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Unintentionally retained foreign objects: a descriptive study of 308 sentinel events and contributing factors. | PSNet

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March 20, 2019 - Study Emerging Classic Unintentionally retained foreign objects: a descriptive study of 308 sentinel events and contributing factors. Citation Text: Steelman VM, Shaw C, Shine L, et al. Unintentionally Retained Foreign Objects: A Descriptive Study of 308 Sentine…

Learning from failure: the need for independent safety investigation in healthcare. | PSNet

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September 24, 2018 - Commentary Learning from failure: the need for independent safety investigation in healthcare. Citation Text: Macrae C, Vincent CA. Learning from failure: the need for independent safety investigation in healthcare. J R Soc Med. 2014;107(11):439-443. doi:10.1177/0141076814555939. Copy…

Reducing errors through discharge medication reconciliation by pharmacy services. | PSNet

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October 20, 2021 - Study Reducing errors through discharge medication reconciliation by pharmacy services. Citation Text: Bishop MA, Cohen BA, Billings LK, et al. Reducing errors through discharge medication reconciliation by pharmacy services. Am J Health Syst Pharm. 2015;72(17 Suppl 2):S120-6. doi:10.21…

Ensuring safe and equitable discharge: a quality improvement initiative for individuals with hypertensive disorders of pregnancy. | PSNet

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October 19, 2022 - Study Ensuring safe and equitable discharge: a quality improvement initiative for individuals with hypertensive disorders of pregnancy. Citation Text: Zacherl KM, Sterrett EC, Hughes BL, et al. Ensuring safe and equitable discharge: a quality improvement initiative for individuals with h…

Medication safety program reduces adverse drug events in a community hospital. | PSNet

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April 24, 2018 - Study Medication safety program reduces adverse drug events in a community hospital. Citation Text: Cohen MM, Kimmel NL, Benage MK, et al. Medication safety program reduces adverse drug events in a community hospital. Qual Saf Health Care. 2005;14(3):169-74. Copy Citation Format:…

Effects of CPOE on provider cognitive workload: a randomized crossover trial. | PSNet

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March 14, 2022 - Study Effects of CPOE on provider cognitive workload: a randomized crossover trial. Citation Text: Avansino J, Leu MG. Effects of CPOE on provider cognitive workload: a randomized crossover trial. Pediatrics. 2012;130(3):e547-52. doi:10.1542/peds.2011-3408. Copy Citation Format: …

Project BOOST: effectiveness of a multihospital effort to reduce rehospitalization. | PSNet

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September 10, 2014 - Study Project BOOST: effectiveness of a multihospital effort to reduce rehospitalization. Citation Text: Hansen LO, Greenwald JL, Budnitz T, et al. Project BOOST: effectiveness of a multihospital effort to reduce rehospitalization. J Hosp Med. 2013;8(8):421-7. doi:10.1002/jhm.2054. Co…

Giving up learning from failures? An examination of learning from one's own failures in the context of heart surgeons. | PSNet

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April 03, 2013 - Study Giving up learning from failures? An examination of learning from one's own failures in the context of heart surgeons. Citation Text: Lee S, Park J. Giving up learning from failures? An examination of learning from one's own failures in the context of heart surgeons. Strat Manage J…

Risk of adverse drug events by patient destination after hospital discharge. | PSNet

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March 04, 2020 - Study Risk of adverse drug events by patient destination after hospital discharge. Citation Text: Triller DM, Clause SL, Hamilton RA. Risk of adverse drug events by patient destination after hospital discharge. Am J Health Syst Pharm. 2005;62(18):1883-9. Copy Citation Format: …

Effect of the 80-hour work week on resident case coverage. | PSNet

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July 21, 2010 - Study Effect of the 80-hour work week on resident case coverage. Citation Text: Shin S, Britt R, Britt LD. Effect of the 80-hour work week on resident case coverage. J Am Coll Surg. 2008;206(5):798-800; discussion 801-3. doi:10.1016/j.jamcollsurg.2007.12.028. Copy Citation Format…

Threats to safety during sedation outside of the operating room and the death of Michael Jackson. | PSNet

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January 25, 2012 - Commentary Threats to safety during sedation outside of the operating room and the death of Michael Jackson. Citation Text: Webster CS, Mason KP, Shafer SL. Threats to safety during sedation outside of the operating room and the death of Michael Jackson. Curr Opin Anaesthesiol. 2016;29 S…

Medication errors with the use of allopurinol and colchicine: a retrospective study of a national, anonymous Internet-accessible error reporting system. | PSNet

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December 21, 2014 - Study Medication errors with the use of allopurinol and colchicine: a retrospective study of a national, anonymous Internet-accessible error reporting system. Citation Text: Mikuls TR, Curtis JR, Allison JJ, et al. Medication errors with the use of allopurinol and colchicine: a retrosp…

Critical incident reports concerning anaesthetic equipment: analysis of the UK National Reporting and Learning System (NRLS) data from 2006-2008. | PSNet

psnet.ahrq.gov/issue/critical-incident-reports-concerning-anaesthetic-equipment-analysis-uk-national-reporting-and

August 03, 2022 - Study Critical incident reports concerning anaesthetic equipment: analysis of the UK National Reporting and Learning System (NRLS) data from 2006-2008. Citation Text: Cassidy CJ, Smith AF, Arnot-Smith J. Critical incident reports concerning anaesthetic equipment: analysis of the UK Nat…

Medication errors: an important component of nonadherence to medication in an outpatient population of lung transplant recipients. | PSNet

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June 23, 2021 - Study Medication errors: an important component of nonadherence to medication in an outpatient population of lung transplant recipients. Citation Text: Irani S, Seba P, Speich R, et al. Medication errors: an important component of nonadherence to medication in an outpatient population …

Opioid prescribing after surgical extraction of teeth in Medicaid patients, 2000–2010. | PSNet

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March 02, 2011 - Study Opioid prescribing after surgical extraction of teeth in Medicaid patients, 2000–2010. Citation Text: Baker JA, Avorn J, Levin R, et al. Opioid Prescribing After Surgical Extraction of Teeth in Medicaid Patients, 2000-2010. JAMA. 2016;315(15):1653-4. doi:10.1001/jama.2015.19058. …

Safety culture and care: a program to prevent surgical errors. | PSNet

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March 25, 2020 - Commentary Safety culture and care: a program to prevent surgical errors. Citation Text: Hemingway MW, O'Malley C, Silvestri S. Safety culture and care: a program to prevent surgical errors. AORN J. 2015;101(4):404-12; quiz 413-5. doi:10.1016/j.aorn.2015.01.002. Copy Citation Forma…

Real-time debriefing after critical events: exploring the gap between principle and reality. | PSNet

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December 15, 2021 - Review Emerging Classic Real-time debriefing after critical events: exploring the gap between principle and reality. Citation Text: Arriaga AF, Szyld D, Pian-Smith MCM. Real-time debriefing after critical events: exploring the gap between principle and reality. …

Time-out and checklists: a survey of rural and urban operating room personnel. | PSNet

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January 09, 2014 - Study Time-out and checklists: a survey of rural and urban operating room personnel. Citation Text: Lyons VE, Popejoy LL. Time-Out and Checklists: A Survey of Rural and Urban Operating Room Personnel. J Nurs Care Qual. 2017;32(1):E3-E10. Copy Citation Format: Google Scholar…

Gaps in the continuity of care and progress on patient safety. | PSNet

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January 16, 2017 - Commentary Classic Gaps in the continuity of care and progress on patient safety. Citation Text: Cook RI, Render M, Woods DD. Gaps in the continuity of care and progress on patient safety. BMJ. 2000;320(7237):791-4. Copy Citation Format: Google Sch…

The uptake of technologies designed to influence medication safety in Canadian hospitals. | PSNet

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March 10, 2021 - Study The uptake of technologies designed to influence medication safety in Canadian hospitals. Citation Text: Saginur M, Graham ID, Forster AJ, et al. The uptake of technologies designed to influence medication safety in Canadian hospitals. J Eval Clin Pract. 2008;14(1):27-35. doi:10.…

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