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Designing a safer process to prevent retained surgical sponges: a healthcare failure mode and effect analysis. | PSNet

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April 27, 2019 - Study Designing a safer process to prevent retained surgical sponges: a healthcare failure mode and effect analysis. Citation Text: Steelman VM, Cullen JJ. Designing a safer process to prevent retained surgical sponges: a healthcare failure mode and effect analysis. AORN J. 2011;94(2):1…

Certain uncertainties: modes of patient safety in healthcare. | PSNet

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April 04, 2011 - Study Certain uncertainties: modes of patient safety in healthcare. Citation Text: Jerak-Zuiderent S. Certain uncertainties: modes of patient safety in healthcare. Soc Stud Sci. 2012;42(5):732-52. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7…

Public comment period extended for strategies to improve patient safety: Draft Report to Congress for Public Comment and Review by the National Academy of Medicine. | PSNet

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June 16, 2021 - Press Release/Announcement Public comment period extended for strategies to improve patient safety: Draft Report to Congress for Public Comment and Review by the National Academy of Medicine. Citation Text: Public comment period extended for strategies to improve patient safety: Draft Re…

Relationship of incorrect dosing of fibrinolytic therapy and clinical outcomes. | PSNet

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November 10, 2015 - Study Relationship of incorrect dosing of fibrinolytic therapy and clinical outcomes. Citation Text: Mehta RH. Relationship of Incorrect Dosing of Fibrinolytic Therapy and Clinical Outcomes. JAMA. 2005;293(14). doi:10.1001/jama.293.14.1746. Copy Citation Format: DOI Googl…

Learning from samples of one or fewer. | PSNet

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December 21, 2017 - Review Classic Learning from samples of one or fewer. Citation Text: Learning from samples of one or fewer. March JG, Sproull LS, Tamuz M. Org Sci.1991;2:1-13. (reprinted in: Qual Saf Health Care 2003;12:465-472.) Copy Citation Save S…

Incidence of accidental awareness during general anaesthesia in obstetrics: a multicentre, prospective cohort study. | PSNet

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December 10, 2024 - Study Emerging Classic Incidence of accidental awareness during general anaesthesia in obstetrics: a multicentre, prospective cohort study. Citation Text: Incidence of accidental awareness during general anaesthesia in obstetrics: a multicentre, prospective coho…

Instituting vincristine minibag administration: an innovative strategy using simulation to enhance chemotherapy safety. | PSNet

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April 24, 2018 - Commentary Instituting vincristine minibag administration: an innovative strategy using simulation to enhance chemotherapy safety. Citation Text: Corbitt N, Malick L, Nishioka J, et al. Instituting Vincristine Minibag Administration: An Innovative Strategy Using Simulation to Enhance Che…

Developing a tool for assessing competency in root cause analysis. | PSNet

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May 01, 2014 - Study Developing a tool for assessing competency in root cause analysis. Citation Text: Gupta P, Varkey P. Developing a tool for assessing competency in root cause analysis. Jt Comm J Qual Patient Saf. 2009;35(1):36-42. Copy Citation Format: Google Scholar PubMed BibTeX E…

What did the doctor say? Health literacy and recall of medical instructions. | PSNet

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December 21, 2014 - Study What did the doctor say? Health literacy and recall of medical instructions. Citation Text: McCarthy D, Waite KR, Curtis LM, et al. What did the doctor say? Health literacy and recall of medical instructions. Med Care. 2012;50(4):277-82. doi:10.1097/MLR.0b013e318241e8e1. Copy C…

One hospital's initiatives to encourage safe opioid use. | PSNet

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October 19, 2022 - Commentary One hospital's initiatives to encourage safe opioid use. Citation Text: Surprise JK, Simpson MH. One Hospital's Initiatives to Encourage Safe Opioid Use. J Infus Nurs. 2015;38(4):278-83. doi:10.1097/NAN.0000000000000110. Copy Citation Format: DOI Google Scholar P…

Patient safety: it's not just carefulness, it's a culture. | PSNet

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December 24, 2008 - Commentary Patient safety: it's not just carefulness, it's a culture. Citation Text: Powell S. Patient Safety: it's not just carefulness, it's a culture. Lippincotts Case Manag. 2004;9(5):211-212. doi:10.1097/00129234-200409000-00001. Copy Citation Format: DOI Google Scho…

Care and outcomes of patients with in-hospital stroke. | PSNet

psnet.ahrq.gov/issue/care-and-outcomes-patients-hospital-stroke

September 18, 2024 - Study Care and outcomes of patients with in-hospital stroke. Citation Text: Saltman AP, Silver FL, Fang J, et al. Care and Outcomes of Patients With In-Hospital Stroke. JAMA Neurol. 2015;72(7):749-55. doi:10.1001/jamaneurol.2015.0284. Copy Citation Format: DOI Google Schola…

The role of technology in clinician-to-clinician communication. | PSNet

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September 09, 2015 - Commentary The role of technology in clinician-to-clinician communication. Citation Text: McElroy LM, Ladner DP, Holl JL. The role of technology in clinician-to-clinician communication. BMJ Qual Saf. 2013;22(12):981-3. doi:10.1136/bmjqs-2013-002191. Copy Citation Format: …

Filling the gaps on the Institute for Safe Medication Practices (ISMP) Do Not Crush List for Immediate-release Products | PSNet

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July 21, 2021 - Study Filling the gaps on the Institute for Safe Medication Practices (ISMP) Do Not Crush List for Immediate-release Products Citation Text: Filling the gaps on the Institute for Safe Medication Practices (ISMP) Do Not Crush List for Immediate-release Products Uttaro E, Zhao F, Schweigha…

Evaluating safety and competency at the bedside. | PSNet

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November 16, 2022 - Commentary Evaluating safety and competency at the bedside. Citation Text: Kaplan T, Pilcher J. Evaluating safety and competency at the bedside. J Nurses Staff Dev. 2011;27(4):187-90. doi:10.1097/NND.0b013e3182236634. Copy Citation Format: DOI Google Scholar PubMed BibTeX…

Medication error prevention by clinical pharmacists in two children's hospitals. | PSNet

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October 15, 2014 - Study Classic Medication error prevention by clinical pharmacists in two children's hospitals. Citation Text: Medication error prevention by clinical pharmacists in two children's hospitals. Folli HL; Poole RL; Benitz WE; Russo JC Copy Citation …

Using fault trees to advance understanding of diagnostic errors. | PSNet

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November 11, 2020 - Commentary Using fault trees to advance understanding of diagnostic errors. Citation Text: Rogith D, Iyengar S, Singh H. Using Fault Trees to Advance Understanding of Diagnostic Errors. Jt Comm J Qual Patient Saf. 2017;43(11):598-605. doi:10.1016/j.jcjq.2017.06.007. Copy Citation F…

The costs of developing, implementing, and operating a safety learning system in community practice. | PSNet

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March 21, 2012 - Study The costs of developing, implementing, and operating a safety learning system in community practice. Citation Text: O'Beirne M, Reid R, Zwicker K, et al. The costs of developing, implementing, and operating a safety learning system in community practice. J Patient Saf. 2013;9(4):2…

Prevention of fatal opioid overdose. | PSNet

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October 03, 2018 - Commentary Prevention of fatal opioid overdose. Citation Text: Beletsky L, Rich JD, Walley AY. Prevention of fatal opioid overdose. JAMA. 2012;308(18):1863-4. doi:10.1001/jama.2012.14205. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML…

Implementing a team-based daily goals sheet in a non-ICU setting. | PSNet

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January 03, 2017 - Commentary Implementing a team-based daily goals sheet in a non-ICU setting. Citation Text: Holzmueller CG, Timmel J, Kent P, et al. Implementing a team-based daily goals sheet in a non-ICU setting. Jt Comm J Qual Patient Saf. 2009;35(7):384-8, 341. Copy Citation Format: Go…

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