-
psnet.ahrq.gov/issue/how-prevent-or-reduce-prescribing-errors-evidence-brief-policy-authors
July 27, 2022 - Review
How to prevent or reduce prescribing errors: an evidence brief for policy authors.
Citation Text:
de Araújo BC, de Melo RC, de Bortoli MC, et al. How to prevent or reduce prescribing errors: an evidence brief for policy authors. Front Pharmacol. 2019;10:439. doi:10.3389/fphar.2019…
-
psnet.ahrq.gov/issue/designing-and-evaluating-automated-system-real-time-medication-administration-error-detection
November 04, 2020 - Study
Designing and evaluating an automated system for real-time medication administration error detection in a neonatal intensive care unit.
Citation Text:
Ni Y, Lingren T, Hall ES, et al. Designing and evaluating an automated system for real-time medication administration error detecti…
-
psnet.ahrq.gov/issue/reductions-sepsis-mortality-and-costs-after-design-and-implementation-nurse-based-early
March 09, 2016 - Study
Reductions in sepsis mortality and costs after design and implementation of a nurse-based early recognition and response program.
Citation Text:
Jones SL, Ashton CM, Kiehne L, et al. Reductions in sepsis mortality and costs after design and implementation of a nurse-based early rec…
-
psnet.ahrq.gov/issue/exploring-pharmacist-experiences-delivering-individualised-prescribing-error-feedback-acute
May 30, 2016 - Study
Exploring pharmacist experiences of delivering individualised prescribing error feedback in an acute hospital setting.
Citation Text:
Lloyd M, Watmough SD, O'Brien S, et al. Exploring pharmacist experiences of delivering individualised prescribing error feedback in an acute hospita…
-
www.ahrq.gov/news/newsroom/case-studies/202101.html
June 01, 2021 - Duke’s Private Diagnostic Clinic Used TeamSTEPPS to Improve Teamwork and Communications
Search All Impact Case Studies
June 2021
Eighty to 90 percent of medical center leaders at Private Diagnostic Clinic (PDC), a multispecialty physician practice affiliated with Duke Health, reported fewer communications b…
-
psnet.ahrq.gov/issue/patient-safety-leadership-walkroundstm-partners-healthcare-learning-implementation
January 04, 2017 - Study
Patient Safety Leadership WalkRounds™ at Partners HealthCare: learning from implementation.
Citation Text:
Frankel A, Grillo SP, Baker EG, et al. Patient Safety Leadership WalkRounds at Partners Healthcare: learning from implementation. Jt Comm J Qual Patient Saf. 2005;31(8):423-37…
-
psnet.ahrq.gov/issue/it-depends-complexity-allowing-residents-fail-perspective-clinical-supervisors
December 14, 2022 - Study
'It depends': The complexity of allowing residents to fail from the perspective of clinical supervisors.
Citation Text:
Klasen JM, Teunissen PW, Driessen EW, et al. ‘It depends’: the complexity of allowing residents to fail from the perspective of clinical supervisors. Med Teach. 2…
-
psnet.ahrq.gov/issue/medicines-related-problems-mrps-originating-primary-care-settings-older-adults-systematic
March 04, 2015 - Review
Medicines related problems (MRPs) originating in primary care settings in older adults - a systematic review.
Citation Text:
Ude-Okeleke RC, Aslanpour Z, Dhillon S, et al. Medicines related problems (MRPs) originating in primary care settings in older adults - a systematic review.…
-
psnet.ahrq.gov/issue/safety-warfarin-therapy-nursing-home-setting
March 11, 2011 - Study
The safety of warfarin therapy in the nursing home setting.
Citation Text:
Gurwitz JH, Field T, Radford MJ, et al. The safety of warfarin therapy in the nursing home setting. Am J Med. 2007;120(6):539-44.
Copy Citation
Format:
Google Scholar PubMed BibTeX EndNote X3…
-
psnet.ahrq.gov/issue/what-do-patients-and-families-observe-about-pediatric-safety-thematic-analysis-real-time
March 02, 2022 - Study
What do patients and families observe about pediatric safety?: A thematic analysis of real-time narratives.
Citation Text:
Studenmund C, Lyndon A, Stotts JR, et al. What do patients and families observe about pediatric safety?: A thematic analysis of real‐time narratives. J Hosp Me…
-
psnet.ahrq.gov/issue/recognition-adverse-drug-events-older-hospitalized-medical-patients
August 10, 2022 - Study
Recognition of adverse drug events in older hospitalized medical patients.
Citation Text:
Klopotowska JE, Wierenga PC, Smorenburg SM, et al. Recognition of adverse drug events in older hospitalized medical patients. Eur J Clin Pharmacol. 2013;69(1):75-85. doi:10.1007/s00228-012-1…
-
psnet.ahrq.gov/issue/inequities-inpatient-pediatric-patient-safety-events-category
April 01, 2009 - Study
Inequities in inpatient pediatric patient safety events by category.
Citation Text:
Pantell MS, Karvonen KL, Porter P, et al. Inequities in inpatient pediatric patient safety events by category. Hosp Pediatr. 2024;14(12):953-962. doi:10.1542/hpeds.2023-007129.
Copy Citation
F…
-
psnet.ahrq.gov/issue/relationship-between-culture-safety-and-rate-adverse-events-long-term-care-facilities
June 09, 2021 - Study
The relationship between culture of safety and rate of adverse events in long-term care facilities.
Citation Text:
Abusalem S, Polivka B, Coty M-B, et al. The Relationship Between Culture of Safety and Rate of Adverse Events in Long-Term Care Facilities. J Patient Saf. 2021;17(4):2…
-
psnet.ahrq.gov/issue/receipt-antibiotics-hospitalized-patients-and-risk-clostridium-difficile-infection-subsequent
September 29, 2017 - Study
Receipt of antibiotics in hospitalized patients and risk for Clostridium difficile infection in subsequent patients who occupy the same bed.
Citation Text:
Freedberg DE, Salmasian H, Cohen B, et al. Receipt of Antibiotics in Hospitalized Patients and Risk for Clostridium difficile …
-
psnet.ahrq.gov/issue/patterns-error-interpretive-pathology
April 07, 2021 - Study
Patterns of error in interpretive pathology.
Citation Text:
Packer MDC, Ravinsky E, Azordegan N. Patterns of error in interpretive pathology. Am J Clin Pathol. 2022;157(5):767-773. doi:10.1093/ajcp/aqab190.
Copy Citation
Format:
DOI Google Scholar BibTeX EndNote X3 XM…
-
psnet.ahrq.gov/issue/flying-lessons-clinicians-developing-system-2-practice
April 24, 2018 - Commentary
Flying lessons for clinicians: developing system 2 practice.
Citation Text:
Gregoire JN, Alfes CM, Reimer AP, et al. Flying Lessons for Clinicians: Developing System 2 Practice. Air Med J. 2017;36(3):135-137. doi:10.1016/j.amj.2017.02.003.
Copy Citation
Format:
D…
-
psnet.ahrq.gov/issue/closing-loop-follow-and-feedback-patient-safety-program
January 04, 2017 - Study
Closing the loop: follow-up and feedback in a patient safety program.
Citation Text:
Gandhi TK, Graydon-Baker E, Huber CN, et al. Closing the loop: follow-up and feedback in a patient safety program. Jt Comm J Qual Patient Saf. 2005;31(11):614-21.
Copy Citation
Format:
…
-
psnet.ahrq.gov/issue/how-well-quality-improvement-described-perioperative-care-literature-systematic-review
January 19, 2022 - Review
How well is quality improvement described in the perioperative care literature? A systematic review.
Citation Text:
Jones EL, Lees N, Martin G, et al. How Well Is Quality Improvement Described in the Perioperative Care Literature? A Systematic Review. Jt Comm J Qual Patient Saf. 2…
-
psnet.ahrq.gov/issue/diagnostic-error-emergency-department-learning-national-patient-safety-incident-report
January 12, 2022 - Study
Diagnostic error in the emergency department: learning from national patient safety incident report analysis.
Citation Text:
Hussain F, Cooper A, Carson-Stevens A, et al. Diagnostic error in the emergency department: learning from national patient safety incident report analysis. B…
-
psnet.ahrq.gov/issue/understanding-diagnostic-safety-emergency-medicine-case-case-review-closed-ed-malpractice
May 11, 2019 - Study
Understanding diagnostic safety in emergency medicine: a case‐by‐case review of closed ED malpractice claims.
Citation Text:
Lemoine N, Dajer A, Konwinski J, et al. Understanding diagnostic safety in emergency medicine: A case-by-case review of closed ED malpractice claims. J Healt…