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Cognitive interventions to reduce diagnostic error: a narrative review. | PSNet

psnet.ahrq.gov/issue/cognitive-interventions-reduce-diagnostic-error-narrative-review

October 16, 2012 - Review Classic Cognitive interventions to reduce diagnostic error: a narrative review. Citation Text: Graber ML, Kissam S, Payne VL, et al. Cognitive interventions to reduce diagnostic error: a narrative review. BMJ Qual Saf. 2012;21(7):535-557. doi:10.1136/bmjq…

The potential for improved teamwork to reduce medical errors in the emergency department. | PSNet

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July 07, 2021 - Review Classic The potential for improved teamwork to reduce medical errors in the emergency department. Citation Text: Risser DT, Rice MM, Salisbury ML, et al. The potential for improved teamwork to reduce medical errors in the emergency department. Ann Emerg M…

Sources of medication omissions among hospitalized older adults with polypharmacy. | PSNet

psnet.ahrq.gov/issue/sources-medication-omissions-among-hospitalized-older-adults-polypharmacy

January 18, 2023 - Study Sources of medication omissions among hospitalized older adults with polypharmacy. Citation Text: Shah AS, Hollingsworth EK, Shotwell MS, et al. Sources of medication omissions among hospitalized older adults with polypharmacy. J Am Geriatr Soc. 2022;70(4):1180-1189. doi:10.1111/jg…

Classifying errors in preventable and potentially preventable trauma deaths: a 9-year review using the Joint Commission's standardized methodology. | PSNet

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November 27, 2012 - Study Classifying errors in preventable and potentially preventable trauma deaths: a 9-year review using the Joint Commission's standardized methodology. Citation Text: Vioque SM, Kim PK, McMaster J, et al. Classifying errors in preventable and potentially preventable trauma deaths: a 9-…

The application of the Global Trigger Tool: a systematic review. | PSNet

psnet.ahrq.gov/issue/application-global-trigger-tool-systematic-review

December 06, 2023 - Review The application of the Global Trigger Tool: a systematic review. Citation Text: Hibbert PD, Molloy CJ, Hooper TD, et al. The application of the Global Trigger Tool: a systematic review. Int J Qual Health Care. 2016;28(6):640-649. doi:10.1093/intqhc/mzw115. Copy Citation For…

A recent two-fold increase in medical adverse event deaths among US inpatients. | PSNet

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April 06, 2022 - Study A recent two-fold increase in medical adverse event deaths among US inpatients. Citation Text: Oura P, Sajantila A. A recent two-fold increase in medical adverse event deaths among US inpatients. J Public Health Res. 2022;11(4):227990362211399. doi:10.1177/22799036221139935. Copy…

Variation in detected adverse events using trigger tools: a systematic review and meta-analysis. | PSNet

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January 25, 2023 - Review Variation in detected adverse events using trigger tools: a systematic review and meta-analysis. Citation Text: Eggenschwiler LC, Rutjes AWS, Musy SN, et al. Variation in detected adverse events using trigger tools: a systematic review and meta-analysis. PLoS ONE. 2022;17(9):e0273…

The value of learning from near misses to improve patient safety: a scoping review. | PSNet

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April 27, 2022 - Review The value of learning from near misses to improve patient safety: a scoping review. Citation Text: Woodier N, Burnett C, Moppett I. The value of learning from near misses to improve patient safety: a scoping review. J Patient Saf. 2022;19(1):42-47. doi:10.1097/pts.0000000000001078…

Caregiver and clinician perspectives on discharge medication counseling: a qualitative study. | PSNet

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January 31, 2024 - Study Caregiver and clinician perspectives on discharge medication counseling: a qualitative study. Citation Text: Carroll AR, Schlundt D, Bonnet K, et al. Caregiver and clinician perspectives on discharge medication counseling: a qualitative study. Hosp Pediatr. 2023;13(4):325-342. doi:…

Serious hazards of transfusion: evaluating the dangers of a wrong patient autologous salvaged blood in cardiac surgery. | PSNet

psnet.ahrq.gov/issue/serious-hazards-transfusion-evaluating-dangers-wrong-patient-autologous-salvaged-blood

May 11, 2022 - Commentary Serious hazards of transfusion: evaluating the dangers of a wrong patient autologous salvaged blood in cardiac surgery. Citation Text: Uramatsu M, Maeda H, Mishima S, et al. Serious hazards of transfusion: evaluating the dangers of a wrong patient autologous salvaged blood in …

Unfinished nursing care, missed care, and implicitly rationed care: state of the science review. | PSNet

psnet.ahrq.gov/issue/unfinished-nursing-care-missed-care-and-implicitly-rationed-care-state-science-review

May 08, 2024 - Review Unfinished nursing care, missed care, and implicitly rationed care: state of the science review. Citation Text: Jones TL, Hamilton P, Murry N. Unfinished nursing care, missed care, and implicitly rationed care: State of the science review. Int J Nurs Stud. 2015;52(6):1121-1137. do…

Preventing in-facility pressure ulcers as a patient safety strategy: a systematic review. | PSNet

psnet.ahrq.gov/issue/preventing-facility-pressure-ulcers-patient-safety-strategy-systematic-review

January 06, 2018 - Review Preventing in-facility pressure ulcers as a patient safety strategy: a systematic review. Citation Text: Sullivan N, Schoelles KM. Preventing in-facility pressure ulcers as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):410-416. doi:10.7326/0003-…

Potentially inappropriate prescribing in long-term care and its relationship with probable delirium. | PSNet

psnet.ahrq.gov/issue/potentially-inappropriate-prescribing-long-term-care-and-its-relationship-probable-delirium

September 23, 2020 - Study Potentially inappropriate prescribing in long-term care and its relationship with probable delirium. Citation Text: Webber C, Milani C, Bjerre LM, et al. Potentially inappropriate prescribing in long-term care and its relationship with probable delirium. J Am Med Dir Assoc. 2024;25…

Improving medication error reporting in hospice care. | PSNet

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June 22, 2022 - Study Improving medication error reporting in hospice care. Citation Text: Boyer R, McPherson ML, Deshpande G, et al. Improving medication error reporting in hospice care. Am J Hosp Palliat Care. 2009;26(5):361-7. doi:10.1177/1049909109335145. Copy Citation Format: DOI Go…

Changes in safety and teamwork climate after adding structured observations to patient safety WalkRounds. | PSNet

psnet.ahrq.gov/issue/changes-safety-and-teamwork-climate-after-adding-structured-observations-patient-safety

August 20, 2018 - Study Changes in safety and teamwork climate after adding structured observations to patient safety WalkRounds. Citation Text: Klimmeck S, Sexton B, Schwendimann R. Changes in safety and teamwork climate after adding structured observations to patient safety WalkRounds. Jt Comm J Qual Pa…

Graduate medical education and patient safety: a busy--and occasionally hazardous--intersection. | PSNet

psnet.ahrq.gov/issue/graduate-medical-education-and-patient-safety-busy-and-occasionally-hazardous-intersection

March 02, 2011 - Commentary Classic Graduate medical education and patient safety: a busy--and occasionally hazardous--intersection. Citation Text: Shojania KG, Fletcher KE, Saint S. Graduate medical education and patient safety: a busy--and occasionally hazardous--intersectio…

Transformational improvement in quality care and health systems: the next decade. | PSNet

psnet.ahrq.gov/issue/transformational-improvement-quality-care-and-health-systems-next-decade

October 14, 2020 - Commentary Transformational improvement in quality care and health systems: the next decade. Citation Text: Braithwaite J, Vincent CA, Garcia-Elorrio E, et al. Transformational improvement in quality care and health systems: the next decade. BMC Med. 2020;18(1):340. doi:10.1186/s12916-02…

Long-term care nurses' experiences with patient safety incident management: a qualitative study. | PSNet

psnet.ahrq.gov/issue/long-term-care-nurses-experiences-patient-safety-incident-management-qualitative-study

March 24, 2021 - Study Long-term care nurses' experiences with patient safety incident management: a qualitative study. Citation Text: Serre N, Espin S, Indar A, et al. Long-term care nurses' experiences with patient safety incident management: a qualitative study. J Nurs Care Qual. 2022;37(2):188-194. d…

Register-based research of adverse events revealing incomplete records threatening patient safety. | PSNet

psnet.ahrq.gov/issue/register-based-research-adverse-events-revealing-incomplete-records-threatening-patient

October 06, 2021 - Review Register-based research of adverse events revealing incomplete records threatening patient safety. Citation Text: Kinnunen U-M, Kivekäs E, Palojoki S, et al. Register-based research of adverse events revealing incomplete records threatening patient safety. Stud Health Technol Info…

Citrate Mix-Up | PSNet

psnet.ahrq.gov/web-mm/citrate-mix

February 01, 2010 - Citrate Mix-Up Citation Text: Weber RJ. Citrate Mix-Up. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

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