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Medication errors and error chains involving high-alert medications in a paediatric hospital setting: a qualitative analysis of self-reported medication safety incidents. | PSNet

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March 27, 2024 - Study Medication errors and error chains involving high-alert medications in a paediatric hospital setting: a qualitative analysis of self-reported medication safety incidents. Citation Text: Kuitunen S, Saksa M, Holmström A-R. Medication errors and error chains involving high-alert medi…

Delayed diagnosis of serious paediatric conditions in 13 regional emergency departments. | PSNet

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July 05, 2023 - Study Delayed diagnosis of serious paediatric conditions in 13 regional emergency departments. Citation Text: Michelson KA, McGarghan FLE, Patterson EE, et al. Delayed diagnosis of serious paediatric conditions in 13 regional emergency departments. BMJ Qual Saf. 2024;33(5):293-300. doi:1…

Academic year-end transfers of outpatients from outgoing to incoming residents: an unaddressed patient safety issue. | PSNet

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January 27, 2016 - Commentary Academic year-end transfers of outpatients from outgoing to incoming residents: an unaddressed patient safety issue. Citation Text: Young JQ, Wachter R. Academic year-end transfers of outpatients from outgoing to incoming residents: an unaddressed patient safety issue. JAMA.…

Communication failures in the operating room: an observational classification of recurrent types and effects. | PSNet

psnet.ahrq.gov/issue/communication-failures-operating-room-observational-classification-recurrent-types-and

April 06, 2011 - Study Classic Communication failures in the operating room: an observational classification of recurrent types and effects. Citation Text: Lingard L, Espin S, Whyte S, et al. Communication failures in the operating room: an observational classification of recu…

Evaluation for occult fractures in injured children. | PSNet

psnet.ahrq.gov/issue/evaluation-occult-fractures-injured-children

August 20, 2014 - Study Evaluation for occult fractures in injured children. Citation Text: Wood JN, French B, Song L, et al. Evaluation for Occult Fractures in Injured Children. Pediatrics. 2015;136(2):232-40. doi:10.1542/peds.2014-3977. Copy Citation Format: DOI Google Scholar PubMed BibTe…

Normal Accidents: Living with High-Risk Technologies. | PSNet

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March 06, 2005 - Book/Report Classic Normal Accidents: Living with High-Risk Technologies. Citation Text: Normal Accidents: Living with High-Risk Technologies. Perrow C. Princeton NJ: Princeton University Press; 1999. Copy Citation Save Save to you…

The practice of respect in the ICU. | PSNet

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August 09, 2018 - Commentary Emerging Classic The practice of respect in the ICU. Citation Text: Brown SM, Azoulay E, Benoit D, et al. The Practice of Respect in the ICU. Am J Respir Crit Care Med. 2018;197(11):1389-1395. doi:10.1164/rccm.201708-1676CP. Copy Citation Format…

Sleep deprivation and medication administration errors in registered nurses- a scoping review. | PSNet

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September 23, 2020 - Review Sleep deprivation and medication administration errors in registered nurses- a scoping review. Citation Text: Martin CV, Joyce‐McCoach J, Peddle M, et al. Sleep deprivation and medication administration errors in registered nurses- a scoping review. J Clin Nurs. 2024;33(3):859-873…

The Anesthesia Patient Safety Foundation Stoelting Conference 2019: perioperative deterioration--early recognition, rapid intervention, and the end of failure-to-rescue. | PSNet

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October 19, 2022 - Meeting/Conference Proceedings The Anesthesia Patient Safety Foundation Stoelting Conference 2019: perioperative deterioration--early recognition, rapid intervention, and the end of failure-to-rescue. Citation Text: Lin D, Peden CJ, Langness SM, et al. The Anesthesia Patient Safety Found…

Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. | PSNet

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November 16, 2022 - Review Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. Citation Text: Kripalani S, Jackson AT, Schnipper JL, et al. Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med. …

Impact of pharmacist previsit input to providers on chronic opioid prescribing safety. | PSNet

psnet.ahrq.gov/issue/impact-pharmacist-previsit-input-providers-chronic-opioid-prescribing-safety

November 16, 2022 - Study Impact of pharmacist previsit input to providers on chronic opioid prescribing safety. Citation Text: Cox N, Tak CR, Cochella SE, et al. Impact of Pharmacist Previsit Input to Providers on Chronic Opioid Prescribing Safety. The Journal of the American Board of Family …

A QI initiative: implementing a patient handoff checklist for pediatric hospitalist attendings. | PSNet

psnet.ahrq.gov/issue/qi-initiative-implementing-patient-handoff-checklist-pediatric-hospitalist-attendings

July 28, 2021 - Commentary A QI initiative: implementing a patient handoff checklist for pediatric hospitalist attendings. Citation Text: Lo H-Y, Mullan PC, Lye C, et al. A QI initiative: implementing a patient handoff checklist for pediatric hospitalist attendings. BMJ Qual Improv Rep. 2016;5(1). doi:1…

A safety evaluation of the impact of maternity-orientated human factors training on safety culture in a tertiary maternity unit. | PSNet

psnet.ahrq.gov/issue/safety-evaluation-impact-maternity-orientated-human-factors-training-safety-culture-tertiary

October 19, 2022 - Study A safety evaluation of the impact of maternity-orientated human factors training on safety culture in a tertiary maternity unit. Citation Text: Ansari SP, Rayfield ME, Wallis VA, et al. A Safety Evaluation of the Impact of Maternity-Orientated Human Factors Training on Safety Cultu…

The proportion of clinically relevant alarms decreases as patient clinical severity decreases in intensive care units: a pilot study. | PSNet

psnet.ahrq.gov/issue/proportion-clinically-relevant-alarms-decreases-patient-clinical-severity-decreases-intensive

November 21, 2021 - Study The proportion of clinically relevant alarms decreases as patient clinical severity decreases in intensive care units: a pilot study. Citation Text: Inokuchi R, Sato H, Nanjo Y, et al. The proportion of clinically relevant alarms decreases as patient clinical severity decreases in…

Recommendations from a national panel on quality improvement in obstetrics. | PSNet

psnet.ahrq.gov/issue/recommendations-national-panel-quality-improvement-obstetrics

July 12, 2023 - Commentary Recommendations from a national panel on quality improvement in obstetrics. Citation Text: Lefebvre G, Calder LA, De Gorter R, et al. Recommendations From a National Panel on Quality Improvement in Obstetrics. J Obstet Gynaecol Can. 2019;41(5):653-659. doi:10.1016/j.jogc.2019.…

What 'just culture' doesn't understand about just punishment. | PSNet

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December 30, 2014 - Commentary What 'just culture' doesn't understand about just punishment. Citation Text: Reis-Dennis S. What 'Just Culture' doesn't understand about just punishment. J Med Ethics. 2018;44(11):739-742. doi:10.1136/medethics-2018-104911. Copy Citation Format: DOI Google Schola…

Mortality and morbidity rounds (MMR) in pathology: relative contribution of cognitive bias vs. systems failures to diagnostic error. | PSNet

psnet.ahrq.gov/issue/mortality-and-morbidity-rounds-mmr-pathology-relative-contribution-cognitive-bias-vs-systems

May 18, 2022 - Study Mortality and morbidity rounds (MMR) in pathology: relative contribution of cognitive bias vs. systems failures to diagnostic error. Citation Text: Eichbaum Q, Adkins B, Craig-Owens L, et al. Mortality and morbidity rounds (MMR) in pathology: relative contribution of cognitive bias…

Changes in physician practice patterns after implementation of a communication-and-resolution program. | PSNet

psnet.ahrq.gov/issue/changes-physician-practice-patterns-after-implementation-communication-and-resolution-program

September 01, 2018 - Study Changes in physician practice patterns after implementation of a communication-and-resolution program. Citation Text: Helmchen LA, Lambert BL, McDonald TB. Changes in Physician Practice Patterns after Implementation of a Communication-and-Resolution Program. Health Serv Res. 2016;5…

How residents think and make medical decisions: implications for education and patient safety. | PSNet

psnet.ahrq.gov/issue/how-residents-think-and-make-medical-decisions-implications-education-and-patient-safety

June 07, 2023 - Study How residents think and make medical decisions: implications for education and patient safety. Citation Text: Young JS, Smith RL, Guerlain S, et al. How residents think and make medical decisions: implications for education and patient safety. Am Surg. 2007;73(6):548-553; discuss…

Safety concerns of hospital-based new-to-practice registered nurses and their preceptors. | PSNet

psnet.ahrq.gov/issue/safety-concerns-hospital-based-new-practice-registered-nurses-and-their-preceptors

September 24, 2016 - Study Safety concerns of hospital-based new-to-practice registered nurses and their preceptors. Citation Text: Myers S, Reidy P, French B, et al. Safety concerns of hospital-based new-to-practice registered nurses and their preceptors. J Contin Educ Nurs. 2010;41(4):163-71. doi:10.3928…

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