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  1. Pilot Testing Fall TIPS (Tailoring Interventions for Patient Safety): a patient-centered fall prevention toolkit. | PSNet

    psnet.ahrq.gov/issue/pilot-testing-fall-tips-tailoring-interventions-patient-safety-patient-centered-fall
    March 27, 2019 - Study Pilot Testing Fall TIPS (Tailoring Interventions for Patient Safety): a patient-centered fall prevention toolkit. Citation Text: Dykes PC, Duckworth M, Cunningham S, et al. Pilot Testing Fall TIPS (Tailoring Interventions for Patient Safety): a Patient-Centered Fall Prevention Tool…

  2. The impact of nontechnical skills on technical performance in surgery: a systematic review. | PSNet

    psnet.ahrq.gov/issue/impact-nontechnical-skills-technical-performance-surgery-systematic-review
    February 10, 2010 - Review The impact of nontechnical skills on technical performance in surgery: a systematic review. Citation Text: Hull L, Arora S, Aggarwal R, et al. The impact of nontechnical skills on technical performance in surgery: a systematic review. J Am Coll Surg. 2012;214(2):214-230. doi:10.…

  3. Wrong-site surgery, retained surgical items, and surgical fires: a systematic review of surgical never events. | PSNet

    psnet.ahrq.gov/issue/wrong-site-surgery-retained-surgical-items-and-surgical-fires-systematic-review-surgical
    March 13, 2013 - Review Wrong-site surgery, retained surgical items, and surgical fires: a systematic review of surgical never events. Citation Text: Hempel S, Maggard-Gibbons M, Nguyen DK, et al. Wrong-Site Surgery, Retained Surgical Items, and Surgical Fires : A Systematic Review of Surgical Never Even…

  4. Information transfer and communication in surgery: a systematic review. | PSNet

    psnet.ahrq.gov/issue/information-transfer-and-communication-surgery-systematic-review
    September 26, 2012 - Review Information transfer and communication in surgery: a systematic review. Citation Text: Nagpal K, Vats A, Lamb B, et al. Information transfer and communication in surgery: a systematic review. Ann Surg. 2010;252(2):225-39. doi:10.1097/SLA.0b013e3181e495c2. Copy Citation For…

  5. Development of a theoretical framework of factors affecting patient safety incident reporting: a theoretical review of the literature. | PSNet

    psnet.ahrq.gov/issue/development-theoretical-framework-factors-affecting-patient-safety-incident-reporting
    January 19, 2016 - Review Development of a theoretical framework of factors affecting patient safety incident reporting: a theoretical review of the literature. Citation Text: Archer S, Hull L, Soukup T, et al. Development of a theoretical framework of factors affecting patient safety incident reporting: a…

  6. The impact of medical errors on ninety-day costs and outcomes: an examination of surgical patients. | PSNet

    psnet.ahrq.gov/issue/impact-medical-errors-ninety-day-costs-and-outcomes-examination-surgical-patients
    August 03, 2017 - Study The impact of medical errors on ninety-day costs and outcomes: an examination of surgical patients. Citation Text: Encinosa W, Hellinger FJ. The impact of medical errors on ninety-day costs and outcomes: an examination of surgical patients. Health Serv Res. 2008;43(6):2067-85. do…

  7. Associations between hospitalist shift busyness, diagnostic confidence, and resource utilization: a pilot study. | PSNet

    psnet.ahrq.gov/issue/associations-between-hospitalist-shift-busyness-diagnostic-confidence-and-resource
    September 16, 2020 - Study Associations between hospitalist shift busyness, diagnostic confidence, and resource utilization: a pilot study. Citation Text: Gupta AB, Greene MT, Fowler KE, et al. Associations between hospitalist shift busyness, diagnostic confidence, and resource utilization: a pilot study. J …

  8. Radiologist errors by modality, anatomic region, and pathology for 1.6 million exams: what we have learned. | PSNet

    psnet.ahrq.gov/issue/radiologist-errors-modality-anatomic-region-and-pathology-16-million-exams-what-we-have
    October 18, 2023 - Study Radiologist errors by modality, anatomic region, and pathology for 1.6 million exams: what we have learned. Citation Text: Lamoureux C, Hanna TN, Sprecher D, et al. Radiologist errors by modality, anatomic region, and pathology for 1.6 million exams: what we have learned. Emerg Rad…

  9. More than algorithms: an analysis of safety events involving ML-enabled medical devices reported to the FDA. | PSNet

    psnet.ahrq.gov/issue/more-algorithms-analysis-safety-events-involving-ml-enabled-medical-devices-reported-fda
    May 01, 2019 - Study More than algorithms: an analysis of safety events involving ML-enabled medical devices reported to the FDA. Citation Text: Lyell D, Wang Y, Coiera E, et al. More than algorithms: an analysis of safety events involving ML-enabled medical devices reported to the FDA. J Am Med Inform…

  10. Detecting medication order discrepancies in nursing homes: how RNs and LPNs differ. | PSNet

    psnet.ahrq.gov/issue/detecting-medication-order-discrepancies-nursing-homes-how-rns-and-lpns-differ
    August 15, 2013 - Study Detecting medication order discrepancies in nursing homes: how RNs and LPNs differ. Citation Text: Vogelsmeier A, Anbari A, Ganong L, et al. Detecting medication order discrepancies in nursing homes: how RNs and LPNs differ. J Nurs Reg. 2015;6(3):48-56. doi:10.1016/s2155-8256(15)30…

  11. Adverse diagnostic events in hospitalised patients: a single-centre, retrospective cohort study. | PSNet

    psnet.ahrq.gov/issue/adverse-diagnostic-events-hospitalised-patients-single-centre-retrospective-cohort-study
    December 07, 2022 - Study Adverse diagnostic events in hospitalised patients: a single-centre, retrospective cohort study. Citation Text: Dalal AK, Plombon S, Konieczny K, et al. Adverse diagnostic events in hospitalised patients: a single-centre, retrospective cohort study. BMJ Qual Saf. 2024;Epub Oct 1. d…

  12. Interunit handoffs from emergency department to inpatient care: a cross-sectional survey of physicians at a university medical center. | PSNet

    psnet.ahrq.gov/issue/interunit-handoffs-emergency-department-inpatient-care-cross-sectional-survey-physicians
    September 23, 2020 - Study Interunit handoffs from emergency department to inpatient care: a cross-sectional survey of physicians at a university medical center. Citation Text: Smith CJ, Britigan DH, Lyden E, et al. Interunit handoffs from emergency department to inpatient care: A cross-sectional survey of p…

  13. Medication reconciliation and patient safety in trauma: Applicability of existing strategies. | PSNet

    psnet.ahrq.gov/issue/medication-reconciliation-and-patient-safety-trauma-applicability-existing-strategies
    September 23, 2020 - Review Medication reconciliation and patient safety in trauma: Applicability of existing strategies. Citation Text: DeAntonio JH, Leichtle SW, Hobgood S, et al. Medication reconciliation and patient safety in trauma: Applicability of existing strategies. J Surg Res. 2019;246:482-489. doi…

  14. Contributory factors and patient harm including deaths associated direct acting oral anticoagulants (DOACs) medication incidents: evaluation of real world data reported to the national reporting and learning system. | PSNet

    psnet.ahrq.gov/issue/contributory-factors-and-patient-harm-including-deaths-associated-direct-acting-oral
    January 12, 2022 - Study Contributory factors and patient harm including deaths associated direct acting oral anticoagulants (DOACs) medication incidents: evaluation of real world data reported to the national reporting and learning system. Citation Text: Rowily AA, Jalal Z, Paudyal V. Contributory factors…

  15. Adverse events in emergency department boarding: a systematic review. | PSNet

    psnet.ahrq.gov/issue/adverse-events-emergency-department-boarding-systematic-review
    March 02, 2022 - Review Adverse events in emergency department boarding: a systematic review. Citation Text: Rocha HM, Farre AGM, Santana Filho VJ. Adverse events in emergency department boarding: a systematic review. J Nurs Scholarsh. 2021;53(4):458-467. doi:10.1111/jnu.12653. Copy Citation Format…

  16. Explanation and elaboration of the SQUIRE (Standards for Quality Improvement Reporting Excellence) Guidelines, V.2.0: examples of SQUIRE elements in the healthcare improvement literature. | PSNet

    psnet.ahrq.gov/issue/explanation-and-elaboration-squire-standards-quality-improvement-reporting-excellence
    November 18, 2016 - Commentary Explanation and elaboration of the SQUIRE (Standards for Quality Improvement Reporting Excellence) Guidelines, V.2.0: examples of SQUIRE elements in the healthcare improvement literature. Citation Text: Goodman D, Ogrinc G, Davies L, et al. Explanation and elaboration of the S…

  17. Transitions of Care Consensus Policy Statement American College of Physicians-Society of General Internal Medicine-Society of Hospital Medicine-American Geriatrics Society-American College of Emergency Physicians-Society of Academic Emergency Medicine. | PSNet

    psnet.ahrq.gov/issue/transitions-care-consensus-policy-statement-american-college-physicians-society-general
    July 27, 2022 - Commentary Transitions of Care Consensus Policy Statement American College of Physicians-Society of General Internal Medicine-Society of Hospital Medicine-American Geriatrics Society-American College of Emergency Physicians-Society of Academic Emergency Medicine. Citation Text: Snow V,…

  18. Improving medication error reporting in hospice care. | PSNet

    psnet.ahrq.gov/issue/improving-medication-error-reporting-hospice-care
    June 22, 2022 - Study Improving medication error reporting in hospice care. Citation Text: Boyer R, McPherson ML, Deshpande G, et al. Improving medication error reporting in hospice care. Am J Hosp Palliat Care. 2009;26(5):361-7. doi:10.1177/1049909109335145. Copy Citation Format: DOI Go…

  19. System issues leading to "found-on-floor" incidents: a multi-incident analysis. | PSNet

    psnet.ahrq.gov/issue/system-issues-leading-found-floor-incidents-multi-incident-analysis
    August 04, 2021 - Study System issues leading to "found-on-floor" incidents: a multi-incident analysis. Citation Text: Shaw J, Bastawrous M, Burns S, et al. System Issues Leading to “Found-on-Floor” Incidents: A Multi-Incident Analysis. J Patient Saf. 2021;17(1):30-35. doi:10.1097/pts.0000000000000294. …

  20. The World Federation of Chiropractic Global Patient Safety Task Force: a call to action. | PSNet

    psnet.ahrq.gov/issue/world-federation-chiropractic-global-patient-safety-task-force-call-action
    December 23, 2020 - Review The World Federation of Chiropractic Global Patient Safety Task Force: a call to action. Citation Text: Coleman BC, Rubinstein SM, Salsbury SA, et al. The World Federation of Chiropractic Global Patient Safety Task Force: a call to action. Chiropr Man Therap. 2024;32(1):15. doi:10…
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