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Leveraging a redesigned morbidity and mortality conference that incorporates the clinical and educational missions of improving quality and patient safety. | PSNet

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April 24, 2018 - Commentary Leveraging a redesigned morbidity and mortality conference that incorporates the clinical and educational missions of improving quality and patient safety. Citation Text: Tad-Y DB, Pierce RG, Pell JM, et al. Leveraging a Redesigned Morbidity and Mortality Conference That Incor…

Undergraduate baccalaureate nursing students' self-reported confidence in learning about patient safety in the classroom and clinical settings: an annual cross-sectional study (2010–2013). | PSNet

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February 04, 2015 - Study Undergraduate baccalaureate nursing students' self-reported confidence in learning about patient safety in the classroom and clinical settings: an annual cross-sectional study (2010–2013). Citation Text: Lukewich J, Edge DS, Tranmer J, et al. Undergraduate baccalaureate nursing stu…

Turning the medical gaze in upon itself: root cause analysis and the investigation of clinical error. | PSNet

psnet.ahrq.gov/issue/turning-medical-gaze-upon-itself-root-cause-analysis-and-investigation-clinical-error

June 14, 2011 - Study Turning the medical gaze in upon itself: root cause analysis and the investigation of clinical error. Citation Text: Iedema RAM, Jorm C, Long D, et al. Turning the medical gaze in upon itself: root cause analysis and the investigation of clinical error. Soc Sci Med. 2006;62(7):16…

Electronic prescribing and other forms of technology to reduce inappropriate medication use and polypharmacy in older people: a review of current evidence. | PSNet

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August 10, 2022 - Review Electronic prescribing and other forms of technology to reduce inappropriate medication use and polypharmacy in older people: a review of current evidence. Citation Text: Clyne B, Bradley MC, Hughes C, et al. Electronic prescribing and other forms of technology to reduce inapprop…

Evaluation of adverse drug events and medication discrepancies in transitions of care between hospital discharge and primary care follow-up. | PSNet

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June 07, 2023 - Study Evaluation of adverse drug events and medication discrepancies in transitions of care between hospital discharge and primary care follow-up. Citation Text: Armor BL, Wight AJ, Carter SM. Evaluation of Adverse Drug Events and Medication Discrepancies in Transitions of Care Between H…

Unplanned transfers to a medical intensive care unit: causes and relationship to preventable errors in care. | PSNet

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July 19, 2023 - Study Unplanned transfers to a medical intensive care unit: causes and relationship to preventable errors in care. Citation Text: Bapoje SR, Gaudiani JL, Narayanan V, et al. Unplanned transfers to a medical intensive care unit: causes and relationship to preventable errors in care. J …

Comparing rates of adverse events detected in incident reporting and the Global Trigger Tool: a systematic review. | PSNet

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December 13, 2023 - Review Comparing rates of adverse events detected in incident reporting and the Global Trigger Tool: a systematic review. Citation Text: Hibbert PD, Molloy CJ, Schultz TJ, et al. Comparing rates of adverse events detected in incident reporting and the Global Trigger Tool: a systematic re…

Interventions to reduce adverse drug event-related outcomes in older adults: a systematic review and meta-analysis. | PSNet

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July 19, 2023 - Review Emerging Classic Interventions to reduce adverse drug event-related outcomes in older adults: a systematic review and meta-analysis. Citation Text: Tecklenborg S, Byrne C, Cahir C, et al. Interventions to Reduce Adverse Drug Event-Related Outcomes in Olde…

Improving administration and documentation of enteral nutrition support therapy in a Veteran Affairs health care system: use of medication administration record and bar code scanning technology. | PSNet

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September 09, 2020 - Study Improving administration and documentation of enteral nutrition support therapy in a Veteran Affairs health care system: use of medication administration record and bar code scanning technology. Citation Text: Chew MM, Rivas S, Chesser M, et al. Improving administration and documen…

Improving resident and fellow engagement in patient safety through a graduate medical education incentive program. | PSNet

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June 02, 2021 - Study Improving resident and fellow engagement in patient safety through a graduate medical education incentive program. Citation Text: Turner DA, Bae J, Cheely G, et al. Improving Resident and Fellow Engagement in Patient Safety Through a Graduate Medical Education Incentive Program. J …

Medication-related emergency department visits in pediatrics: a prospective observational study. | PSNet

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October 16, 2013 - Study Medication-related emergency department visits in pediatrics: a prospective observational study. Citation Text: Zed PJ, Black KJL, Fitzpatrick EA, et al. Medication-related emergency department visits in pediatrics: a prospective observational study. Pediatrics. 2015;135(3):435-43.…

Identifying safe care processes when GPs work in or alongside emergency departments: a realist evaluation. | PSNet

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January 12, 2022 - Study Identifying safe care processes when GPs work in or alongside emergency departments: a realist evaluation. Citation Text: Cooper A, Carson-Stevens A, Edwards M, et al. Identifying safe care processes when GPs work in or alongside emergency departments: a realist evaluation. Br J Ge…

FDA alerts patients and health care professionals of EpiPen auto-injector errors related to device malfunctions and user administration. | PSNet

psnet.ahrq.gov/issue/fda-alerts-patients-and-health-care-professionals-epipen-auto-injector-errors-related-device

April 07, 2019 - Press Release/Announcement FDA alerts patients and health care professionals of EpiPen auto-injector errors related to device malfunctions and user administration. Citation Text: FDA alerts patients and health care professionals of EpiPen auto-injector errors related to device malfunctio…

An analysis of electronic health record–related patient safety concerns. | PSNet

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January 21, 2019 - Study Classic An analysis of electronic health record–related patient safety concerns. Citation Text: Meeks DW, Smith MW, Taylor L, et al. An analysis of electronic health record-related patient safety concerns. J Am Med Inform Assoc. 2014;21(6):1053-9. doi:10.1…

Health system redesign of cardiac monitoring oversight to optimize alarm management, safety, and staff engagement. | PSNet

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February 15, 2023 - Study Health system redesign of cardiac monitoring oversight to optimize alarm management, safety, and staff engagement. Citation Text: Engel JR, Lindsay M, O'Brien S, et al. Health system redesign of cardiac monitoring oversight to optimize alarm management, safety, and staff engagement…

Does responsibility affect the public's valuation of health care interventions? A relative valuation approach to health care safety. | PSNet

psnet.ahrq.gov/issue/does-responsibility-affect-publics-valuation-health-care-interventions-relative-valuation

October 12, 2022 - Study Does responsibility affect the public's valuation of health care interventions? A relative valuation approach to health care safety. Citation Text: Singh J, Lord J, Longworth L, et al. Does responsibility affect the public's valuation of health care interventions? A relative valuat…

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…

Demonstrating high reliability on accountability measures at The Johns Hopkins Hospital. | PSNet

psnet.ahrq.gov/issue/demonstrating-high-reliability-accountability-measures-johns-hopkins-hospital

January 27, 2016 - Study Demonstrating high reliability on accountability measures at The Johns Hopkins Hospital. Citation Text: Pronovost P, Demski R, Callender T, et al. Demonstrating high reliability on accountability measures at the Johns Hopkins Hospital. Jt Comm J Qual Patient Saf. 2013;39(12):531…

The analysis of hospital readmission rates after the implementation of Hospital Readmissions Reduction Program. | PSNet

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October 12, 2022 - Study The analysis of hospital readmission rates after the implementation of Hospital Readmissions Reduction Program. Citation Text: Muchiri S, Azadeh-Fard N, Pakdil F. The analysis of hospital readmission rates after the implementation of hospital readmissions reduction program. J Patie…

The effects of hospital safety scores, total price, out-of-pocket cost, and household income on consumers' self-reported choice of hospitals. | PSNet

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July 02, 2014 - Study The effects of hospital safety scores, total price, out-of-pocket cost, and household income on consumers' self-reported choice of hospitals. Citation Text: Duke CC, Smith B, Lynch W, et al. The Effects of Hospital Safety Scores, Total Price, Out-of-Pocket Cost, and Household Incom…

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