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Multiple points of system failure underpin continuous subcutaneous infusion safety incidents in palliative care: a mixed methods analysis. | PSNet

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December 16, 2020 - Study Multiple points of system failure underpin continuous subcutaneous infusion safety incidents in palliative care: a mixed methods analysis. Citation Text: Brown AJ, Yardley S, Bowers B, et al. Multiple points of system failure underpin continuous subcutaneous infusion safety inciden…

Impact of a relocation to a new critical care building on pediatric safety events. | PSNet

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May 27, 2020 - Study Impact of a relocation to a new critical care building on pediatric safety events. Citation Text: Furthmiller A, Sahay R, Zhang B, et al. Impact of a relocation to a new critical care building on pediatric safety events. J Hosp Med. 2024;19(5):589-595. doi:10.1002/jhm.13324. Copy…

The Psychiatry Morbidity and Mortality Incident Reporting Tool increases psychiatrist participation in reporting adverse events. | PSNet

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March 10, 2021 - Study The Psychiatry Morbidity and Mortality Incident Reporting Tool increases psychiatrist participation in reporting adverse events. Citation Text: Kroll DS, Shellman AD, Gitlin DF. The Psychiatry Morbidity and Mortality Incident Reporting Tool Increases Psychiatrist Participation in R…

Perceptions of U.S. and U.K. incident reporting systems: a scoping review. | PSNet

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January 19, 2022 - Review Perceptions of U.S. and U.K. incident reporting systems: a scoping review. Citation Text: Gampetro PJ, Nickum A, Schultz CM. Perceptions of U.S. and U.K. incident reporting systems: a scoping review. J Patient Saf. 2024;20(5):360-365. doi:10.1097/pts.0000000000001231. Copy Citat…

Delays in care during the COVID-19 pandemic in the Veterans Health Administration. | PSNet

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May 17, 2023 - Study Delays in care during the COVID-19 pandemic in the Veterans Health Administration. Citation Text: Mills PD, Louis RP, Yackel E. Delays in care during the COVID-19 pandemic in the Veterans Health Administration. J Healthc Qual. 2023;45(4):242-253. doi:10.1097/jhq.0000000000000383. …

More than algorithms: an analysis of safety events involving ML-enabled medical devices reported to the FDA. | PSNet

psnet.ahrq.gov/issue/more-algorithms-analysis-safety-events-involving-ml-enabled-medical-devices-reported-fda

May 01, 2019 - Study More than algorithms: an analysis of safety events involving ML-enabled medical devices reported to the FDA. Citation Text: Lyell D, Wang Y, Coiera E, et al. More than algorithms: an analysis of safety events involving ML-enabled medical devices reported to the FDA. J Am Med Inform…

Online patient feedback as a safety valve: an automated language analysis of unnoticed and unresolved safety incidents. | PSNet

psnet.ahrq.gov/issue/online-patient-feedback-safety-valve-automated-language-analysis-unnoticed-and-unresolved

August 05, 2020 - Study Online patient feedback as a safety valve: an automated language analysis of unnoticed and unresolved safety incidents. Citation Text: Gillespie A, Reader TW. Online patient feedback as a safety valve: an automated language analysis of unnoticed and unresolved safety incidents. Ris…

Factors related to serious safety events in a children's hospital patient safety collaborative. | PSNet

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February 16, 2022 - Study Factors related to serious safety events in a children's hospital patient safety collaborative. Citation Text: Burrus S, Hall M, Tooley E, et al. Factors related to serious safety events in a children's hospital patient safety collaborative. Pediatrics. 2021;148(3):e2020030346. doi…

Strategies for improving the value of the radiology report: a retrospective analysis of errors in formally over-read studies. | PSNet

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November 10, 2021 - Study Strategies for improving the value of the radiology report: a retrospective analysis of errors in formally over-read studies. Citation Text: Kabadi SJ, Krishnaraj A. Strategies for improving the value of the radiology report: a retrospective analysis of errors in formally over-read…

Specificity of computerized physician order entry has a significant effect on the efficiency of workflow for critically ill patients. | PSNet

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March 14, 2022 - Study Specificity of computerized physician order entry has a significant effect on the efficiency of workflow for critically ill patients. Citation Text: Ali NA, Mekhjian HS, Kuehn L, et al. Specificity of computerized physician order entry has a significant effect on the efficiency o…

Detection and prevention of medication misadventures in general practice. | PSNet

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May 13, 2020 - Study Detection and prevention of medication misadventures in general practice. Citation Text: Tam KWT, Kwok KH, Fan YMC, et al. Detection and prevention of medication misadventures in general practice. Int J Qual Health Care. 2008;20(3):192-9. doi:10.1093/intqhc/mzn002. Copy Citatio…

Next of kin involvement in regulatory investigations of adverse events that caused patient death: a process evaluation. | PSNet

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March 02, 2022 - Study Next of kin involvement in regulatory investigations of adverse events that caused patient death: a process evaluation. Citation Text: Next of kin involvement in regulatory investigations of adverse events that caused patient death: a process evaluation. Wiig S, Haraldseid-Driftlan…

Electronic prescribing: improving the efficiency and accuracy of prescribing in the ambulatory care setting. | PSNet

psnet.ahrq.gov/issue/electronic-prescribing-improving-efficiency-and-accuracy-prescribing-ambulatory-care-setting

March 16, 2022 - Review Electronic prescribing: improving the efficiency and accuracy of prescribing in the ambulatory care setting. Citation Text: Porterfield A, Engelbert K, Coustasse A. Electronic prescribing: improving the efficiency and accuracy of prescribing in the ambulatory care setting. Perspec…

10,000 good catches: increasing safety event reporting in a pediatric health care system. | PSNet

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April 20, 2022 - Study 10,000 good catches: increasing safety event reporting in a pediatric health care system. Citation Text: Crandall KM, Almuhanna A, Cady R, et al. 10,000 Good Catches: Increasing Safety Event Reporting In A Pediatric Health Care System. Pediatr Qual Saf. 2019;3(2):e072. doi:10.1097/…

What patients' complaints and praise tell the health practitioner: implications for health care quality. A qualitative research study. | PSNet

psnet.ahrq.gov/issue/what-patients-complaints-and-praise-tell-health-practitioner-implications-health-care-quality

February 21, 2024 - Study What patients' complaints and praise tell the health practitioner: implications for health care quality. A qualitative research study. Citation Text: Mattarozzi K, Sfrisi F, Caniglia F, et al. What patients' complaints and praise tell the health practitioner: implications for healt…

Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia | PSNet

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Heparin-containing medical devices and combination products: recommendations for labeling and safety testing. Draft guidance for industry and Food and Drug Administration staff. | PSNet

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November 23, 2015 - Regulation Heparin-containing medical devices and combination products: recommendations for labeling and safety testing. Draft guidance for industry and Food and Drug Administration staff. Citation Text: Heparin-containing medical devices and combination products: recommendations for lab…

Medication error reporting in nursing homes: identifying targets for patient safety improvement. | PSNet

psnet.ahrq.gov/issue/medication-error-reporting-nursing-homes-identifying-targets-patient-safety-improvement

March 24, 2011 - Study Medication error reporting in nursing homes: identifying targets for patient safety improvement. Citation Text: Greene SB, Williams CE, Pierson S, et al. Medication error reporting in nursing homes: identifying targets for patient safety improvement. Qual Saf Health Care. 2010;19…

Infections associated with reprocessed flexible bronchoscopes. | PSNet

psnet.ahrq.gov/issue/infections-associated-reprocessed-flexible-bronchoscopes

March 11, 2015 - Press Release/Announcement Infections associated with reprocessed flexible bronchoscopes. Citation Text: Infections associated with reprocessed flexible bronchoscopes. FDA Safety Communication. Silver Spring, MD: US Food and Drug Administration; September 17, 2015. Copy Citation …

A patient reported approach to identify medical errors and improve patient safety in the emergency department. | PSNet

psnet.ahrq.gov/issue/patient-reported-approach-identify-medical-errors-and-improve-patient-safety-emergency

July 13, 2010 - Study A patient reported approach to identify medical errors and improve patient safety in the emergency department. Citation Text: Glickman SW, Mehrotra A, Shea CM, et al. A Patient Reported Approach to Identify Medical Errors and Improve Patient Safety in the Emergency Department. J Pa…

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