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psnet.ahrq.gov/node/836840/psn-pdf
April 22, 2021 - The Johns Hopkins Venous Thromboembolism (VTE)
Collaborative Studies and Implements Methods to Prevent
Avoidable Cases of Hospital Associated VTE
April 7, 2022
https://psnet.ahrq.gov/innovation/johns-hopkins-venous-thromboembolism-vte-collaborative-studies-and-
implements-methods
Summary
Venous thromboembolism (…
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psnet.ahrq.gov/node/74830/psn-pdf
June 01, 2022 - The Michigan Hospital Medicine Safety Consortium (HMS)
Finds Infectious Diseases (ID) Physician Approval for
Placement of Peripherally Inserted Central Catheters
(PICCs) Prevents Unnecessary PICC Use and Reduces
Complications
February 23, 2022
https://psnet.ahrq.gov/innovation/michigan-hospital-medicine-safety-co…
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psnet.ahrq.gov/issue/characteristics-initial-prescription-episodes-and-likelihood-long-term-opioid-use-united
April 24, 2018 - Study
Classic
Characteristics of initial prescription episodes and likelihood of long-term opioid use—United States, 2006–2015.
Citation Text:
Shah A, Hayes CJ, Martin BC. Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use - …
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psnet.ahrq.gov/issue/preventable-deaths-due-problems-care-english-acute-hospitals-retrospective-case-record-review
July 20, 2022 - Study
Classic
Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review study.
Citation Text:
Hogan H, Healey F, Neale G, et al. Preventable deaths due to problems in care in English acute hospitals: a retrospect…
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psnet.ahrq.gov/issue/impact-coronavirus-disease-2019-covid-19-healthcare-associated-infections-2020-summary-data
February 07, 2022 - Study
The impact of coronavirus disease 2019 (COVID-19) on healthcare-associated infections in 2020: a summary of data reported to the National Healthcare Safety Network.
Citation Text:
Weiner-Lastinger LM, Pattabiraman V, Konnor RY, et al. The impact of coronavirus disease 2019 (COVID-1…
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psnet.ahrq.gov/issue/national-implementation-project-prevent-catheter-associated-urinary-tract-infection-nursing
April 05, 2017 - Study
Classic
A national implementation project to prevent catheter-associated urinary tract infection in nursing home residents.
Citation Text:
Mody L, Greene T, Meddings J, et al. A National Implementation Project to Prevent Catheter-Associated Urinary Tract I…
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psnet.ahrq.gov/issue/serious-misdiagnosis-related-harms-malpractice-claims-big-three-vascular-events-infections
July 28, 2023 - Study
Emerging Classic
Serious misdiagnosis-related harms in malpractice claims: the "Big Three": vascular events, infections, and cancers.
Citation Text:
Newman-Toker DE, Schaffer AC, Yu-Moe CW, et al. Serious misdiagnosis-related harms in malpractice claims: T…
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psnet.ahrq.gov/issue/clinical-pharmacist-led-transitions-care-program-veterans-two-planned-care-transitions
December 23, 2011 - Study
A clinical pharmacist-led transitions of care program for veterans with two planned care transitions (hospital to skilled care and skilled care to home) amid the COVID-19 pandemic.
Citation Text:
Scannell GA, Bevan DJ, Cowan A, et al. A clinical pharmacist-led transitions of care p…
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psnet.ahrq.gov/issue/sustained-user-engagement-health-information-technology-long-road-implementation-system
December 21, 2022 - Study
Sustained user engagement in health information technology: the long road from implementation to system optimization of computerized physician order entry and clinical decision support systems for prescribing in hospitals in England.
Citation Text:
Cresswell K, Lee L, Mozaffar H, e…
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psnet.ahrq.gov/issue/safety-risks-associated-lack-integration-and-interfacing-hospital-health-information
December 21, 2022 - Study
Safety risks associated with the lack of integration and interfacing of hospital health information technologies: a qualitative study of hospital electronic prescribing systems in England.
Citation Text:
Cresswell K, Mozaffar H, Lee L, et al. Safety risks associated with the lack o…
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psnet.ahrq.gov/issue/patient-doctor-continuity-and-diagnosis-cancer-electronic-medical-records-study-general
September 11, 2019 - Study
Patient–doctor continuity and diagnosis of cancer: electronic medical records study in general practice.
Citation Text:
Ridd MJ, Ferreira DLS, Montgomery AA, et al. Patient-doctor continuity and diagnosis of cancer: electronic medical records study in general practice. Br J Gen Pra…
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psnet.ahrq.gov/issue/diagnostic-errors-reported-primary-healthcare-and-emergency-departments-retrospective-and
March 11, 2020 - Study
Diagnostic errors reported in primary healthcare and emergency departments: a retrospective and descriptive cohort study of 4830 reported cases of preventable harm in Sweden.
Citation Text:
Fernholm R, Pukk Härenstam K, Wachtler C, et al. Diagnostic errors reported in primary healt…
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psnet.ahrq.gov/issue/situ-simulation-tool-longitudinally-identify-and-track-latent-safety-threats-structured
June 08, 2022 - Study
In situ simulation as a tool to longitudinally identify and track latent safety threats in a structured quality improvement initiative for SARS-CoV-2 airway management: a single-center study.
Citation Text:
Jafri FN, Yang CJ, Kumar A, et al. In situ simulation as a tool to longitud…
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psnet.ahrq.gov/issue/enhancing-teamwork-communication-and-patient-safety-responsiveness-paediatric-intensive-care
March 10, 2021 - Study
Enhancing teamwork communication and patient safety responsiveness in a paediatric intensive care unit using the daily safety huddle tool.
Citation Text:
Aldawood F, Kazzaz Y, AlShehri A, et al. Enhancing teamwork communication and patient safety responsiveness in a paediatric inte…
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psnet.ahrq.gov/issue/high-reliability-organization-framework-health-care-multiyear-implementation-strategy-and
November 17, 2021 - Study
A high-reliability organization framework for health care: a multiyear implementation strategy and associated outcomes.
Citation Text:
Sculli GL, Pendley-Louis R, Neily J, et al. A high-reliability organization framework for health care: a multiyear implementation strategy and asso…
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psnet.ahrq.gov/issue/high-prevalence-medication-discrepancies-between-home-health-referrals-and-centers-medicare
December 23, 2011 - Study
High prevalence of medication discrepancies between home health referrals and Centers for Medicare and Medicaid Services home health certification and plan of care and their potential to affect safety of vulnerable elderly adults.
Citation Text:
Brody AA, Gibson B, Tresner-Kirsch D…
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psnet.ahrq.gov/issue/workarounds-hospital-electronic-prescribing-systems-qualitative-study-english-hospitals
December 21, 2022 - Study
Workarounds to hospital electronic prescribing systems: a qualitative study in English hospitals.
Citation Text:
Cresswell K, Mozaffar H, Lee L, et al. Workarounds to hospital electronic prescribing systems: a qualitative study in English hospitals. BMJ Qual Saf. 2017;26(7):542-551…
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psnet.ahrq.gov/issue/antecedent-treat-and-release-diagnoses-prior-sepsis-hospitalization-among-adult-emergency
May 12, 2021 - Study
Antecedent treat-and-release diagnoses prior to sepsis hospitalization among adult emergency department patients: a look-back analysis employing insurance claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) methodology.
Citation Text:
Nassery N, Horberg MA, …
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psnet.ahrq.gov/issue/rate-sepsis-hospitalizations-after-misdiagnosis-adult-emergency-department-patients-look
December 08, 2021 - Study
Rate of sepsis hospitalizations after misdiagnosis in adult emergency department patients: a look-forward analysis with administrative claims data using Symptom-Disease Pair Analysis of Diagnostic Error methodology in an integrated health system.
Citation Text:
Horberg MA, Nassery …
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psnet.ahrq.gov/issue/association-between-unmet-nonmedication-needs-after-hospital-discharge-and-readmission-or
September 23, 2020 - Study
Association between unmet nonmedication needs after hospital discharge and readmission or death among acute respiratory failure survivors: a multicenter prospective cohort study.
Citation Text:
Bose S, Groat D, Dinglas VD, et al. Association between unmet nonmedication needs after …