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Fast does not imply flawed: analyzing emergency physician productivity and medical errors. | PSNet

psnet.ahrq.gov/issue/fast-does-not-imply-flawed-analyzing-emergency-physician-productivity-and-medical-errors

January 25, 2023 - Study Fast does not imply flawed: analyzing emergency physician productivity and medical errors. Citation Text: Hoot NR, Barbosa TJ, Chan HK, et al. Fast does not imply flawed: analyzing emergency physician productivity and medical errors. J Am Coll Emerg Physicians Open. 2022;3(6):e1284…

Call-shift fatigue and use of countermeasures and avoidance strategies by certified registered nurse anesthetists: a national survey. | PSNet

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March 15, 2023 - Study Call-shift fatigue and use of countermeasures and avoidance strategies by certified registered nurse anesthetists: a national survey. Citation Text: Domen R, Connelly CD, Spence D. Call-shift fatigue and use of countermeasures and avoidance strategies by certified registered nurse …

The Institute of Medicine report on medical errors—could it do harm? | PSNet

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February 18, 2011 - Commentary Classic The Institute of Medicine report on medical errors—could it do harm? Citation Text: Brennan TA. The Institute of Medicine report on medical errors--could it do harm? N Engl J Med. 2002;342(15):1123-1125. doi:10.1056/nejm200004133421510. Co…

From HRO to HERO: making health equity a core system capability. | PSNet

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September 30, 2020 - Commentary From HRO to HERO: making health equity a core system capability. Citation Text: Moy E, Hausmann LRM, Clancy CM. From HRO to HERO: making health equity a core system capability. Am J Med Qual. 2022;37(1):81-83. doi:10.1097/jmq.0000000000000020. Copy Citation Format: …

Assessing and supporting late career practitioners: four key questions. | PSNet

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May 18, 2022 - Commentary Assessing and supporting late career practitioners: four key questions. Citation Text: White AA, Sage WM, Mazor KM, et al. Assessing and supporting late career practitioners: four key questions. Jt Comm J Qual Patient Saf. 2020;46(10):591-595. doi:10.1016/j.jcjq.2020.07.001. …

Impact of patient safety culture on missed nursing care and adverse patient events. | PSNet

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March 16, 2022 - Study Emerging Classic Impact of patient safety culture on missed nursing care and adverse patient events. Citation Text: Hessels AJ, Paliwal M, Weaver SH, et al. Impact of Patient Safety Culture on Missed Nursing Care and Adverse Patient Events. J Nurs Care Qua…

Quality of Care Concerns and the Facility Response Following a Medical Emergency at the VA Southern Nevada Health Care System in Las Vegas. | PSNet

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July 13, 2022 - Book/Report Quality of Care Concerns and the Facility Response Following a Medical Emergency at the VA Southern Nevada Health Care System in Las Vegas. Citation Text: Quality of Care Concerns and the Facility Response Following a Medical Emergency at the VA Southern Nevada Health Care Sy…

Deficiencies in Care, Care Coordination, and Facility Response to a Patient Who Died by Suicide, Memphis VA Medical Center in Tennessee. | PSNet

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December 16, 2020 - Book/Report Deficiencies in Care, Care Coordination, and Facility Response to a Patient Who Died by Suicide, Memphis VA Medical Center in Tennessee. Citation Text: Deficiencies in Care, Care Coordination, and Facility Response to a Patient Who Died by Suicide, Memphis VA Medical Center i…

Detection, classification, and correction of defective chemotherapy orders through nursing and pharmacy oversight. | PSNet

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May 27, 2011 - Study Detection, classification, and correction of defective chemotherapy orders through nursing and pharmacy oversight. Citation Text: Mertens WC, Brown DE, Parisi R, et al. Detection, Classification, and Correction of Defective Chemotherapy Orders Through Nursing and Pharmacy Oversig…

Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, WA. | PSNet

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March 16, 2022 - Book/Report Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, WA. Citation Text: Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, WA. Washington, DC: VA Office o…

Healthcare Inspection—Emergency Department Patient Deaths: Memphis VAMC, Memphis, Tennessee. | PSNet

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November 29, 2023 - Book/Report Healthcare Inspection—Emergency Department Patient Deaths: Memphis VAMC, Memphis, Tennessee. Citation Text: Healthcare Inspection—Emergency Department Patient Deaths: Memphis VAMC, Memphis, Tennessee. Washington, DC: Department of Veterans Affairs, Office of Inspector…

Comprehensive Healthcare Inspection Summary Report: Evaluation of Care Coordination in Veterans Health Administration Facilities, Fiscal Year 2021. | PSNet

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July 27, 2022 - Book/Report Comprehensive Healthcare Inspection Summary Report: Evaluation of Care Coordination in Veterans Health Administration Facilities, Fiscal Year 2021. Citation Text: Comprehensive Healthcare Inspection Summary Report: Evaluation of Care Coordination in Veterans Health Administra…

Use of simulation to measure the effects of just-in-time information to prevent nursing medication errors: a randomized controlled study. | PSNet

psnet.ahrq.gov/issue/use-simulation-measure-effects-just-time-information-prevent-nursing-medication-errors

August 04, 2021 - Study Use of simulation to measure the effects of just-in-time information to prevent nursing medication errors: a randomized controlled study. Citation Text: Berg TA, Hebert SH, Chyka D, et al. Use of Simulation to Measure the Effects of Just-in-Time Information to Prevent Nursing Medi…

Deficiencies in the Veterans Crisis Line Response to a Veteran Caller Who Died. | PSNet

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September 30, 2020 - Book/Report Deficiencies in the Veterans Crisis Line Response to a Veteran Caller Who Died. Citation Text: Deficiencies in the Veterans Crisis Line Response to a Veteran Caller Who Died. Washington, DC: Department of Veterans Affairs, Office of Inspector General; November 17, 2020. Repor…

Types of diagnostic errors in neurological emergencies in the emergency department. | PSNet

psnet.ahrq.gov/issue/types-diagnostic-errors-neurological-emergencies-emergency-department

October 30, 2019 - Study Types of diagnostic errors in neurological emergencies in the emergency department. Citation Text: Dubosh NM, Edlow JA, Lefton M, et al. Types of diagnostic errors in neurological emergencies in the emergency department. Diagnosis (Berl). 2015;2(1):21-28. doi:10.1515/dx-2014-0040. …

Implementation of a pediatric rapid response team: experience of the Hospital for Sick Children in Toronto. | PSNet

psnet.ahrq.gov/issue/implementation-pediatric-rapid-response-team-experience-hospital-sick-children-toronto

September 10, 2014 - Commentary Implementation of a pediatric rapid response team: experience of the Hospital for Sick Children in Toronto. Citation Text: Kukreti V, Gaiteiro R, Mohseni-Bod H. Implementation of a pediatric rapid response team: experience of the Hospital for Sick Children in Toronto. Indian …

Certified registered nurse anesthetist perceptions of factors impacting patient safety. | PSNet

psnet.ahrq.gov/issue/certified-registered-nurse-anesthetist-perceptions-factors-impacting-patient-safety

May 18, 2022 - Study Certified registered nurse anesthetist perceptions of factors impacting patient safety. Citation Text: McMullan SP, Thomas-Hawkins C, Shirey MR. Certified Registered Nurse Anesthetist Perceptions of Factors Impacting Patient Safety. Nurs Adm Q. 2017;41(1):56-69. Copy Citation …

Impact of interruptions, distractions, and cognitive load on procedure failures and medication administration errors. | PSNet

psnet.ahrq.gov/issue/impact-interruptions-distractions-and-cognitive-load-procedure-failures-and-medication

March 02, 2012 - Study Impact of interruptions, distractions, and cognitive load on procedure failures and medication administration errors. Citation Text: Thomas L, Donohue-Porter P, Fishbein JS. Impact of Interruptions, Distractions, and Cognitive Load on Procedure Failures and Medication Administratio…

An evolution of reporting: identifying the missing link. | PSNet

psnet.ahrq.gov/issue/evolution-reporting-identifying-missing-link

August 17, 2022 - Commentary An evolution of reporting: identifying the missing link. Citation Text: Harsini S, Tofighi S, Eibschutz L, et al. An evolution of reporting: identifying the missing link. Diagnostics (Basel). 2022;12(7):1761. doi:10.3390/diagnostics12071761. Copy Citation Format: …

Care and Oversight Deficiencies Related to Multiple Homicides at the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia. | PSNet

psnet.ahrq.gov/issue/care-and-oversight-deficiencies-related-multiple-homicides-louis-johnson-va-medical-center

February 10, 2021 - Book/Report Care and Oversight Deficiencies Related to Multiple Homicides at the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia. Citation Text: Care and Oversight Deficiencies Related to Multiple Homicides at the Louis A. Johnson VA Medical Center in Clarksburg, West Vir…

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