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Evaluation of the role of the critical care pharmacist in identifying and avoiding or minimizing significant drug–drug interactions in medical intensive care patients. | PSNet

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December 15, 2021 - Study Evaluation of the role of the critical care pharmacist in identifying and avoiding or minimizing significant drug–drug interactions in medical intensive care patients. Citation Text: Rivkin A, Yin H. Evaluation of the role of the critical care pharmacist in identifying and avoidi…

Five strategies for a safer EHR modernization journey. | PSNet

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November 11, 2020 - Commentary Five strategies for a safer EHR modernization journey. Citation Text: Sittig DF, Yackel EE, Singh H. Five strategies for a safer EHR modernization journey. J Gen Intern Med. 2023;38(S4):940-942. doi:10.1007/s11606-023-08331-z. Copy Citation Format: DOI Google Sch…

Evaluation of Quality, Safety and Value in Veterans Health Administration Facilities, Fiscal 2021. | PSNet

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October 12, 2022 - Book/Report Evaluation of Quality, Safety and Value in Veterans Health Administration Facilities, Fiscal 2021. Citation Text: Evaluation of Quality, Safety and Value in Veterans Health Administration Facilities, Fiscal 2021. Washington, DC: Veterans Affairs Office of Inspector General; 2…

Towards a unified model of accident causation: refining and validating the systems thinking safety tenets. | PSNet

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March 14, 2022 - Commentary Towards a unified model of accident causation: refining and validating the systems thinking safety tenets. Citation Text: Salmon PM, Hulme A, Walker GH, et al. Towards a unified model of accident causation: refining and validating the systems thinking safety tenets. Ergonomics…

Preventing a parallel pandemic - a national strategy to protect clinicians' well-being. | PSNet

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January 23, 2019 - Commentary Classic Preventing a parallel pandemic - a national strategy to protect clinicians' well-being. Citation Text: Dzau VJ, Kirch D, Nasca TJ. Preventing a parallel pandemic - a national strategy to protect clinicians' well-being. N Engl J Med. 2020;383(6…

High performance teamwork training and systems redesign in outpatient oncology. | PSNet

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November 16, 2022 - Study High performance teamwork training and systems redesign in outpatient oncology. Citation Text: Bunnell CA, Gross AH, Weingart SN, et al. High performance teamwork training and systems redesign in outpatient oncology. BMJ Qual Saf. 2013;22(5):405-13. doi:10.1136/bmjqs-2012-000948.…

A practical framework for patient care teams to prospectively identify and mitigate clinical hazards. | PSNet

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March 01, 2011 - Commentary A practical framework for patient care teams to prospectively identify and mitigate clinical hazards. Citation Text: Herzer KR, Rodriguez-Paz JM, Doyle PA, et al. A practical framework for patient care teams to prospectively identify and mitigate clinical hazards. Jt Comm J Qu…

Hospital Survey on Patient Safety Culture: 2011 User Comparative Database Report. | PSNet

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September 14, 2011 - Book/Report Hospital Survey on Patient Safety Culture: 2011 User Comparative Database Report. Citation Text: Hospital Survey on Patient Safety Culture: 2011 User Comparative Database Report. Sorra J, Famolaro T, Dyer N, et al. Rockville, MD: Agency for Healthcare Research and Quality; Ap…

Half-life of a printed handoff document. | PSNet

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April 24, 2018 - Study Half-life of a printed handoff document. Citation Text: Rosenbluth G, Jacolbia R, Milev D, et al. Half-life of a printed handoff document. BMJ Qual Saf. 2016;25(5):324-8. doi:10.1136/bmjqs-2015-004585. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 …

Multidisciplinary in-hospital teams improve patient outcomes: a review. | PSNet

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February 03, 2011 - Review Multidisciplinary in-hospital teams improve patient outcomes: a review. Citation Text: Epstein NE. Multidisciplinary in-hospital teams improve patient outcomes: A review. Surg Neurol Int. 2014;5(Suppl 7):S295-303. doi:10.4103/2152-7806.139612. Copy Citation Format: D…

The poor state of health care quality in the U.S.: is malpractice liability part of the problem or part of the solution? | PSNet

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March 01, 2023 - Review The poor state of health care quality in the U.S.: is malpractice liability part of the problem or part of the solution? Citation Text: Hyman DA, Silver C. The poor state of health care quality in the U.S.: is malpractice liability part of the problem or part of the solution? Co…

Why stigma matters in addressing alcohol harm. | PSNet

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August 04, 2021 - Commentary Why stigma matters in addressing alcohol harm. Citation Text: Morris J, Schomerus G. Why stigma matters in addressing alcohol harm. Drug Alcohol Rev. 2023;42(5):1264-1268. doi:10.1111/dar.13660. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNo…

Nurses' workarounds in acute healthcare settings: a scoping review. | PSNet

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December 08, 2021 - Review Nurses' workarounds in acute healthcare settings: a scoping review. Citation Text: Debono DS, Greenfield D, Travaglia J, et al. Nurses' workarounds in acute healthcare settings: a scoping review. BMC Health Serv Res. 2013;13:175. doi:10.1186/1472-6963-13-175. Copy Citation …

Understanding the link between burnout and sub-optimal care: why should healthcare education be interested in employee silence? | PSNet

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August 03, 2022 - Review Understanding the link between burnout and sub-optimal care: why should healthcare education be interested in employee silence? Citation Text: Montgomery A, Lainidi O. Understanding the link between burnout and sub-optimal care: why should healthcare education be interested in emp…

Tiered daily huddles: the power of teamwork in managing large healthcare organisations. | PSNet

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December 09, 2020 - Commentary Tiered daily huddles: the power of teamwork in managing large healthcare organisations. Citation Text: Mihaljevic T. Tiered daily huddles: the power of teamwork in managing large healthcare organisations. BMJ Qual Saf. 2020;29(12):1050-1052. doi:10.1136/bmjqs-2019-010575. Co…

Missed diagnoses of acute cardiac ischemia in the emergency department. | PSNet

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November 30, 2012 - Study Classic Missed diagnoses of acute cardiac ischemia in the emergency department. Citation Text: Pope JH, Aufderheide TP, Ruthazer R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med. 2000;342(16):1163-1170. doi:10.…

Is there a 'weekend effect' in major trauma? | PSNet

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September 23, 2020 - Study Is there a 'weekend effect' in major trauma? Citation Text: Metcalfe D, Perry DC, Bouamra O, et al. Is there a 'weekend effect' in major trauma? Emerg Med J. 2016;33(12):836-842. doi:10.1136/emermed-2016-206049. Copy Citation Format: DOI Google Scholar PubMed BibTeX E…

Peer support: healthcare professionals supporting each other after adverse medical events. | PSNet

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July 24, 2024 - Study Peer support: healthcare professionals supporting each other after adverse medical events. Citation Text: van Pelt F. Peer support: healthcare professionals supporting each other after adverse medical events. Qual Saf Health Care. 2008;17(4):249-52. doi:10.1136/qshc.2007.025536. …

'So why didn't you think this baby was ill?' Decision-making in acute paediatrics. | PSNet

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April 10, 2019 - Review 'So why didn't you think this baby was ill?' Decision-making in acute paediatrics. Citation Text: Roland D, Snelson E. 'So why didn't you think this baby was ill?' Decision-making in acute paediatrics. Arch Dis Child Educ Pract Ed. 2019;104(1):43-48. doi:10.1136/archdischild-2017-…

Submit Case | PSNet

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March 25, 2025 - Breadcrumb Home Training and Education WebM&M: Case Studies WebM&M Case Submission PSNet is looking for interesting, provocative cases that illustrate key issues in patient safety such as medication errors, diagnostic errors, and adverse events that either had the potential …

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