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psnet.ahrq.gov/issue/investigating-us-medical-students-motivation-respond-lapses-professionalism
January 12, 2022 - August 10, 2016
Prevalence of medication transfer errors in nephrology patients and potential … 2020
Inappropriate prescriptions of direct oral anticoagulants (DOACs) in hospitalized patients … More
Related Resources
Bad things can happen: are medical students aware of patient … March 19, 2018
Speaking up about traditional and professionalism-related patient safety … threats: a national survey of interns and residents.
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psnet.ahrq.gov/issue/handover-after-pediatric-heart-surgery-simple-tool-improves-information-exchange
July 03, 2016 - of a structured tool improved the quality of handoffs for postoperative pediatric cardiac surgery patients … March 5, 2025
Purchase of prescription medicines via social media: a survey-based study … May 28, 2015
Tracing the foundations of a conceptual framework for a patient safety ontology … A prospective observational study of physician handoff for intensive-care-unit-to-ward patient … , 2011
Standardized multidisciplinary protocol improves handover of cardiac surgery patients
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psnet.ahrq.gov/issue/hospital-board-and-management-practices-are-strongly-related-hospital-performance-clinical
October 27, 2021 - This study, which used survey data from a large sample of hospitals in the United States and England, … As many hospital boards still do not prioritize patient safety, these results help identify management … framework to identify and categorise patient-reported breakdowns related to the diagnostic process in … Mixed methods evaluation of the impact of 100% single-room accommodation on staff and patient experience … March 2, 2016
Post event debriefs: a commitment to learning how to better care for patients
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psnet.ahrq.gov/issue/selection-incorrect-medication-pump-leads-chemotherapy-overdose
September 09, 2015 - June 10, 2018
Pump up the volume: tips for increasing error reporting and decreasing patient … , 2015
ISMP updates its list of drug names with tall man (mixed case) letters based on … survey results.
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psnet.ahrq.gov/web-mm/bowel-injury-after-laparoscopic-surgery
January 19, 2016 - His physical examination was documented as unremarkable, and he was started on a patient-controlled analgesia … On postoperative day 2, the patient was weaned off the PCA and started on a clear liquid diet. … Hospital and patient characteristics associated with death after surgery. … May 6, 2015
The WHO surgical safety checklist: survey of patients' views. … June 13, 2018
Patient safety in the OR.
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psnet.ahrq.gov/issue/managing-competing-demands-through-task-switching-and-multitasking-multi-setting
December 19, 2018 - using the internet: a multisite survey. … error rates in hospital in-patients: a before and after study. … February 15, 2012
Drug-drug interactions and actual harm to hospitalized patients: a … June 12, 2024
View More
Related Resources
Patient Safety … May 28, 2014
Is culture associated with patient safety in the emergency department?
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psnet.ahrq.gov/issue/giving-voice-mothers-study-inequity-and-mistreatment-during-pregnancy-and-childbirth-united
January 23, 2020 - April 24, 2018
Nursing home patient safety culture perceptions among US and immigrant … January 24, 2018
Lost information during the handover of critically injured trauma patients … February 7, 2024
‘The Retrievals’ reveals painful experiences of female patients are … February 15, 2023
Explaining the negative effects of patient participation in patient … September 8, 2021
Parent engagement in perinatal mortality reviews: an online survey
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psnet.ahrq.gov/issue/racial-disparities-maternal-mortality-and-impact-structural-racism-and-implicit-racial-bias
July 13, 2009 - The racial disparities in maternal mortality and impact of structural racism and implicit racial bias on … The racial disparities in maternal mortality and impact of structural racism and implicit racial bias on … increased risk of maternal morbidity and mortality among Black women in the United States is a patient … November 13, 2024
Impact of patient safety bundle and team-based training on obstetric … September 21, 2022
Psychometric properties of the perinatal missed care survey and missed
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psnet.ahrq.gov/web-mm/failure-report
July 01, 2008 - acknowledge the potentially harmful medication error, caregivers missed a chance to protect future patients … How many other patients must be harmed by similar mistakes before the factors that led to the mistakes … The Handbook on Storing and Securing Medications. … Committed to Safety: Ten Case Studies on Reducing Harm to Patients. … December 14, 2022
ISMP survey on tall man (mixed case) lettering to reduce drug name
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psnet.ahrq.gov/issue/proactive-risk-avoidance-system-using-failure-mode-and-effects-analysis-same-name-physician
February 23, 2022 - Jt Comm J Qual Patient Saf. 2010;36(10):461-7. … Jt Comm J Qual Patient Saf. 2010;36(10):461-7. … February 23, 2022
Survey of nurses' experiences applying The Joint Commission's medication … September 1, 2016
The role of housestaff in implementing medication reconciliation on … June 8, 2011
Contraindicated medication use in dialysis patients undergoing percutaneous
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psnet.ahrq.gov/issue/decision-making-processes-used-nurses-during-intravenous-drug-preparation-and-administration
June 29, 2022 - s)
Changes to primary care delivery during the COVID-19 pandemic and perceived impact on … medication safety: a survey study. … The effect of computerised decision support alerts tailored to intensive care on … September 27, 2016
Missed medication doses in hospitalised patients: a descriptive account … 4, 2012
Medication errors reported in a pediatric intensive care unit for oncologic patients
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psnet.ahrq.gov/issue/views-children-parents-and-health-care-providers-pediatric-disclosure-medical-errors
April 08, 2020 - These results echo earlier studies demonstrating a gap between patient preferences and clinician concerns … April 27, 2022
More than words: patients' views on apology and disclosure when things … March 11, 2013
Operating room to intensive care unit handoffs and the risks of patient … Delayed access to care and late presentations in children during the COVID-19 pandemic: a snapshot survey … pediatric patients.
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psnet.ahrq.gov/node/49612/psn-pdf
November 01, 2010 - After a urine culture was obtained in the
ED, the patient was started on vancomycin and admitted to … Finally, patients often have poor access to
primary care, resulting in patients having no medical support … Consequently, patient care suffers, and often, patients recently discharged return to the hospital
for … In a survey of the leaders of seven Divisions of Hospital Medicine at academic
centers across the country … Several large programs have focused on improving the discharge process for patients.
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psnet.ahrq.gov/perspective/workplace-safety-health-care
January 01, 2017 - Real and lasting progress in improving workplace safety can only be achieved by changing the safety culture … implementing Job Safety Behavioral Observation teams and adopting a robust, repeatable process can improve the safety … culture of the workplace and result in fewer injuries. … So you're no longer taking care of four patients; you're sitting on your butt waiting for your back to … Mixed methods evaluation of the impact of 100% single-room accommodation on staff and patient experience
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psnet.ahrq.gov/perspective/conversation-withwilliam-b-munier-md-mba
July 01, 2011 - To give you one example, we did a survey of about 2,000 hospitals a few years ago. … The whole survey was about incident reporting systems in those hospitals, to find out how many were automated … organization (PSO) to serve California hospitals and their patients. … Peer-review protections and attorney–client privileges create the opposite tendency: to inhibit open … Reflections on the National Patient Safety Agency's database of medical errors.
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psnet.ahrq.gov/node/49441/psn-pdf
March 01, 2004 - On
postoperative day (POD) 2, the patient was tachycardic, despite receiving a low-dose beta-blocker … On POD 3, the patient had no complaints for
the primary team on morning rounds. … On POD 4, the patient complained to the nurse of mild chest discomfort. … Communication breakdown and discontinuity of care have deleterious effects on patients. … Gaps in the continuity of care and progress on patient safety.
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psnet.ahrq.gov/clinical-areas
March 24, 2025 - Date Range
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On … Findings from this cross-sectional survey with 255 nurse leaders highlight the important role of authentic … Survey respondents also endorsed the importance of formal support programs, including peer support, education … This methodology ensured the audit was patient-centered and focused on the patient's journey through … factors on decision fatigue.
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psnet.ahrq.gov/node/49784/psn-pdf
February 01, 2017 - inadequate training and lack of knowledge about good laboratory practices were other factors
included on … However, it is hazardous to depend on the vigilance of busy providers to prevent errors. … When patients use point-of-care testing at home, such as international normalized ratio for monitoring … Good laboratory practices for waived
testing sites: survey findings from testing sites holding a certificate … Results of a survey among GP practices on how they manage
patient safety aspects related to point-of-care
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psnet.ahrq.gov/web-mm/physical-diagnosis-lost-art
January 17, 2018 - The practice of "handing off" patients necessitated by the 80-hour work week imposed on physicians in … The old clinical saw, "There is no substitute for laying hands on your patient," remains true today, … Reliance on program directors to sign-off on the residents' clinical skills is putting too much faith … Skilled clinicians test the candidate at the bedside on real patients to see if they can sort out valvular … undergraduate grade point averages (GPA) with intern performance measured by residency program director surveys
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psnet.ahrq.gov/perspective/conversation-bernardo-perea-perez-md-dds-phd
August 01, 2016 - He is perhaps the world's leading expert on patient safety in the field of dentistry.
Dr. … In our Spanish Observatory for Dental Patient Safety database, we have five cases of patients dying … And we have more work to do here in Spain on dental patient safety. … safety culture in the dental ecosystem.( 20 ) As challenging as it has been to establish a safety culture … Open wide: looking into the safety culture of dental school clinics. J Dent Educ. 2014;78:745-756.