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psnet.ahrq.gov/node/865871/psn-pdf
May 15, 2024 - Delivery at an inadequate level of maternal care is
associated with severe maternal morbidity.
May 15, 2024
Osei-Poku GK, Prentice JC, Easter SR, et al. Delivery at an inadequate level of maternal care is associated
with severe maternal morbidity. Am J Obstet Gynecol. 2024;231(5):e1-546.e520.
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July 02, 2017 - A hybrid methodology for modeling risk of adverse
events in complex health-care settings.
July 2, 2017
Kazemi R, Mosleh A, Dierks M. A Hybrid Methodology for Modeling Risk of Adverse Events in Complex
Health-Care Settings. Risk Anal. 2017;37(3):421-440. doi:10.1111/risa.12702.
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September 21, 2022 - Exploration of a rapid response team model of care: a
descriptive dual methods study.
September 21, 2022
Shiell A, Fry M, Elliott D, et al. Exploration of a rapid response team model of care: a descriptive dual
methods study. Intensive Crit Care Nurs. 2022;73:103294. doi:10.1016/j.iccn.2022.103294.
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April 29, 2020 - Effectiveness of N95 respirators versus surgical masks
against influenza: a systematic review and meta-analysis.
April 29, 2020
Long Y, Hu T, Liu L, et al. Effectiveness of N95 respirators versus surgical masks against influenza: a
systematic review and meta-analysis. J Evid Based Med. 2020. doi:10.1111/jebm.12381.…
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June 12, 2019 - Can mindfulness in health care professionals improve
patient care? An integrative review and proposed model.
June 12, 2019
Braun SE, Kinser PA, Rybarczyk B. Can mindfulness in health care professionals improve patient care? An
integrative review and proposed model. Transl Behav Med. 2019;9(2):187-201. doi:10.1093/t…
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July 22, 2020 - Are you surgically current? Lessons from aviation for
returning to non-urgent surgery following COVID-19.
July 22, 2020
Hardie JA, Brennan PA. Are you surgically current? Lessons from aviation for returning to non-urgent
surgery following COVID-19. Br J Oral Maxillofac Surg. 2020;58(7):843-847.
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September 15, 2021 - Evaluation of Quality, Safety, and Value in Veterans
Health Administration Facilities, FY 2020.
September 15, 2021
Washington, DC: Veterans Affairs Office of Inspector General; August 26, 2021. Report No. 21-01502-240.
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September 03, 2014 - Nighttime cross-coverage is associated with decreased
intensive care unit mortality. A single-center study.
September 3, 2014
Amaral ACK-B, Barros BS, Barros CCPP, et al. Nighttime cross-coverage is associated with decreased
intensive care unit mortality. A single-center study. Am J Respir Crit Care Med. 2014;189(1…
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April 25, 2016 - Addressing disease-related malnutrition in hospitalized
patients: a call for a national goal.
April 25, 2016
Guenter P, Jensen G, Patel V, et al. Addressing Disease-Related Malnutrition in Hospitalized Patients: A
Call for a National Goal. Jt Comm J Qual Patient Saf. 2015;41(10):469-473.
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November 06, 2019 - Comparing rates of adverse events and medical errors on
inpatient psychiatric units at Veterans Health
Administration and community-based general hospitals.
November 6, 2019
Cullen SW, Xie M, Vermeulen JM, et al. Comparing Rates of Adverse Events and Medical Errors on
Inpatient Psychiatric Units at Veterans Health…
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January 14, 2015 - Healthcare Inspection: Evaluation of the Veterans Health
Administration's National Consult Delay Review and
Associated Fact Sheet.
January 14, 2015
Daigh JD Jr. Washington, DC: VA Office of the Inspector General; December 15, 2014. Report No. 14-
04705-62.
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October 23, 2024 - Supporting perioperative safety during a disaster through
clinical crisis education.
October 23, 2024
Kirkman A, Tripp H, Ward L, et al. Supporting perioperative safety during a disaster through clinical crisis
education. AORN J. 2024;120(4):226-237. doi:10.1002/aorn.14217.
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May 31, 2017 - A quality improvement approach to standardization and
sustainability of the hand-off process.
May 31, 2017
Fryman C, Hamo C, Raghavan S, et al. A Quality Improvement Approach to Standardization and
Sustainability of the Hand-off Process. BMJ Qual Improv Rep. 2017;6(1).
doi:10.1136/bmjquality.u222156.w8291.
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September 20, 2023 - Pharmacy e-prescription dispensing before and after
CancelRx implementation.
September 20, 2023
Pitts SI, Olson S, Yanek LR, et al. Pharmacy e-prescription dispensing before and after CancelRx
implementation. JAMA Intern Med. 2023;183(10):1120-1126. doi:10.1001/jamainternmed.2023.4192.
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May 11, 2019 - Incorporation of quality and safety principles in
maintenance of certification: a qualitative analysis of
American Board of Medical Specialties member boards.
May 11, 2019
Davis JJ, Price DW, Kraft W, et al. Incorporation of Quality and Safety Principles in Maintenance of
Certification: A Qualitative Analysis of A…
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August 16, 2023 - American Geriatrics Society 2023 updated AGS Beers
Criteria for Potentially Inappropriate Medication Use in
Older Adults.
August 16, 2023
American Geriatrics Society Beers Criteria® Update Expert Panel. J Am Geriatr Soc. 2023;71(7):2052-
2081.
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May 21, 2013 - Improving Hand-Off Communication.
May 21, 2013
Oakbrook Terrace lL: Joint Commission Resources; 2007. ISBN 9781599400907.
https://psnet.ahrq.gov/issue/improving-hand-communication
The process of transferring primary responsibility for patient care is commonly referred to as a handoff.
Handoffs are inherently dange…
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psnet.ahrq.gov/node/47510/psn-pdf
June 30, 2019 - Rethinking high reliability in healthcare: the role of error
management theory towards advancing high reliability
organizing.
June 30, 2019
Guttman O, Keebler JR, Lazzara EH, et al. J Patient Saf Risk Manag. 2019;24:127–133.
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September 28, 2016 - Measurement of patient safety: a systematic review of the
reliability and validity of adverse event detection with
record review.
September 28, 2016
Hanskamp-Sebregts M, Zegers M, Vincent CA, et al. Measurement of patient safety: a systematic review of
the reliability and validity of adverse event detection with r…
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July 12, 2017 - Optimizing a Business Case for Safe Health Care: An
Integrated Approach to Safety and Finance.
July 12, 2017
Institute for Healthcare Improvement, National Patient Safety Foundation. Cambridge, MA: Institute for
Healthcare Improvement; 2017.
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