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ED handoffs: observed practices and communication errors. | PSNet

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October 19, 2022 - Study ED handoffs: observed practices and communication errors. Citation Text: Maughan BC, Lei L, Cydulka RK. ED handoffs: observed practices and communication errors. Am J Emerg Med. 2011;29(5):502-11. doi:10.1016/j.ajem.2009.12.004. Copy Citation Format: DOI Google Scho…

Impact of regionalized care on concordance of plan and preventable adverse events on general medicine services. | PSNet

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November 16, 2022 - Study Impact of regionalized care on concordance of plan and preventable adverse events on general medicine services. Citation Text: Mueller SK, Schnipper JL, Giannelli K, et al. Impact of regionalized care on concordance of plan and preventable adverse events on general medicine service…

Training health care professionals in root cause analysis: a cross-sectional study of post-training experiences, benefits and attitudes. | PSNet

psnet.ahrq.gov/issue/training-health-care-professionals-root-cause-analysis-cross-sectional-study-post-training

February 29, 2012 - Study Training health care professionals in root cause analysis: a cross-sectional study of post-training experiences, benefits and attitudes. Citation Text: Bowie P, Skinner J, de Wet C. Training health care professionals in root cause analysis: a cross-sectional study of post-training…

Changes in error patterns in unanticipated trauma deaths during 20 years: in pursuit of zero preventable deaths. | PSNet

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March 23, 2022 - Study Changes in error patterns in unanticipated trauma deaths during 20 years: in pursuit of zero preventable deaths. Citation Text: LaGrone LN, McIntyre LK, Riggle A, et al. Changes in error patterns in unanticipated trauma deaths during 20 years: In pursuit of zero preventable deaths.…

Preventable deaths: who, how often, and why? | PSNet

psnet.ahrq.gov/issue/preventable-deaths-who-how-often-and-why

February 22, 2011 - Study Classic Preventable deaths: who, how often, and why? Citation Text: Dubois RW, Brook RH. Preventable deaths: who, how often, and why? Ann Intern Med. 1988;109(7):582-9. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNo…

Implementing an electronic root cause analysis reporting system to decrease hospital-acquired pressure injuries. | PSNet

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December 22, 2021 - Study Implementing an electronic root cause analysis reporting system to decrease hospital-acquired pressure injuries. Citation Text: Armstrong AA. Implementing an electronic root cause analysis reporting system to decrease hospital-acquired pressure injuries. J Healthc Qual. 2023;45(3):…

Caught in the middle: a resident perspective on influences from the learning environment that perpetuate mistreatment. | PSNet

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September 04, 2019 - Commentary Caught in the middle: a resident perspective on influences from the learning environment that perpetuate mistreatment. Citation Text: Bynum WE, Lindeman B. Caught in the Middle: A Resident Perspective on Influences From the Learning Environment That Perpetuate Mistreatment. Ac…

Patients use an internet technology to report when things go wrong. | PSNet

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July 21, 2009 - Study Patients use an internet technology to report when things go wrong. Citation Text: Wasson JH, MacKenzie TA, Hall M. Patients use an internet technology to report when things go wrong. Qual Saf Health Care. 2007;16(3):213-5. Copy Citation Format: Google Scholar PubMe…

DEEP SCOPE: a framework for safe healthcare design. | PSNet

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August 18, 2021 - Commentary DEEP SCOPE: a framework for safe healthcare design. Citation Text: Taylor E, Hignett S. DEEP SCOPE: a framework for safe healthcare design. Int J Environ Res Public Health. 2021;18(15):7780. doi:10.3390/ijerph18157780. Copy Citation Format: DOI Google Scholar Bib…

ICU admittance by a rapid response team versus conventional admittance, characteristics, and outcome. | PSNet

psnet.ahrq.gov/issue/icu-admittance-rapid-response-team-versus-conventional-admittance-characteristics-and-outcome

January 28, 2010 - Study ICU admittance by a rapid response team versus conventional admittance, characteristics, and outcome. Citation Text: Jäderling G, Bell M, Martling C-R, et al. ICU admittance by a rapid response team versus conventional admittance, characteristics, and outcome. Crit Care Med. 2013…

Safety of overlapping surgery at a high-volume referral center. | PSNet

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January 11, 2017 - Study Classic Safety of overlapping surgery at a high-volume referral center. Citation Text: Hyder JA, Hanson KT, Storlie CB, et al. Safety of Overlapping Surgery at a High-volume Referral Center. Ann Surg. 2017;265(4):639-644. doi:10.1097/SLA.0000000000002084. …

Using proactive risk assessment (HFMEA) to improve patient safety and quality associated with intraocular lens selection and implantation in cataract surgery. | PSNet

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September 19, 2016 - Study Using proactive risk assessment (HFMEA) to improve patient safety and quality associated with intraocular lens selection and implantation in cataract surgery. Citation Text: DeRosier JM, Hansemann BK, Smith-Wheelock MW, et al. Using Proactive Risk Assessment (HFMEA) to Improve Pati…

Patient safety in community dementia services: what can we learn from the experiences of caregivers and healthcare professionals? | PSNet

psnet.ahrq.gov/issue/patient-safety-community-dementia-services-what-can-we-learn-experiences-caregivers-and

March 05, 2025 - Study Patient safety in community dementia services: what can we learn from the experiences of caregivers and healthcare professionals? Citation Text: Behrman S, Wilkinson P, Lloyd H, et al. Patient safety in community dementia services: what can we learn from the experiences of caregive…

Improving care safety by characterizing task interruptions during interactions between healthcare professionals: an observational study. | PSNet

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March 05, 2025 - Study Improving care safety by characterizing task interruptions during interactions between healthcare professionals: an observational study. Citation Text: Teigné D, Cazet L, Birgand G, et al. Improving care safety by characterizing task interruptions during interactions between health…

The effectiveness of tele-triage during the COVID-19 pandemic: a systematic review and narrative synthesis. | PSNet

psnet.ahrq.gov/issue/effectiveness-tele-triage-during-covid-19-pandemic-systematic-review-and-narrative-synthesis

February 01, 2023 - Review The effectiveness of tele-triage during the COVID-19 pandemic: a systematic review and narrative synthesis. Citation Text: Farzandipour M, Nabovati E, Sharif R. The effectiveness of tele-triage during the COVID-19 pandemic: a systematic review and narrative synthesis. J Telemed Te…

Care Deficiencies and Leaders' Inadequate Reviews of a Patient Who Died at the Lt. Col. Luke Weathers, Jr. VA Medical Center in Memphis, Tennessee. | PSNet

psnet.ahrq.gov/issue/care-deficiencies-and-leaders-inadequate-reviews-patient-who-died-lt-col-luke-weathers-jr-va

April 10, 2024 - Book/Report Care Deficiencies and Leaders' Inadequate Reviews of a Patient Who Died at the Lt. Col. Luke Weathers, Jr. VA Medical Center in Memphis, Tennessee. Citation Text: Care Deficiencies and Leaders' Inadequate Reviews of a Patient Who Died at the Lt. Col. Luke Weathers, Jr. VA Me…

Burnout mediates the association between depression and patient safety perceptions: a cross-sectional study in hospital nurses. | PSNet

psnet.ahrq.gov/issue/burnout-mediates-association-between-depression-and-patient-safety-perceptions-cross

June 30, 2021 - Study Burnout mediates the association between depression and patient safety perceptions: a cross-sectional study in hospital nurses. Citation Text: Johnson J, Louch G, Dunning A, et al. Burnout mediates the association between depression and patient safety perceptions: a cross-sectional…

Understanding diagnostic safety in emergency medicine: a case‐by‐case review of closed ED malpractice claims. | PSNet

psnet.ahrq.gov/issue/understanding-diagnostic-safety-emergency-medicine-case-case-review-closed-ed-malpractice

May 11, 2019 - Study Understanding diagnostic safety in emergency medicine: a case‐by‐case review of closed ED malpractice claims. Citation Text: Lemoine N, Dajer A, Konwinski J, et al. Understanding diagnostic safety in emergency medicine: A case-by-case review of closed ED malpractice claims. J Healt…

Do words matter? Stigmatizing language and the transmission of bias in the medical record. | PSNet

psnet.ahrq.gov/issue/do-words-matter-stigmatizing-language-and-transmission-bias-medical-record

June 06, 2021 - Study Do words matter? Stigmatizing language and the transmission of bias in the medical record. Citation Text: P. Goddu A, O’Conor KJ, Lanzkron S, et al. Do words matter? Stigmatizing language and the transmission of bias in the medical record. J Gen Intern Med. 2018;33(5):685-691. doi:…

Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. | PSNet

psnet.ahrq.gov/issue/missed-and-delayed-diagnoses-emergency-department-study-closed-malpractice-claims-4-liability

March 02, 2011 - Study Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. Citation Text: Kachalia A, Gandhi TK, Puopolo AL, et al. Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4…

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