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Causes, consequences, detection, and prevention of identification errors in laboratory diagnostics. | PSNet

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July 05, 2017 - Review Causes, consequences, detection, and prevention of identification errors in laboratory diagnostics. Citation Text: Lippi G, Blanckaert N, Bonini P, et al. Causes, consequences, detection, and prevention of identification errors in laboratory diagnostics. Clin Chem Lab Med. 2009;…

ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: a meta-analysis. | PSNet

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August 19, 2020 - Review ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: a meta-analysis. Citation Text: Tarnutzer AA, Lee S-H, Robinson K, et al. ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: A meta-analysis. Neurology. 2017;88(15):1468-1477. do…

Incorporating harms into the weighting of the Revised AHRQ Patient Safety for Selected Indicators Composite (PSI 90). | PSNet

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June 29, 2022 - Study Incorporating harms into the weighting of the Revised AHRQ Patient Safety for Selected Indicators Composite (PSI 90). Citation Text: Zrelak PA, Utter GH, McDonald KM, et al. Incorporating harms into the weighting of the revised Agency for Healthcare Research and Quality Patient Saf…

Addressing veteran health-related social needs: how Joint Commission standards accelerated integration and expansion of tools and services in the Veterans Health Administration. | PSNet

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November 24, 2021 - Commentary Addressing veteran health-related social needs: how Joint Commission standards accelerated integration and expansion of tools and services in the Veterans Health Administration. Citation Text: List JM, Russell LE, Hausmann LRM, et al. Addressing veteran health-related social n…

Characterisations of adverse events detected in a university hospital: a 4-year study using the Global Trigger Tool method. | PSNet

psnet.ahrq.gov/issue/characterisations-adverse-events-detected-university-hospital-4-year-study-using-global

December 09, 2020 - Study Characterisations of adverse events detected in a university hospital: a 4-year study using the Global Trigger Tool method. Citation Text: Rutberg H, Risberg MB, Sjödahl R, et al. Characterisations of adverse events detected in a university hospital: a 4-year study using the Global…

The 'go-between' study: a simulation study comparing the 'Traffic Lights' and 'SBAR' tools as a means of communication between anaesthetic staff. | PSNet

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March 01, 2023 - Study The 'go-between' study: a simulation study comparing the 'Traffic Lights' and 'SBAR' tools as a means of communication between anaesthetic staff. Citation Text: MacDougall-Davis SR, Kettley L, Cook TM. The 'go-between' study: a simulation study comparing the 'Traffic Lights' and 'S…

Multistate point-prevalence survey of health care-associated infections. | PSNet

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November 14, 2018 - Study Multistate point-prevalence survey of health care-associated infections. Citation Text: Magill SS, Edwards JR, Bamberg W, et al. Multistate point-prevalence survey of health care-associated infections. N Engl J Med. 2014;370(13):1198-208. doi:10.1056/NEJMoa1306801. Copy Citation …

Rates of serious surgical errors in California and plans to prevent recurrence. | PSNet

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March 09, 2022 - Study Rates of serious surgical errors in California and plans to prevent recurrence. Citation Text: Cohen AJ, Lui H, Zheng M, et al. Rates of serious surgical errors in California and plans to prevent recurrence. JAMA Netw Open. 2021;4(5):e217058. doi:10.1001/jamanetworkopen.2021.7058. …

Vital signs: epidemiology of sepsis: prevalence of health care factors and opportunities for prevention. | PSNet

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September 23, 2020 - Study Vital signs: epidemiology of sepsis: prevalence of health care factors and opportunities for prevention. Citation Text: 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…

Patient safety monitoring in acute care in a decentralized national health care system: conceptual framework and initial set of actionable indicators. | PSNet

psnet.ahrq.gov/issue/patient-safety-monitoring-acute-care-decentralized-national-health-care-system-conceptual

July 27, 2022 - Study Patient safety monitoring in acute care in a decentralized national health care system: conceptual framework and initial set of actionable indicators. Citation Text: Barbara L, Roberta DB, Vanda R, et al. Patient safety monitoring in acute care in a decentralized national health ca…

Analysis of medication therapy discontinuation orders in new electronic prescriptions and opportunities for implementing CancelRx. | PSNet

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July 23, 2018 - Study Analysis of medication therapy discontinuation orders in new electronic prescriptions and opportunities for implementing CancelRx. Citation Text: Yang Y, Ward-Charlerie S, Kashyap N, et al. Analysis of medication therapy discontinuation orders in new electronic prescriptions and op…

A machine learning-based clinical predictive tool to identify patients at high risk of medication errors. | PSNet

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March 29, 2012 - Study A machine learning-based clinical predictive tool to identify patients at high risk of medication errors. Citation Text: Abdo A, Gallay L, Vallecillo T, et al. A machine learning-based clinical predictive tool to identify patients at high risk of medication errors. Sci Rep. 2024;14…

The working hours of hospital staff nurses and patient safety. | PSNet

psnet.ahrq.gov/issue/working-hours-hospital-staff-nurses-and-patient-safety

December 19, 2012 - Study Classic The working hours of hospital staff nurses and patient safety. Citation Text: Rogers AE, Hwang W-T, Scott LD, et al. The working hours of hospital staff nurses and patient safety. Health Aff (Millwood). 2004;23(4):202-212. Copy Citation For…

The National Emergency Department Safety Study: study rationale and design. | PSNet

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June 16, 2009 - Commentary The National Emergency Department Safety Study: study rationale and design. Citation Text: Sullivan AF, Camargo CA, Cleary PD, et al. The National Emergency Department Safety Study: Study Rationale and Design. Acad Emerg Med. 2007;14(12):1182-1189. doi:10.1197/j.aem.2007.07.…

Missing clinical information during primary care visits. | PSNet

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March 28, 2011 - Study Missing clinical information during primary care visits. Citation Text: Smith PC, Araya-Guerra R, Bublitz C, et al. Missing clinical information during primary care visits. JAMA. 2005;293(5):565-71. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML E…

A coaching program to improve employee engagement, culture of safety, and patient experience. | PSNet

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April 05, 2013 - Study A coaching program to improve employee engagement, culture of safety, and patient experience. Citation Text: Scheurer D, Coulter A, Harper K, et al. A coaching program to improve employee engagement, culture of safety, and patient experience. NEJM Catalyst. 2024;6(1):CAT.24.0225. d…

Implementing hospital-based communication-and-resolution programs: lessons learned in New York City. | PSNet

psnet.ahrq.gov/issue/implementing-hospital-based-communication-and-resolution-programs-lessons-learned-new-york

September 01, 2018 - Study Implementing hospital-based communication-and-resolution programs: lessons learned in New York City. Citation Text: Mello MM, Senecal SK, Kuznetsov Y, et al. Implementing hospital-based communication-and-resolution programs: lessons learned in New York City. Health Aff (Millwood).…

Quality & safety in the time of coronavirus--design better, learn faster. | PSNet

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March 29, 2017 - Commentary Quality & safety in the time of coronavirus--design better, learn faster. Citation Text: Fitzsimons J. Quality and safety in the time of Coronavirus: design better, learn faster. Int J Qual Health Care. 2021;33(1):mzaa051. doi:10.1093/intqhc/mzaa051. Copy Citation Format…

The incidence and nature of prescribing and medication administration errors in paediatric inpatients. | PSNet

psnet.ahrq.gov/issue/incidence-and-nature-prescribing-and-medication-administration-errors-paediatric-inpatients

July 08, 2008 - Study The incidence and nature of prescribing and medication administration errors in paediatric inpatients. Citation Text: Ghaleb M, Barber N, Franklin BD, et al. The incidence and nature of prescribing and medication administration errors in paediatric inpatients. Arch Dis Child. 201…

The Definition of Quality and Approaches to Its Assessment. Vol 1. Explorations in Quality Assessment and Monitoring. | PSNet

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May 24, 2015 - Book/Report Classic The Definition of Quality and Approaches to Its Assessment. Vol 1. Explorations in Quality Assessment and Monitoring. Citation Text: The Definition of Quality and Approaches to Its Assessment. Vol 1. Explorations in Quality Assessment and Mon…

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