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Patient record review of the incidence, consequences, and causes of diagnostic adverse events. | PSNet

psnet.ahrq.gov/issue/patient-record-review-incidence-consequences-and-causes-diagnostic-adverse-events

July 02, 2014 - Study Patient record review of the incidence, consequences, and causes of diagnostic adverse events. Citation Text: Zwaan L, de Bruijne M, Wagner C, et al. Patient record review of the incidence, consequences, and causes of diagnostic adverse events. Arch Intern Med. 2010;170(12):1015-21…

Impact of adverse events on outcomes in intensive care unit patients. | PSNet

psnet.ahrq.gov/issue/impact-adverse-events-outcomes-intensive-care-unit-patients

April 18, 2012 - Study Impact of adverse events on outcomes in intensive care unit patients. Citation Text: Orgeas MG, Timsit JF, Soufir L, et al. Impact of adverse events on outcomes in intensive care unit patients. Crit Care Med. 2008;36(7):2041-2047. doi:10.1097/CCM.0b013e31817b879c. Copy Citation…

Electronic prescribing systems in hospitals to improve medication safety: a multi-methods research programme. | PSNet

psnet.ahrq.gov/issue/electronic-prescribing-systems-hospitals-improve-medication-safety-multi-methods-research

November 09, 2022 - Review Electronic prescribing systems in hospitals to improve medication safety: a multi-methods research programme. Citation Text: Sheikh A, Coleman JJ, Chuter A, et al. Electronic prescribing systems in hospitals to improve medication safety: a multimethods research programme. Programm…

Effects of a communication-and-resolution program on hospitals' malpractice claims and costs. | PSNet

psnet.ahrq.gov/issue/effects-communication-and-resolution-program-hospitals-malpractice-claims-and-costs

October 11, 2017 - Study Effects of a communication-and-resolution program on hospitals' malpractice claims and costs. Citation Text: Kachalia A, Sands K, Van Niel M, et al. Effects Of A Communication-And-Resolution Program On Hospitals' Malpractice Claims And Costs. Health Aff (Millwood). 2018;37(11):1836…

Root causes of adverse drug events in hospitals and artificial intelligence capabilities for prevention. | PSNet

psnet.ahrq.gov/issue/root-causes-adverse-drug-events-hospitals-and-artificial-intelligence-capabilities-prevention

May 20, 2020 - Study Root causes of adverse drug events in hospitals and artificial intelligence capabilities for prevention. Citation Text: Gordo C, Núñez‐Córdoba JM, Mateo R. Root causes of adverse drug events in hospitals and artificial intelligence capabilities for prevention. J Adv Nurs. 2021;77(7…

The Critical Care Safety Study: the incidence and nature of adverse events and serious medical errors in intensive care. | PSNet

psnet.ahrq.gov/issue/critical-care-safety-study-incidence-and-nature-adverse-events-and-serious-medical-errors

July 15, 2020 - Study The Critical Care Safety Study: the incidence and nature of adverse events and serious medical errors in intensive care. Citation Text: Rothschild JM, Landrigan CP, Cronin JW, et al. The Critical Care Safety Study: The incidence and nature of adverse events and serious medical e…

Examining patient safety events using the behaviour change wheel: a cross-sectional analysis. | PSNet

psnet.ahrq.gov/issue/examining-patient-safety-events-using-behaviour-change-wheel-cross-sectional-analysis

September 20, 2012 - Study Examining patient safety events using the behaviour change wheel: a cross-sectional analysis. Citation Text: Somerville M, Cassidy C, MacPhee S, et al. Examining patient safety events using the behaviour change wheel: a cross-sectional analysis. Jt Comm J Qual Patient Saf. 2025;51(…

Trends of diagnostic adverse events in hospital deaths: longitudinal analyses of four retrospective record review studies. | PSNet

psnet.ahrq.gov/issue/trends-diagnostic-adverse-events-hospital-deaths-longitudinal-analyses-four-retrospective

May 18, 2022 - Study Trends of diagnostic adverse events in hospital deaths: longitudinal analyses of four retrospective record review studies. Citation Text: Hooftman J, Zwaan L, Sikkens JJ, et al. Trends of diagnostic adverse events in hospital deaths: longitudinal analyses of four retrospective reco…

Incorrect surgical procedures within and outside of the operating room. | PSNet

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November 21, 2011 - Study Incorrect surgical procedures within and outside of the operating room. Citation Text: Neily J, Mills PD, Eldridge N, et al. Incorrect surgical procedures within and outside of the operating room. Arch Surg. 2009;144(11):1028-34. doi:10.1001/archsurg.2009.126. Copy Citation F…

Hemodialysis bleeding events and deaths: an 18-year retrospective analysis of patient safety and root cause analysis reports in the Veterans Health Administration. | PSNet

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June 23, 2021 - Study Hemodialysis bleeding events and deaths: an 18-year retrospective analysis of patient safety and root cause analysis reports in the Veterans Health Administration. Citation Text: Walton E, Charles M, Morrish W, et al. Hemodialysis bleeding events and deaths: an 18-year retrospectiv…

Examining the effect of quality improvement initiatives on decreasing racial disparities in maternal morbidity. | PSNet

psnet.ahrq.gov/issue/examining-effect-quality-improvement-initiatives-decreasing-racial-disparities-maternal

May 11, 2022 - Study Examining the effect of quality improvement initiatives on decreasing racial disparities in maternal morbidity. Citation Text: Davidson C, Denning S, Thorp K, et al. Examining the effect of quality improvement initiatives on decreasing racial disparities in maternal morbidity. BMJ …

Interprofessional clinical event debriefing-does it make a difference? Attitudes of emergency department care providers to INFO clinical event debriefings. | PSNet

psnet.ahrq.gov/issue/interprofessional-clinical-event-debriefing-does-it-make-difference-attitudes-emergency

April 06, 2022 - Study Interprofessional clinical event debriefing-does it make a difference? Attitudes of emergency department care providers to INFO clinical event debriefings. Citation Text: Rose SC, Ashari NA, Davies JM, et al. Interprofessional clinical event debriefing-does it make a difference? At…

Use of patient complaints to identify diagnosis-related safety concerns: a mixed-method evaluation. | PSNet

psnet.ahrq.gov/issue/use-patient-complaints-identify-diagnosis-related-safety-concerns-mixed-method-evaluation

April 13, 2022 - Study Use of patient complaints to identify diagnosis-related safety concerns: a mixed-method evaluation. Citation Text: Giardina TD, Korukonda S, Shahid U, et al. Use of patient complaints to identify diagnosis-related safety concerns: a mixed-method evaluation. BMJ Qual Saf. 2021;30(12…

Facilitators and barriers of care transitions - comparing the perspectives of hospital and community healthcare staff. | PSNet

psnet.ahrq.gov/issue/facilitators-and-barriers-care-transitions-comparing-perspectives-hospital-and-community

July 21, 2021 - Study Facilitators and barriers of care transitions - comparing the perspectives of hospital and community healthcare staff. Citation Text: Carman E-M, Fray M, Waterson P. Facilitators and barriers of care transitions - comparing the perspectives of hospital and community healthcare staf…

Root cause analysis of serious adverse events among older patients in the Veterans Health Administration. | PSNet

psnet.ahrq.gov/issue/root-cause-analysis-serious-adverse-events-among-older-patients-veterans-health

August 02, 2015 - Study Root cause analysis of serious adverse events among older patients in the Veterans Health Administration. Citation Text: Lee A, Mills PD, Neily J, et al. Root cause analysis of serious adverse events among older patients in the Veterans Health Administration. Jt Comm J Qual Patient…

Root cause analysis using the prevention and recovery information system for monitoring and analysis method in healthcare facilities: a systematic literature review. | PSNet

psnet.ahrq.gov/issue/root-cause-analysis-using-prevention-and-recovery-information-system-monitoring-and-analysis

May 18, 2022 - Review Root cause analysis using the prevention and recovery information system for monitoring and analysis method in healthcare facilities: a systematic literature review. Citation Text: Driesen BEJM, Baartmans M, Merten H, et al. Root cause analysis using the prevention and recovery in…

Delays in diagnosis, treatment, and surgery: root causes, actions taken, and recommendations for healthcare improvement. | PSNet

psnet.ahrq.gov/issue/delays-diagnosis-treatment-and-surgery-root-causes-actions-taken-and-recommendations

March 25, 2020 - Study Delays in diagnosis, treatment, and surgery: root causes, actions taken, and recommendations for healthcare improvement. Citation Text: Politi RE, Mills PD, Zubkoff L, et al. Delays in diagnosis, treatment, and surgery: root causes, actions taken, and recommendations for healthcare…

Missing diagnoses during the COVID-19 pandemic: a year in review. | PSNet

psnet.ahrq.gov/issue/missing-diagnoses-during-covid-19-pandemic-year-review

December 23, 2020 - Commentary Missing diagnoses during the COVID-19 pandemic: a year in review. Citation Text: Pifarré i Arolas H, Vidal-Alaball J, Gil J, et al. Missing diagnoses during the COVID-19 pandemic: a year in review. Int J Environ Res Public Health. 2021;18(10):5335. doi:10.3390/ijerph18105335. …

Death by suicide within 1 week of hospital discharge: a retrospective study of root cause analysis reports. | PSNet

psnet.ahrq.gov/issue/death-suicide-within-1-week-hospital-discharge-retrospective-study-root-cause-analysis

May 04, 2022 - Study Death by suicide within 1 week of hospital discharge: a retrospective study of root cause analysis reports. Citation Text: Riblet N, Shiner B, Watts B, et al. Death by Suicide Within 1 Week of Hospital Discharge: A Retrospective Study of Root Cause Analysis Reports. J Nerv Ment Dis…

The safety implications of missed test results for hospitalised patients: a systematic review. | PSNet

psnet.ahrq.gov/issue/safety-implications-missed-test-results-hospitalised-patients-systematic-review

November 26, 2014 - Review Classic The safety implications of missed test results for hospitalised patients: a systematic review. Citation Text: Callen J, Georgiou A, Li J, et al. The safety implications of missed test results for hospitalised patients: a systematic review. BMJ Q…

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