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An internal quality improvement collaborative significantly reduces hospital-wide medication error related adverse drug events. | PSNet

psnet.ahrq.gov/issue/internal-quality-improvement-collaborative-significantly-reduces-hospital-wide-medication

March 20, 2014 - Study An internal quality improvement collaborative significantly reduces hospital-wide medication error related adverse drug events. Citation Text: McClead RE, Catt C, Davis T, et al. An internal quality improvement collaborative significantly reduces hospital-wide medication error rela…

Race differences in a malpractice event database in a large healthcare system. | PSNet

psnet.ahrq.gov/issue/race-differences-malpractice-event-database-large-healthcare-system

December 15, 2021 - Study Race differences in a malpractice event database in a large healthcare system. Citation Text: Thomas AD, Pandit C, Krevat S. Race differences in a malpractice event database in a large healthcare system. J Patient Saf. 2023;19(2):67-70. doi:10.1097/pts.0000000000001090. Copy Cita…

Semi-supervised classification of patient safety event reports. | PSNet

psnet.ahrq.gov/issue/semi-supervised-classification-patient-safety-event-reports

October 31, 2011 - Study Semi-supervised classification of patient safety event reports. Citation Text: McKnight SD. Semi-supervised classification of patient safety event reports. J Patient Saf. 2012;8(2):60-4. doi:10.1097/PTS.0b013e31824ab987. Copy Citation Format: DOI Google Scholar PubM…

Advanced practice nursing students' identification of patient safety issues in ambulatory care. | PSNet

psnet.ahrq.gov/issue/advanced-practice-nursing-students-identification-patient-safety-issues-ambulatory-care

March 02, 2012 - Study Advanced practice nursing students' identification of patient safety issues in ambulatory care. Citation Text: Schnall R, Larson EL, Stone PW, et al. Advanced practice nursing students' identification of patient safety issues in ambulatory care. J Nurs Care Qual. 2013;28(2):169-75…

Can surveillance systems identify and avert adverse drug events? A prospective evaluation of a commercial application. | PSNet

psnet.ahrq.gov/issue/can-surveillance-systems-identify-and-avert-adverse-drug-events-prospective-evaluation

February 10, 2015 - Study Can surveillance systems identify and avert adverse drug events? A prospective evaluation of a commercial application. Citation Text: Jha AK, Laguette J, Seger AC, et al. Can surveillance systems identify and avert adverse drug events? A prospective evaluation of a commercial app…

Diagnostic errors in obstetric morbidity and mortality: methods for and challenges in seeking diagnostic excellence. | PSNet

psnet.ahrq.gov/issue/diagnostic-errors-obstetric-morbidity-and-mortality-methods-and-challenges-seeking-diagnostic

May 18, 2022 - Commentary Diagnostic errors in obstetric morbidity and mortality: methods for and challenges in seeking diagnostic excellence. Citation Text: Krenitsky NM, Perez-Urbano I, Goffman D. Diagnostic errors in obstetric morbidity and mortality: methods for and challenges in seeking diagnostic…

How to mitigate the effects of cognitive biases during patient safety incident investigations. | PSNet

psnet.ahrq.gov/issue/how-mitigate-effects-cognitive-biases-during-patient-safety-incident-investigations

June 29, 2022 - Commentary How to mitigate the effects of cognitive biases during patient safety incident investigations. Citation Text: Rogers JE, Hilgers TR, Keebler JR, et al. How to mitigate the effects of cognitive biases during patient safety incident investigations. Jt Comm J Qual Patient Saf. 20…

Supporting second victims of patient safety events: shouldn't these communications be covered by legal privilege? | PSNet

psnet.ahrq.gov/issue/supporting-second-victims-patient-safety-events-shouldnt-these-communications-be-covered

November 06, 2019 - Commentary Supporting second victims of patient safety events: shouldn't these communications be covered by legal privilege? Citation Text: de Wit ME, Marks CM, Natterman JP, et al. Supporting second victims of patient safety events: shouldn't these communications be covered by legal pri…

Beyond clinical engagement: a pragmatic model for quality improvement interventions, aligning clinical and managerial priorities. | PSNet

psnet.ahrq.gov/issue/beyond-clinical-engagement-pragmatic-model-quality-improvement-interventions-aligning

April 24, 2018 - Review Beyond clinical engagement: a pragmatic model for quality improvement interventions, aligning clinical and managerial priorities. Citation Text: Pannick S, Sevdalis N, Athanasiou T. Beyond clinical engagement: a pragmatic model for quality improvement interventions, aligning clini…

Adverse event rates as measures of hospital performance. | PSNet

psnet.ahrq.gov/issue/adverse-event-rates-measures-hospital-performance

July 29, 2020 - Study Adverse event rates as measures of hospital performance. Citation Text: Hauck K, Zhao X, Jackson T. Adverse event rates as measures of hospital performance. Health Policy (New York). 2012;104(2):146-154. doi:10.1016/j.healthpol.2011.06.010. Copy Citation Format: DOI…

Please reconcile, not wait a while. | PSNet

psnet.ahrq.gov/issue/please-reconcile-not-wait-while

April 19, 2023 - Commentary Please reconcile, not wait a while. Citation Text: Trivedi A, Sharma S, Ajitsaria R, et al. Please reconcile, not wait a while. Arch Dis Child Educ Pract Ed. 2019;105(2):122-126. doi:10.1136/archdischild-2018-316356. Copy Citation Format: DOI Google Scholar BibTe…

The problem with…using stories as a source of evidence and learning. | PSNet

psnet.ahrq.gov/issue/problem-withusing-stories-source-evidence-and-learning

June 19, 2018 - Commentary The problem with…using stories as a source of evidence and learning. Citation Text: Iedema R. The problem with … using stories as a source of evidence and learning. BMJ Qual Saf. 2022;31(3):234-237. doi:10.1136/bmjqs-2021-014221. Copy Citation Format: DOI Google …

Engaging the patient and family in the surgical safety process utilizing SafeStart. | PSNet

psnet.ahrq.gov/issue/engaging-patient-and-family-surgical-safety-process-utilizing-safestart

October 19, 2022 - Study Engaging the patient and family in the surgical safety process utilizing SafeStart. Citation Text: Elger BM, Esparaz JR, Nierstedt RT, et al. Engaging the patient and family in the surgical safety process utilizing. J Pediatr Surg. 2020;55(4). doi:10.1016/j.jpedsurg.2019.06.012. …

Impact of resident participation in surgical operations on postoperative outcomes: National Surgical Quality Improvement Program. | PSNet

psnet.ahrq.gov/issue/impact-resident-participation-surgical-operations-postoperative-outcomes-national-surgical

November 16, 2022 - Study Impact of resident participation in surgical operations on postoperative outcomes: National Surgical Quality Improvement Program. Citation Text: Kiran RP, Ahmed Ali U, Coffey JC, et al. Impact of Resident Participation in Surgical Operations on Postoperative Outcomes. Ann Surg. 20…

Improved incident reporting following the implementation of a standardized emergency department peer review process. | PSNet

psnet.ahrq.gov/issue/improved-incident-reporting-following-implementation-standardized-emergency-department-peer

September 10, 2014 - Study Improved incident reporting following the implementation of a standardized emergency department peer review process. Citation Text: Reznek MA, Barton BA. Improved incident reporting following the implementation of a standardized emergency department peer review process. Int J Qual …

Using a bar-coded medication administration system to prevent medication errors in a community hospital network. | PSNet

psnet.ahrq.gov/issue/using-bar-coded-medication-administration-system-prevent-medication-errors-community-hospital

October 01, 2008 - Study Using a bar-coded medication administration system to prevent medication errors in a community hospital network. Citation Text: Sakowski J, Leonard T, Colburn S, et al. Using a bar-coded medication administration system to prevent medication errors in a community hospital network…

Discrepant advanced directives and code status orders: a preventable medical error. | PSNet

psnet.ahrq.gov/issue/discrepant-advanced-directives-and-code-status-orders-preventable-medical-error

October 31, 2018 - Journal Article Discrepant advanced directives and code status orders: a preventable medical error. Citation Text: Meisenberg B, Zaidi S, Franks L, et al. Discrepant Advanced Directives and Code Status Orders: A Preventable Medical Error. J Hosp Med. 2019;14(10):716-718. doi:10.12788/jhm…

Learning from near misses: from quick fixes to closing off the Swiss-cheese holes. | PSNet

psnet.ahrq.gov/issue/learning-near-misses-quick-fixes-closing-swiss-cheese-holes

April 11, 2012 - Study Learning from near misses: from quick fixes to closing off the Swiss-cheese holes. Citation Text: Jeffs L, Berta W, Lingard LA, et al. Learning from near misses: from quick fixes to closing off the Swiss-cheese holes. BMJ Qual Saf. 2012;21(4):287-94. doi:10.1136/bmjqs-2011-000256…

What do family physicians consider an error? A comparison of definitions and physician perception. | PSNet

psnet.ahrq.gov/issue/what-do-family-physicians-consider-error-comparison-definitions-and-physician-perception

February 15, 2011 - Study What do family physicians consider an error? A comparison of definitions and physician perception. Citation Text: Elder NC, Pallerla H, Regan S. What do family physicians consider an error? A comparison of definitions and physician perception. BMC Fam Pract. 2006;7:73. Copy Cit…

Prospective daily review of discharge medications by pharmacists: effects on measures of safety and efficiency. | PSNet

psnet.ahrq.gov/issue/prospective-daily-review-discharge-medications-pharmacists-effects-measures-safety-and

July 14, 2010 - Commentary Prospective daily review of discharge medications by pharmacists: effects on measures of safety and efficiency. Citation Text: Craynon R, Hager DR, Reed M, et al. Prospective daily review of discharge medications by pharmacists: Effects on measures of safety and efficiency. Am…

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