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psnet.ahrq.gov/issue/harms-discharge-primary-care-mixed-methods-analysis-incident-reports
October 12, 2016 - Study
Harms from discharge to primary care: mixed methods analysis of incident reports.
Citation Text:
Williams H, Edwards A, Hibbert P, et al. Harms from discharge to primary care: mixed methods analysis of incident reports. Br J Gen Pract. 2015;65(641):e829-e837. doi:10.3399/bjgp15X687…
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psnet.ahrq.gov/issue/potentially-harmful-medication-dispenses-after-fall-or-hip-fracture-mixed-methods-study
May 05, 2021 - Study
Potentially harmful medication dispenses after a fall or hip fracture: a mixed methods study of a commonly used quality measure.
Citation Text:
Fischer H, Hahn EE, Li BH, et al. Potentially harmful medication dispenses after a fall or hip fracture: a mixed methods study of a common…
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psnet.ahrq.gov/issue/co-design-implementation-and-evaluation-serious-board-game-playdecide-patient-safety-educate
September 12, 2018 - Journal Article
The co-design, implementation and evaluation of a serious board game 'PlayDecide patient safety' to educate junior doctors about patient safety and the importance of reporting safety concerns
Citation Text:
Ward M, Shé ÉN, De Brún A, et al. The co-design, implementation a…
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psnet.ahrq.gov/issue/implementation-discharge-education-program-improve-transitions-care-patients-high-risk
January 12, 2022 - Study
Implementation of a discharge education program to improve transitions of care for patients at high risk of medication errors.
Citation Text:
Crannage AJ, Hennessey EK, Challen LM, et al. . Implementation of a discharge education program to improve transitions of care for patients …
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psnet.ahrq.gov/issue/longitudinal-study-manifestations-and-mechanisms-technology-related-prescribing-errors
January 18, 2023 - Study
Longitudinal study of the manifestations and mechanisms of technology-related prescribing errors in pediatrics.
Citation Text:
Raban MZ, Fitzpatrick E, Merchant A, et al. Longitudinal study of the manifestations and mechanisms of technology-related prescribing errors in pediatrics.…
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psnet.ahrq.gov/issue/exploring-black-box-recommendation-generation-local-health-care-incident-investigations
November 16, 2016 - Review
Exploring the "Black Box" of recommendation generation in local health care incident investigations: a scoping review.
Citation Text:
Lea W, Lawton R, Vincent CA, et al. Exploring the "Black Box" of recommendation generation in local health care incident investigations: a scoping …
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psnet.ahrq.gov/issue/developing-learning-health-system-insights-qualitative-process-evaluation-pharmacist-led
February 17, 2021 - Study
Developing a learning health system: insights from a qualitative process evaluation of a pharmacist-led electronic audit and feedback intervention to improve medication safety in primary care.
Citation Text:
Jeffries M, Keers RN, Phipps D, et al. Developing a learning health system…
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psnet.ahrq.gov/issue/discontinuation-outpatient-medications-implications-electronic-messaging-pharmacies-using
October 05, 2022 - Study
Discontinuation of outpatient medications: implications for electronic messaging to pharmacies using CancelRx.
Citation Text:
Pitts S, Yang Y, Thomas BA, et al. Discontinuation of outpatient medications: implications for electronic messaging to pharmacies using CancelRx. J Am Med I…
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psnet.ahrq.gov/issue/medication-discrepancies-upon-hospital-skilled-nursing-facility-transitions
July 20, 2011 - Study
Medication discrepancies upon hospital to skilled nursing facility transitions.
Citation Text:
Tjia J, Bonner A, Briesacher BA, et al. Medication discrepancies upon hospital to skilled nursing facility transitions. J Gen Intern Med. 2009;24(5):630-5. doi:10.1007/s11606-009-0948-2…
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psnet.ahrq.gov/issue/transitioning-between-electronic-health-records-effects-ambulatory-prescribing-safety
June 03, 2013 - Study
Transitioning between electronic health records: effects on ambulatory prescribing safety.
Citation Text:
Abramson EL, Malhotra S, Fischer K, et al. Transitioning between electronic health records: effects on ambulatory prescribing safety. J Gen Intern Med. 2011;26(8):868-74. doi:1…
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psnet.ahrq.gov/issue/electronic-health-record-related-events-medical-malpractice-claims
April 03, 2018 - Study
Classic
Electronic health record–related events in medical malpractice claims.
Citation Text:
Graber ML, Siegal D, Riah H, et al. Electronic Health Record-Related Events in Medical Malpractice Claims. J Patient Saf. 2019;15(2):77-85. doi:10.1097/PTS.000000…
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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.
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psnet.ahrq.gov/issue/prospective-evaluation-medication-related-clinical-decision-support-over-rides-intensive-care
April 07, 2019 - Study
Emerging Classic
Prospective evaluation of medication-related clinical decision support over-rides in the intensive care unit.
Citation Text:
Wong A, Amato MG, Seger DL, et al. Prospective evaluation of medication-related clinical decision support over-rid…
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psnet.ahrq.gov/issue/surgery-itself-risk-factor-patient
November 18, 2020 - Study
Surgery is in itself a risk factor for the patient.
Citation Text:
Aranaz-Ostáriz V, Gea-Velázquez De Castro MT, López-Rodríguez-Arias F, et al. Surgery is in itself a risk factor for the patient. Int J Environ Res Public Health. 2022;19(8):4761. doi:10.3390/ijerph19084761.
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psnet.ahrq.gov/issue/association-between-handover-anesthesiology-care-and-1-year-mortality-among-adults-undergoing
June 08, 2022 - Study
Association between handover of anesthesiology care and 1-year mortality among adults undergoing cardiac surgery.
Citation Text:
Sun LY, Jones PM, Wijeysundera DN, et al. Association between handover of anesthesiology care and 1-year mortality among adults undergoing cardiac surger…
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psnet.ahrq.gov/issue/incidence-and-variables-associated-inconsistencies-opioid-prescribing-hospital-discharge-and
April 29, 2018 - Study
Incidence and variables associated with inconsistencies in opioid prescribing at hospital discharge and its associated adverse drug outcomes.
Citation Text:
Kurteva S, Habib B, Moraga T, et al. Incidence and variables associated with inconsistencies in opioid prescribing at hospita…
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psnet.ahrq.gov/issue/simulation-based-event-analysis-improves-error-discovery-and-generates-improved-strategies
July 07, 2021 - Study
Simulation-based event analysis improves error discovery and generates improved strategies for error prevention.
Citation Text:
Lobos A-T, Ward N, Farion KJ, et al. Simulation-based event analysis improves error discovery and generates improved strategies for error prevention. Simu…
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psnet.ahrq.gov/issue/higher-incidence-adverse-events-isolated-patients-compared-non-isolated-patients-cohort-study
June 01, 2022 - Study
Higher incidence of adverse events in isolated patients compared with non-isolated patients: a cohort study.
Citation Text:
Jiménez-Pericás F, Gea Velázquez de Castro MT, Pastor-Valero M, et al. Higher incidence of adverse events in isolated patients compared with non-isolated pati…
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psnet.ahrq.gov/issue/improving-patient-family-and-clinician-experience-after-harmful-events-when-things-go-wrong
July 01, 2020 - Study
Improving the patient, family, and clinician experience after harmful events: the "When Things Go Wrong" curriculum.
Citation Text:
Bell SK, Moorman D, Delbanco T. Improving the patient, family, and clinician experience after harmful events: the "when things go wrong" curriculum. A…
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psnet.ahrq.gov/issue/family-conferences-facilitate-deprescribing-older-outpatients-frailty-and-polypharmacy
July 29, 2020 - Study
Family conferences to facilitate deprescribing in older outpatients with frailty and with polypharmacy: the COFRAIL cluster randomized trial.
Citation Text:
Mortsiefer A, Löscher S, Pashutina Y, et al. Family conferences to facilitate deprescribing in older outpatients with frailty…