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psnet.ahrq.gov/issue/targeted-chart-review-pediatric-patient-safety-events-identified-agency-healthcare-research
April 11, 2011 - Study
Targeted chart review of pediatric patient safety events identified by the Agency for Healthcare Research and Quality's Patient Safety Indicators methodology.
Citation Text:
Scanlon M, Miller MR, Harris JM, et al. Targeted Chart Review of Pediatric Patient Safety Events Identifie…
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psnet.ahrq.gov/primer/ambulatory-care-safety
December 15, 2024 - fragmentation of ambulatory care in outpatient settings increases the challenge of making a timely and accurate
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psnet.ahrq.gov/primer/diagnostic-errors
June 15, 2024 - care system reforms, including establishing a work system and safety culture that foster timely and accurate
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psnet.ahrq.gov/issue/hospital-safety-climate-and-safety-outcomes-there-relationship-va
October 14, 2009 - Study
Hospital safety climate and safety outcomes: is there a relationship in the VA?
Citation Text:
Rosen AK, Singer SJ, Zhao S, et al. Hospital safety climate and safety outcomes: is there a relationship in the VA? Med Care Res Rev. 2010;67(5):590-608. doi:10.1177/1077558709356703.
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psnet.ahrq.gov/issue/wisdom-and-justice-not-paying-preventable-complications
January 22, 2014 - Commentary
Classic
The wisdom and justice of not paying for "preventable complications."
Citation Text:
Pronovost P, Goeschel CA, Wachter R. The wisdom and justice of not paying for "preventable complications". JAMA. 2008;299(18):2197-9. doi:10.1001/jama.299.1…
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psnet.ahrq.gov/perspective/conversation-neel-shah-md-mpp
October 30, 2019 - everybody up when we're in these gray zones, hopefully we're doing it with better, and therefore more accurate … There is a big difference between accurate information and useful information, or precise information … And there's a public image of what maternal mortality is that may not be fully accurate.
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psnet.ahrq.gov/issue/cost-implications-reduced-work-hours-and-workloads-resident-physicians
August 05, 2015 - Study
Cost implications of reduced work hours and workloads for resident physicians.
Citation Text:
Nuckols TK, Bhattacharya J, Wolman DM, et al. Cost implications of reduced work hours and workloads for resident physicians. N Engl J Med. 2009;360(21):2202-15. doi:10.1056/NEJMsa0810251…
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psnet.ahrq.gov/issue/diagnostic-concordance-among-pathologists-interpreting-breast-biopsy-specimens
July 13, 2016 - Study
Classic
Diagnostic concordance among pathologists interpreting breast biopsy specimens.
Citation Text:
Elmore JG, Longton GM, Carney PA, et al. Diagnostic concordance among pathologists interpreting breast biopsy specimens. JAMA. 2015;313(11):1122-1132. do…
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psnet.ahrq.gov/issue/global-trigger-tool-shows-adverse-events-hospitals-may-be-ten-times-greater-previously
February 15, 2011 - Study
Classic
'Global Trigger Tool' shows that adverse events in hospitals may be ten times greater than previously measured.
Citation Text:
Classen D, Resar RK, Griffin F, et al. 'Global trigger tool' shows that adverse events in hospitals may be ten times grea…
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psnet.ahrq.gov/issue/validation-diagnostic-reminder-system-emergency-medicine-multi-centre-study
April 14, 2011 - Study
Validation of a diagnostic reminder system in emergency medicine: a multi-centre study.
Citation Text:
Ramnarayan P, Cronje N, Brown R, et al. Validation of a diagnostic reminder system in emergency medicine: a multi-centre study. Emerg Med J. 2007;24(9):619-24.
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psnet.ahrq.gov/issue/interventions-reduce-burnout-and-improve-resilience-impact-health-systems-outcomes
January 10, 2018 - Study
Interventions to reduce burnout and improve resilience: impact on a health system's outcomes.
Citation Text:
Moffatt-Bruce SD, Nguyen MC, Steinberg B, et al. Interventions to Reduce Burnout and Improve Resilience: Impact on a Health System's Outcomes. Clin Obstet Gynecol. 2019;62(3…
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psnet.ahrq.gov/issue/automated-identification-postoperative-complications-within-electronic-medical-record-using
March 09, 2011 - Study
Classic
Automated identification of postoperative complications within an electronic medical record using natural language processing.
Citation Text:
Murff HJ, FitzHenry F, Matheny ME, et al. Automated identification of postoperative complications within a…
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psnet.ahrq.gov/issue/what-return-investment-implementation-crew-resource-management-program-academic-medical
April 24, 2018 - Study
What is the return on investment for implementation of a crew resource management program at an academic medical center?
Citation Text:
Moffatt-Bruce SD, Hefner JL, Mekhjian H, et al. What Is the Return on Investment for Implementation of a Crew Resource Management Program at an Ac…
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psnet.ahrq.gov/issue/development-measure-patient-safety-event-learning-responses
June 28, 2010 - Study
Development of a measure of patient safety event learning responses.
Citation Text:
Ginsburg LR, Chuang Y-T, Norton PG, et al. Development of a measure of patient safety event learning responses. Health Serv Res. 2009;44(6):2123-47. doi:10.1111/j.1475-6773.2009.01021.x.
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psnet.ahrq.gov/issue/performance-global-assessment-pediatric-patient-safety-gapps-tool
August 14, 2018 - Study
Performance of the Global Assessment of Pediatric Patient Safety (GAPPS) tool.
Citation Text:
Landrigan CP, Stockwell DC, Toomey SL, et al. Performance of the Global Assessment of Pediatric Patient Safety (GAPPS) Tool. Pediatrics. 2016;137(6). doi:10.1542/peds.2015-4076.
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psnet.ahrq.gov/primer/falls
October 27, 2021 - prediction rules for identifying high-risk patients, but none has been shown to be significantly more accurate
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psnet.ahrq.gov/web-mm/duplicate-therapies-retail-pharmacy
August 05, 2022 - best practices in medication reconciliation , which is defined as the process of identifying the most accurate … simpler and easier to see and read; and
Ensuring that the after-visit-summary for the encounter is accurate
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psnet.ahrq.gov/web-mm/managing-complexity-diagnosis-life-threatening-complications-after-gastric-bypass-surgery
September 25, 2019 - considered, would have shifted the problem representation and differential diagnosis toward a fulsome and accurate … Accurate problem representation requires input from all members of the diagnostic team, and it is imperative
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psnet.ahrq.gov/web-mm/delayed-diagnosis-mesenteric-ischemia
March 31, 2021 - There are no laboratory studies that are sufficient or accurate enough to diagnose bowel ischemia or … report, the National Academy of Medicine defines diagnostic errors as “the failure to (a) establish an accurate
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psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls
May 01, 2006 - Medication Reconciliation Pitfalls
Citation Text:
Weber RJ. Medication Reconciliation Pitfalls. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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