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Wrong-patient blood transfusion error: leveraging technology to overcome human error in intraoperative blood component administration. | PSNet

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December 09, 2020 - Study Wrong-patient blood transfusion error: leveraging technology to overcome human error in intraoperative blood component administration. Citation Text: Hensley NB, Koch CG, Pronovost P, et al. Wrong-Patient Blood Transfusion Error: Leveraging Technology to Overcome Human Error in Int…

Leadership behavior associations with domains of safety culture, engagement, and healthcare worker well-being. | PSNet

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February 24, 2021 - Study Leadership behavior associations with domains of safety culture, engagement, and healthcare worker well-being. Citation Text: Tawfik DS, Adair KC, Palassof S, et al. Leadership behavior associations with domains of safety culture, engagement, and healthcare worker well-being. Jt Co…

What can we learn from in-depth analysis of human errors resulting in diagnostic errors in the emergency department: an analysis of serious adverse event reports. | PSNet

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June 08, 2022 - Study What can we learn from in-depth analysis of human errors resulting in diagnostic errors in the emergency department: an analysis of serious adverse event reports. Citation Text: Baartmans MC, Hooftman J, Zwaan L, et al. What can we learn from in-depth analysis of human errors resul…

Lessons learned from a systems approach to engaging patients and families in patient safety transformation. | PSNet

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February 12, 2020 - Study Lessons learned from a systems approach to engaging patients and families in patient safety transformation. Citation Text: Hatlie MJ, Nahum A, Leonard R, et al. Lessons Learned from a Systems Approach to Engaging Patients and Families in Patient Safety Transformation. Jt Comm J Qua…

Impact of technological and departmental changes on incident rates in radiation oncology over a seventeen-year period. | PSNet

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February 16, 2022 - Study Impact of technological and departmental changes on incident rates in radiation oncology over a seventeen-year period. Citation Text: Le Cornu E, Murray S, Brown EJ, et al. Impact of technological and departmental changes on incident rates in radiation oncology over a seventeen‐yea…

Evaluation of symptom checkers for self diagnosis and triage: audit study. | PSNet

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December 08, 2021 - Study Classic Evaluation of symptom checkers for self diagnosis and triage: audit study. Citation Text: Semigran HL, Linder JA, Gidengil C, et al. Evaluation of symptom checkers for self diagnosis and triage: audit study. BMJ. 2015;351:h3480. doi:10.1136/bmj.h34…

The impact of COVID-19 workflow changes on radiation oncology incident reporting. | PSNet

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June 30, 2021 - Study The impact of COVID-19 workflow changes on radiation oncology incident reporting. Citation Text: Volpini ME, Lekx‐Toniolo K, Mahon R, et al. The impact of COVID‐19 workflow changes on radiation oncology incident reporting. J Appl Clin Med Phys. 2022;23(11):e13742. doi:10.1002/acm2.…

Outcomes and patient safety in overlapping vs. nonoverlapping total joint arthroplasty: a systematic review and meta-analysis. | PSNet

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February 02, 2022 - Review Outcomes and patient safety in overlapping vs. nonoverlapping total joint arthroplasty: a systematic review and meta-analysis. Citation Text: Malahias M-A, Antoniadou T, Jang SJ, et al. Outcomes and patient safety in overlapping vs. nonoverlapping total joint arthroplasty: a syste…

Measuring variation in use of the WHO surgical safety checklist in the operating room: a multicenter prospective cross-sectional study. | PSNet

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January 19, 2016 - Study Measuring variation in use of the WHO surgical safety checklist in the operating room: a multicenter prospective cross-sectional study. Citation Text: Russ S, Rout S, Caris J, et al. Measuring variation in use of the WHO surgical safety checklist in the operating room: a multicente…

Targeted implementation of the Comprehensive Unit-Based Safety Program through an assessment of safety culture to minimize central line-associated bloodstream infections. | PSNet

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November 20, 2015 - Study Targeted implementation of the Comprehensive Unit-Based Safety Program through an assessment of safety culture to minimize central line-associated bloodstream infections. Citation Text: Richter J, McAlearney AS. Targeted implementation of the Comprehensive Unit-Based Safety Program…

The effect of facility complexity on perceptions of safety climate in the operating room: size matters. | PSNet

psnet.ahrq.gov/issue/effect-facility-complexity-perceptions-safety-climate-operating-room-size-matters

December 21, 2014 - Study The effect of facility complexity on perceptions of safety climate in the operating room: size matters. Citation Text: Carney BT, West P, Neily J, et al. The effect of facility complexity on perceptions of safety climate in the operating room: size matters. Am J Med Qual. 2010;25…

Reporting of hazards and near-misses in the ambulatory care setting. | PSNet

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October 19, 2011 - Study Reporting of hazards and near-misses in the ambulatory care setting. Citation Text: Schnall R, Bakken S. Reporting of hazards and near-misses in the ambulatory care setting. J Nurs Care Qual. 2011;26(4):328-334. doi:10.1097/NCQ.0b013e3182109204. Copy Citation Format: …

Classics and Emerging Classics | PSNet

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August 01, 2023 - Although interventions varied, there were international similarities in workplace norms and culture.

Triaging Interhospital Transfers | PSNet

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April 12, 2023 - to streamline aspects of interhospital transfer, practices between distinct transfer centers remain varied

Finding Fault With the Default Alert | PSNet

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August 28, 2024 - Finding Fault With the Default Alert Citation Text: Baysari M. Finding Fault With the Default Alert. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNot…

Reporting and using near-miss events to improve patient safety in diverse primary care practices: a collaborative approach to learning from our mistakes. | PSNet

psnet.ahrq.gov/issue/reporting-and-using-near-miss-events-improve-patient-safety-diverse-primary-care-practices

June 22, 2011 - Study Reporting and using near-miss events to improve patient safety in diverse primary care practices: a collaborative approach to learning from our mistakes. Citation Text: Crane S, Sloane PD, Elder NC, et al. Reporting and Using Near-miss Events to Improve Patient Safety in Diverse Pr…

Adverse drug event–related emergency department visits associated with complex chronic conditions. | PSNet

psnet.ahrq.gov/issue/adverse-drug-event-related-emergency-department-visits-associated-complex-chronic-conditions

August 20, 2016 - Study Adverse drug event–related emergency department visits associated with complex chronic conditions. Citation Text: Feinstein JA, Feudtner C, Kempe A. Adverse drug event-related emergency department visits associated with complex chronic conditions. Pediatrics. 2014;133(6):e1575-85. …

Focus on the Quadruple Aim: development of a resiliency center to promote faculty and staff wellness initiatives. | PSNet

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February 10, 2015 - Commentary Focus on the Quadruple Aim: development of a resiliency center to promote faculty and staff wellness initiatives. Citation Text: Morrow E, Call M, Marcus R, et al. Focus on the Quadruple Aim: Development of a Resiliency Center to Promote Faculty and Staff Wellness Initiatives.…

Order Interrupted by Text: Multitasking Mishap | PSNet

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August 21, 2015 - Clinicians have multi-tasked and worked in settings with multiple and varied interruptions long before

Failure to Report | PSNet

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July 01, 2008 - a much-researched question in recent years, with the reasons for nonreporting found to be many and varied

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