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A piece of my mind. Coping with fallibility. | PSNet

psnet.ahrq.gov/issue/piece-my-mind-coping-fallibility

June 26, 2015 - February 12, 2020 The role of quality improvement and patient safety in academic promotion … : results of a survey of chairs of departments of internal medicine in North America. … Building the bridge to quality: an urgent call to integrate quality improvement and patient … April 24, 2019 Pain as the neglected patient safety concern: five years on. … Snakes on a dock.

AHRQ patient safety project reduces bloodstream infections by 40 percent. | PSNet

psnet.ahrq.gov/issue/ahrq-patient-safety-project-reduces-bloodstream-infections-40-percent

January 22, 2020 - Patient Saf Qual Hcare. September 12, 2012. … Patient Saf Qual Hcare. September 12, 2012. … intervention included the comprehensive unit-based safety program (CUSP) and interventions to improve safety … culture in participating ICUs. … surveys of patient experience in the English NHS: an observational study.

Adherence to recommended electronic health record safety practices across eight health care organizations. | PSNet

psnet.ahrq.gov/issue/adherence-recommended-electronic-health-record-safety-practices-across-eight-health-care

May 20, 2019 - November 11, 2020 Dashboards for visual display of patient safety data: a systematic … November 15, 2018 Resource-based view on safety culture's influence on hospital performance … September 19, 2018 A national survey assessing the number of records allowed open in … April 24, 2018 Examining the relationship of an all-cause harm patient safety measure … February 10, 2018 The impact of electronic medical records on hospital-acquired adverse

Coping with errors in the operating room: intraoperative strategies, postoperative strategies, and sex differences. | PSNet

psnet.ahrq.gov/issue/coping-errors-operating-room-intraoperative-strategies-postoperative-strategies-and-sex

September 09, 2020 - March 10, 2021 Operating room to intensive care unit handoffs and the risks of patient … September 9, 2015 Diagnostic error experiences of patients and families with limited … English-language health literacy or disadvantaged socioeconomic position in a cross-sectional US population-based survey … July 18, 2019 Clinical impact of intraoperative electronic health record downtime on … surgical patients.

Use of an audit with feedback implementation strategy to promote medication error reporting by nurses. | PSNet

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March 24, 2021 - Audit and feedback are key patient safety strategies intended to improve error reporting behavior . … , 2021 Barriers and enablers to nurses' use of harm prevention strategies for older patients … in hospital: a cross-sectional survey. … December 9, 2020 Nurses as 'second victims' to their patients' suicidal attempts: a mixed-method … The effect of structured medication review followed by face-to-face feedback to prescribers on

Swimming against the tide: primary care physicians' views on deprescribing in everyday practice. | PSNet

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March 15, 2023 - Study Swimming against the tide: primary care physicians' views on deprescribing … Swimming Against the Tide: Primary Care Physicians’ Views on Deprescribing in Everyday Practice. … medical culture to continue prescribing medications even in situations of little or no benefit for patients … July 6, 2022 Patient safety skills in primary care: a national survey of GP educators … team and patients.

Using evidence, rigorous measurement, and collaboration to eliminate central catheter-associated bloodstream infections. | PSNet

psnet.ahrq.gov/issue/using-evidence-rigorous-measurement-and-collaboration-eliminate-central-catheter-associated

January 15, 2014 - program report highlights the implementation processes of the AHRQ-funded CUSP initiative that builds on … Same Author(s) Eliminating central line-associated bloodstream infections: a national patient … device-associated infections during the coronavirus disease 2019 (COVID-19) pandemic: results from a national survey … May 22, 2019 AHRQ patient safety project reduces bloodstream infections by 40 percent … April 21, 2015 Tennessee Center for Patient Safety.

Preventable harm in the Canadian organ donation and transplantation system: a descriptive study of missed organ donor identification and referral. | PSNet

psnet.ahrq.gov/issue/preventable-harm-canadian-organ-donation-and-transplantation-system-descriptive-study-missed

October 19, 2022 - July 5, 2023 Postoperative opioid prescribing and the pain scores on Hospital Consumer … Assessment of Healthcare Providers and Systems survey. … Safety Initiatives July 10, 2024 Perspectives on Safety … Health Plan Patient Safety Initiatives July 10, 2024 Structural … March 1, 2023 Healthcare-associated adverse events in alternate level of care patients

An empirically derived taxonomy of factors affecting physicians' willingness to disclose medical errors. | PSNet

psnet.ahrq.gov/issue/empirically-derived-taxonomy-factors-affecting-physicians-willingness-disclose-medical-errors

February 15, 2011 - In this study, researchers reviewed the medical literature on error disclosure and conducted focus groups … The authors were able to identify four facilitating factors, which primarily centered on physicians' … safety: a survey of physicians in teaching hospitals. … April 12, 2023 Impact of providing patients access to electronic health records on quality … Disclosure Provider-Patient Communication

Development of a core drug list towards improving prescribing education and reducing errors in the UK. | PSNet

psnet.ahrq.gov/issue/development-core-drug-list-towards-improving-prescribing-education-and-reducing-errors-uk

April 13, 2022 - This list included most of the medications associated with adverse events in geriatric patients and … performance of a drug-drug interaction clinical decision support system: quantitative evaluation and end-user survey … Drug-drug interactions and prescription appropriateness at hospital discharge: experience with COVID-19 patients … the prevalence and association of polypharmacy and drug administration errors in hospitalized adult patients … May 24, 2015 Improving teamwork: impact of structured interdisciplinary rounds on a medical

At Walgreens, complaints of medication errors go missing. | PSNet

psnet.ahrq.gov/issue/walgreens-complaints-medication-errors-go-missing

February 19, 2020 - Related Resources From the Same Author(s) How chaos at chain pharmacies is putting patients … 2022 Addiction treatment providers in Pa. face little state scrutiny despite harm to clients … May 12, 2021 Survey by Ohio regulator shows stress, fatigue among pharmacists at chain … July 29, 2020 How chaos at chain pharmacies is putting patients at risk.

Cognitive balanced model: a conceptual scheme of diagnostic decision making. | PSNet

psnet.ahrq.gov/issue/cognitive-balanced-model-conceptual-scheme-diagnostic-decision-making

July 10, 2013 - July 10, 2013 A new perspective on blame culture: an experimental study. … attitudes and barriers to a medical emergency team among nurses and medical doctors: a multi-centre survey … February 25, 2015 Impact of intensive care unit discharge time on patient outcome. … April 8, 2020 Building a safer foundation: the Lessons Learnt patient safety training … physicians, nurses, and patients.

Hospital characteristics associated with penalties in the Centers for Medicare & Medicaid Services Hospital-Acquired Condition Reduction Program. | PSNet

psnet.ahrq.gov/issue/hospital-characteristics-associated-penalties-centers-medicare-medicaid-services-hospital

November 18, 2016 - Teaching institutions, hospitals whose case mix included more complex patients, and safety-net hospitals … were all more likely to face penalties than nonteaching, nonsafety institutions with healthier patients … June 7, 2017 Development and validation of a brief culture-of-safety survey. … September 19, 2012 Effect of illness severity and comorbidity on patient safety and adverse … January 4, 2012 Effect of critical access hospital conversion on patient safety.

Quality improvement initiative to decrease central line-associated bloodstream infections during the COVID-19 pandemic: a "zero harm" approach. | PSNet

psnet.ahrq.gov/issue/quality-improvement-initiative-decrease-central-line-associated-bloodstream-infections-during

November 16, 2022 - A systematic review of the effects of resident duty hour restrictions in surgery: impact on … July 3, 2016 Ward round template: enhancing patient safety on ward rounds. … October 4, 2023 Operational failures in general practice: a consensus-building study on … device-associated infections during the coronavirus disease 2019 (COVID-19) pandemic: results from a national survey … 2023 Eliminating central line associated bloodstream infections in pediatric oncology patients

"It's like two worlds apart": an analysis of vulnerable patient handover practices at discharge from hospital. | PSNet

psnet.ahrq.gov/issue/its-two-worlds-apart-analysis-vulnerable-patient-handover-practices-discharge-hospital

January 15, 2025 - This qualitative study from Spain used in-depth interviews with patients, hospital staff, and primary … processes are often haphazard and a major source of frustration for hospital providers, and that patients … -Routine measurement of patient experience with patient safety in ambulatory care: a mixed-mode survey … September 24, 2016 The effects of patient handoff characteristics on subsequent care: … and delivery: development, validation, and application of the Coordination of Handoff Effectiveness Questionnaire

Has improved hand hygiene compliance reduced the risk of hospital-acquired infections among hospitalized patients in Ontario? Analysis of publicly reported patient safety data from 2008 to 2011. | PSNet

psnet.ahrq.gov/issue/has-improved-hand-hygiene-compliance-reduced-risk-hospital-acquired-infections-among

July 10, 2024 - Analysis of publicly reported patient safety data from 2008 to 2011. … Analysis of publicly reported patient safety data from 2008 to 2011. … attitudes and barriers to a medical emergency team among nurses and medical doctors: a multi-centre survey … April 21, 2015 Impact of a hospital-wide hand hygiene initiative on healthcare-associated … December 30, 2014 The effect of hospital-acquired Clostridium difficile infection on

Large language models for preventing medication direction errors in online pharmacies. | PSNet

psnet.ahrq.gov/issue/large-language-models-preventing-medication-direction-errors-online-pharmacies

February 27, 2019 - March 15, 2023 Optimizing Pediatric Patient Safety in the Emergency Care Setting. … October 19, 2022 ASHP Guidelines on the Safe Use of Automated Compounding Devices for … telephone-based self-management support program to identify adverse events among ambulatory diabetes patients … February 22, 2011 Development of a high-value care culture survey: a modified Delphi … A multi-method exploratory evaluation of a service designed to improve medication safety for patients

Can first-year medical students acquire quality improvement knowledge prior to substantial clinical exposure? A mixed-methods evaluation of a pre-clerkship curriculum that uses education as the context for learning. | PSNet

psnet.ahrq.gov/issue/can-first-year-medical-students-acquire-quality-improvement-knowledge-prior-substantial

April 24, 2019 - The National Patient Safety Foundation has called for medical educators to emphasize quality, safety … September 23, 2020 Optimizing Pediatric Patient Safety in the Emergency Care Setting. … November 28, 2018 Sustaining quality improvement and patient safety training in graduate … and postgraduate trainees: a cross-sectional survey. … January 18, 2012 Graduate medical education and patient safety: a busy--and occasionally

The safe day call: reducing silos in health care through frontline risk assessment. | PSNet

psnet.ahrq.gov/issue/safe-day-call-reducing-silos-health-care-through-frontline-risk-assessment

May 25, 2016 - January 15, 2025 Preventing harm in the ICU—building a culture of safety and engaging patients … March 2, 2011 Preventing patient harm via adverse event review: An APSA survey regarding … July 5, 2016 The influence of organizational factors on patient safety: examining successful … January 20, 2016 What do patients think about year-end resident continuity clinic handoffs … Healthcare professional views on hospital to home care transitions.

The emotional impact of medical errors on practicing physicians in the United States and Canada. | PSNet

psnet.ahrq.gov/issue/emotional-impact-medical-errors-practicing-physicians-united-states-and-canada

January 23, 2008 - Study Classic The emotional impact of medical errors on … The emotional impact of medical errors on practicing physicians in the United States and Canada. … This survey sought to evaluate the effects of medical errors on the emotional health of the physician … majority of more than 3000 physicians surveyed had been involved with a serious medical error resulting in patient … July 10, 2008 Patient concerns about medical errors in emergency departments.

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