reduce parenteral medication administration errors and associated potential risk of harm. | PSNet

psnet.ahrq.gov/issue/experiences-lean-six-sigma-improvement-strategy-reduce-parenteral-medication-administration

October 13, 2021 - Commentary Experiences with Lean Six Sigma as improvement strategy to reduce parenteral medication administration errors and associated potential risk of harm. Citation Text: van de Plas A, Slikkerveer M, Hoen S, et al. Experiences with Lean Six Sigma as improvement strategy to reduce pa…

Patient misidentification in Papanicolaou tests: a systems-based approach to reducing errors. | PSNet

psnet.ahrq.gov/issue/patient-misidentification-papanicolaou-tests-systems-based-approach-reducing-errors

December 26, 2014 - Study Patient misidentification in Papanicolaou tests: a systems-based approach to reducing errors. Citation Text: Meyer E, Underwood S, Padmanabhan V. Patient misidentification in Papanicolaou tests: a systems-based approach to reducing errors. Arch Pathol Lab Med. 2009;133(8):1297-30…

Towards a common framework to support decision-making in high-risk, low-time environments. | PSNet

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November 16, 2022 - Commentary Towards a common framework to support decision-making in high-risk, low-time environments. Citation Text: Launder D, Penney G. Towards a common framework to support decision‐making in high‐risk, low‐time environments. J Contin Crisis Manag. 2023;31(4):862-876. doi:10.1111/1468…

Diagnosing fast and slow: cognitive bias in obstetrics. | PSNet

psnet.ahrq.gov/issue/diagnosing-fast-and-slow-cognitive-bias-obstetrics

February 22, 2019 - Commentary Diagnosing fast and slow: cognitive bias in obstetrics. Citation Text: Atallah F, Gomes C, Minkoff H. Diagnosing fast and slow: cognitive bias in obstetrics. Obstet Gynecol. 2023;142(3):727-732. doi:10.1097/aog.0000000000005303. Copy Citation Format: DOI Google S…

Anesthesia machine as a cause of intraoperative "code red" in the labor and delivery suite. | PSNet

psnet.ahrq.gov/issue/anesthesia-machine-cause-intraoperative-code-red-labor-and-delivery-suite

August 16, 2023 - Commentary Anesthesia machine as a cause of intraoperative "code red" in the labor and delivery suite. Citation Text: Kuczkowski KM. Anesthesia machine as a cause of intraoperative "code red" in the labor and delivery suite. Arch Gynecol Obstet. 2008;278(5):477-8. doi:10.1007/s00404-008-…

Mentorship for newly appointed physicians: a strategy for enhancing patient safety? | PSNet

psnet.ahrq.gov/issue/mentorship-newly-appointed-physicians-strategy-enhancing-patient-safety

April 22, 2012 - Study Mentorship for newly appointed physicians: a strategy for enhancing patient safety? Citation Text: Harrison R, McClean S, Lawton R, et al. Mentorship for newly appointed physicians: a strategy for enhancing patient safety? J Patient Saf. 2014;10(3):159-67. doi:10.1097/PTS.0b013e318…

Associations of patient safety outcomes with models of nursing care organization at unit level in hospitals. | PSNet

psnet.ahrq.gov/issue/associations-patient-safety-outcomes-models-nursing-care-organization-unit-level-hospitals

August 20, 2014 - Study Associations of patient safety outcomes with models of nursing care organization at unit level in hospitals. Citation Text: Dubois C-A, D'Amour D, Tchouaket E, et al. Associations of patient safety outcomes with models of nursing care organization at unit level in hospitals. Int J …

Comparative safety of endovascular aortic aneurysm repair over open repair using Patient Safety Indicators during adoption. | PSNet

psnet.ahrq.gov/issue/comparative-safety-endovascular-aortic-aneurysm-repair-over-open-repair-using-patient-safety

November 16, 2022 - Study Comparative safety of endovascular aortic aneurysm repair over open repair using Patient Safety Indicators during adoption. Citation Text: Rose J, Evans C, Barleben A, et al. Comparative safety of endovascular aortic aneurysm repair over open repair using patient safety indicators …

Predictors of completeness of patients' self-reported personal medication lists and discrepancies with clinic medication lists. | PSNet

psnet.ahrq.gov/issue/predictors-completeness-patients-self-reported-personal-medication-lists-and-discrepancies

October 19, 2022 - Study Predictors of completeness of patients' self-reported personal medication lists and discrepancies with clinic medication lists. Citation Text: Lee KP, Nishimura K, Ngu B, et al. Predictors of completeness of patients' self-reported personal medication lists and discrepancies with…

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