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psnet.ahrq.gov/node/37873/psn-pdf
June 16, 2009 - Dropping the baton: a qualitative analysis of failures
during the transition from emergency department to
inpatient care.
June 16, 2009
Horwitz LI, Meredith T, Schuur JD, et al. Dropping the baton: a qualitative analysis of failures during the
transition from emergency department to inpatient care. Ann Emerg Med. …
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psnet.ahrq.gov/node/847537/psn-pdf
April 12, 2023 - Measuring team hierarchy during high-stakes clinical
decision making: development and validation of a new
behavioral observation method.
April 12, 2023
Johansson AC, Manago B, Sell J, et al. Measuring team hierarchy during high-stakes clinical decision
making: development and validation of a new behavioral observa…
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psnet.ahrq.gov/node/39800/psn-pdf
January 19, 2011 - Medication errors in paediatric outpatients.
January 19, 2011
Kaushal R, Goldmann DA, Keohane CA, et al. Medication errors in paediatric outpatients. BMJ Qual Saf.
2010;19(6). doi:10.1136/qshc.2008.031179.
https://psnet.ahrq.gov/issue/medication-errors-paediatric-outpatients
Pediatric medication errors are common …
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psnet.ahrq.gov/node/45055/psn-pdf
December 04, 2016 - Analysis of clinical decision support system
malfunctions: a case series and survey.
December 4, 2016
Wright A, Hickman T-TT, McEvoy D, et al. Analysis of clinical decision support system malfunctions: a case
series and survey. J Am Med Inform Assoc. 2016;23(6):1068-1076. doi:10.1093/jamia/ocw005.
https://psnet.ah…
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psnet.ahrq.gov/node/42038/psn-pdf
June 03, 2013 - A systematic review of simulation for multidisciplinary
team training in operating rooms.
June 3, 2013
Cumin D, Boyd MJ, Webster CS, et al. A systematic review of simulation for multidisciplinary team training
in operating rooms. Simul Healthc. 2013;8(3):171-179. doi:10.1097/SIH.0b013e31827e2f4c.
https://psnet.ahr…
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psnet.ahrq.gov/node/72566/psn-pdf
January 01, 2021 - Incidence, nature and causes of avoidable significant
harm in primary care in England: retrospective case note
review.
December 16, 2020
Avery AJ, Sheehan C, Bell BG, et al. Incidence, nature and causes of avoidable significant harm in primary
care in England: retrospective case note review. BMJ Qual Saf. 2021;30(…
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psnet.ahrq.gov/node/849596/psn-pdf
May 31, 2023 - Patients admitted on weekends have higher in-hospital
mortality than those admitted on weekdays: analysis of
national inpatient sample.
May 31, 2023
Manadan A, Arora S, Whittier M, et al. Patients admitted on weekends have higher in-hospital mortality
than those admitted on weekdays: analysis of national inpatient…
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psnet.ahrq.gov/node/60177/psn-pdf
April 01, 2020 - What do emergency department physicians and nurses
feel? A qualitative study of emotions, triggers, regulation
strategies, and effects on patient care.
April 1, 2020
Isbell LM, Boudreaux ED, Chimowitz H, et al. What do emergency department physicians and nurses feel?
A qualitative study of emotions, triggers, regu…
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psnet.ahrq.gov/node/45120/psn-pdf
September 11, 2016 - Saving lives: a meta-analysis of team training in
healthcare.
September 11, 2016
Hughes A, Gregory ME, Joseph DL, et al. Saving lives: A meta-analysis of team training in healthcare. J
Appl Psychol. 2016;101(9):1266-304. doi:10.1037/apl0000120.
https://psnet.ahrq.gov/issue/saving-lives-meta-analysis-team-training-…
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psnet.ahrq.gov/node/37499/psn-pdf
January 10, 2017 - Medicare's decision to withhold payment for hospital
errors: the devil is in the details.
January 10, 2017
Wachter R, Foster NE, Dudley A. Medicare's decision to withhold payment for hospital errors: the devil is in
the det. Jt Comm J Qual Patient Saf. 2008;34(2):116-23.
https://psnet.ahrq.gov/issue/medicares-deci…
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psnet.ahrq.gov/node/37787/psn-pdf
May 28, 2008 - Adoption of health information technology for medication
safety in US hospitals, 2006.
May 28, 2008
Furukawa MF, Raghu TS, Spaulding TJ, et al. Adoption of health information technology for medication
safety in U.S. Hospitals, 2006. Health Aff (Millwood). 2008;27(3):865-75. doi:10.1377/hlthaff.27.3.865.
https://ps…
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psnet.ahrq.gov/node/39931/psn-pdf
April 24, 2011 - Emotional influences in patient safety.
April 24, 2011
Croskerry P, Abbass A, Wu AW. Emotional Influences in Patient Safety. J Patient Saf. 2010;6(4):199-205.
doi:10.1097/pts.0b013e3181f6c01a.
https://psnet.ahrq.gov/issue/emotional-influences-patient-safety
Clinicians are intimately familiar with the pressures of …
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psnet.ahrq.gov/node/866081/psn-pdf
June 05, 2024 - "The patient is awake and we need to stay calm":
reconsidering indirect communication in the face of
medical error and professionalism lapses.
June 5, 2024
Taylor T, Columbus L, Banner H, et al. “The patient is awake and we need to stay calm”: reconsidering
indirect communication in the face of medical error and p…
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psnet.ahrq.gov/node/45829/psn-pdf
June 27, 2018 - Learning from errors: analysis of medication order
voiding in CPOE systems.
June 27, 2018
Kannampallil TG, Abraham J, Solotskaya A, et al. Learning from errors: analysis of medication order
voiding in CPOE systems. J Am Med Inform Assoc. 2017;24(4):762-768. doi:10.1093/jamia/ocw187.
https://psnet.ahrq.gov/issue/le…
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psnet.ahrq.gov/node/840170/psn-pdf
November 16, 2022 - Predicting dispensing errors in community pharmacies:
an application of the Systematic Human Error Reduction
and Prediction Approach (SHERPA).
November 16, 2022
Ashour A, Phipps DL, Ashcroft DM. PLoS ONE. 2022;17(1):e0261672.
https://psnet.ahrq.gov/innovation/predicting-dispensing-errors-community-pharmacies-…
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psnet.ahrq.gov/node/836828/psn-pdf
March 30, 2022 - Effects of state opioid prescribing laws on use of opioid
and other pain treatments among commercially insured
U.S. adults.
March 30, 2022
McGinty EE, Bicket MC, Seewald NJ, et al. Effects of state opioid prescribing laws on use of opioid and
other pain treatments among commercially insured U.S. adults. Ann Intern…
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psnet.ahrq.gov/node/46529/psn-pdf
November 08, 2017 - Automatable algorithms to identify nonmedical opioid use
using electronic data: a systematic review.
November 8, 2017
Canan C, Polinski JM, Alexander C, et al. Automatable algorithms to identify nonmedical opioid use using
electronic data: a systematic review. J Am Med Inform Assoc. 2017;24(6):1204-1210.
doi:10.10…
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psnet.ahrq.gov/node/73483/psn-pdf
July 14, 2021 - Critical care nurses’ physical and mental health, worksite
wellness support, and medical errors.
July 14, 2021
Melnyk BM, Tan A, Hsieh AP, et al. Critical Care Nurses’ Physical and Mental Health, Worksite Wellness
Support, and Medical Errors. Am J Crit Care. 2021;30(3):176-184. doi:10.4037/ajcc2021301.
https://psn…
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psnet.ahrq.gov/node/45535/psn-pdf
January 23, 2017 - Surgical specimen management: a descriptive study of
648 adverse events and near misses.
January 23, 2017
Steelman VM, Williams TL, Szekendi MK, et al. Surgical specimen management: a descriptive study of 648
adverse events and near misses. Arch Pathol Lab Med. 2016;140(12):1390-1396.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/38173/psn-pdf
October 29, 2008 - The use of medical emergency teams in medical and
surgical patients: impact of patient, nurse and
organisational characteristics.
October 29, 2008
Schmid-Mazzoccoli A, Hoffman LA, Wolf GA, et al. The use of medical emergency teams in medical and
surgical patients: impact of patient, nurse and organisational charac…