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Implementing a robust process improvement program in the neonatal intensive care unit to reduce harm. | PSNet

psnet.ahrq.gov/issue/implementing-robust-process-improvement-program-neonatal-intensive-care-unit-reduce-harm

March 23, 2022 - Study Implementing a robust process improvement program in the neonatal intensive care unit to reduce harm. Citation Text: Nether KG, Thomas EJ, Khan A, et al. Implementing a robust process improvement program in the neonatal intensive care unit to reduce harm. J Healthc Qual. 2022;44(1)…

Transforming the medication regimen review process using telemedicine to prevent adverse events. | PSNet

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November 11, 2015 - Study Transforming the medication regimen review process using telemedicine to prevent adverse events. Citation Text: Kane‐Gill SL, Wong A, Culley CM, et al. Transforming the medication regimen review process using telemedicine to prevent adverse events. J Am Geriatr Soc. 2020;69(2):530-…

A cluster randomized trial of two implementation strategies to deliver audit and feedback in the EQUIPPED medication safety program. | PSNet

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September 01, 2018 - Study A cluster randomized trial of two implementation strategies to deliver audit and feedback in the EQUIPPED medication safety program. Citation Text: Vaughan CP, Burningham Z, Kelleher JL, et al. A cluster‐randomized trial of two implementation strategies to deliver audit and feedbac…

Using Health Care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective risk analysis system. | PSNet

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January 17, 2012 - Study Classic Using Health Care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective risk analysis system. Citation Text: DeRosier JM, Stalhandske E, Bagian JP, et al. Using health care Failure Mode and Effect Analysis: the V…

Discrepancy between emergency department admission diagnosis and hospital discharge diagnosis and its impact on length of stay, up-triage to the intensive care unit, and mortality. | PSNet

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December 08, 2021 - Study Discrepancy between emergency department admission diagnosis and hospital discharge diagnosis and its impact on length of stay, up-triage to the intensive care unit, and mortality. Citation Text: Bastakoti M, Muhailan M, Nassar A, et al. Discrepancy between emergency department adm…

The new recommendations on duty hours from the ACGME Task Force. | PSNet

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July 14, 2021 - Commentary Classic The new recommendations on duty hours from the ACGME Task Force. Citation Text: Nasca TJ, Day SH, Amis S, et al. The new recommendations on duty hours from the ACGME Task Force. N Engl J Med. 2010;363(2):e3. doi:10.1056/NEJMsb1005800. Copy…

Failure to follow-up test results for ambulatory patients: a systematic review. | PSNet

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March 23, 2012 - Review Classic Failure to follow-up test results for ambulatory patients: a systematic review. Citation Text: Callen JL, Westbrook JI, Georgiou A, et al. Failure to Follow-Up Test Results for Ambulatory Patients: A Systematic Review. J Gen Intern Med. 2011;27(10…

Psychological impact and recovery after involvement in a patient safety incident: a repeated measures analysis. | PSNet

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September 19, 2016 - Study Psychological impact and recovery after involvement in a patient safety incident: a repeated measures analysis. Citation Text: Van Gerven E, Bruyneel L, Panella M, et al. Psychological impact and recovery after involvement in a patient safety incident: a repeated measures analysis.…

Outcomes associated with the nationwide introduction of rapid response systems in the Netherlands. | PSNet

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January 18, 2013 - Study Outcomes associated with the nationwide introduction of rapid response systems in the Netherlands. Citation Text: Ludikhuize J, Brunsveld-Reinders AH, Dijkgraaf MGW, et al. Outcomes Associated With the Nationwide Introduction of Rapid Response Systems in The Netherlands. Crit Care …

Entangled in complexity: an ethnographic study of organizational adaptability and safe care transitions for patients with complex care needs. | PSNet

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August 21, 2024 - Study Entangled in complexity: an ethnographic study of organizational adaptability and safe care transitions for patients with complex care needs. Citation Text: Hedqvist A‐T, Praetorius G, Ekstedt M, et al. Entangled in complexity: an ethnographic study of organizational adaptability a…

Patient safety in emergency departments: a problem for health care systems? An international survey. | PSNet

psnet.ahrq.gov/issue/patient-safety-emergency-departments-problem-health-care-systems-international-survey

February 26, 2020 - Study Patient safety in emergency departments: a problem for health care systems? An international survey. Citation Text: Petrino R, Tuunainen E, Bruzzone G, et al. Patient safety in emergency departments: a problem for health care systems? An international survey. Eur J Emerg Med. 2023;…

Prevalence, nature, severity and preventability of adverse drug events in mental health settings: findings from the MedicAtion relateD harm in mEntal health hospitals (MADE) study. | PSNet

psnet.ahrq.gov/issue/prevalence-nature-severity-and-preventability-adverse-drug-events-mental-health-settings

December 18, 2017 - Study Prevalence, nature, severity and preventability of adverse drug events in mental health settings: findings from the MedicAtion relateD harm in mEntal health hospitals (MADE) study. Citation Text: Alshehri GH, Ashcroft DM, Nguyen J, et al. Prevalence, nature, severity and preventabi…

Just what the doctor ordered: missed ordering of venous thromboembolism chemoprophylaxis is associated with increased VTE events in high-risk general surgery patients. | PSNet

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September 07, 2022 - Study Just what the doctor ordered: missed ordering of venous thromboembolism chemoprophylaxis is associated with increased VTE events in high-risk general surgery patients. Citation Text: Baimas-George MR, Ross SW, Yang H, et al. Just what the doctor ordered: missed ordering of venous t…

Integrating and evaluating the data quality and utility of smart pump information in detecting medication administration errors: evaluation study. | PSNet

psnet.ahrq.gov/issue/integrating-and-evaluating-data-quality-and-utility-smart-pump-information-detecting

September 09, 2020 - Study Integrating and evaluating the data quality and utility of smart pump information in detecting medication administration errors: evaluation study. Citation Text: Ni Y, Lingren T, Huth H, et al. Integrating and evaluating the data quality and utility of smart pump information in det…

Allocation of physician time in ambulatory practice: a time and motion study in four specialties. | PSNet

psnet.ahrq.gov/issue/allocation-physician-time-ambulatory-practice-time-and-motion-study-four-specialties

August 26, 2020 - Study Classic Allocation of physician time in ambulatory practice: a time and motion study in four specialties. Citation Text: Sinsky CA, Colligan L, Li L, et al. Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties. Ann …

Adverse events among emergency department patients with cardiovascular conditions: a multicenter study. | PSNet

psnet.ahrq.gov/issue/adverse-events-among-emergency-department-patients-cardiovascular-conditions-multicenter

December 01, 2021 - Study Adverse events among emergency department patients with cardiovascular conditions: a multicenter study. Citation Text: Calder LA, Perry J, Yan JW, et al. Adverse events among emergency department patients with cardiovascular conditions: a multicenter study. Ann Emerg Med. 2021;77(6…

A systems approach to morbidity and mortality conference. | PSNet

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July 22, 2020 - Study Classic A systems approach to morbidity and mortality conference. Citation Text: Szostek JH, Wieland ML, Loertscher LL, et al. A systems approach to morbidity and mortality conference. Am J Med. 2010;123(7):663-668. doi:10.1016/j.amjmed.2010.03.010. Co…

Organizational, cultural, and psychological determinants of smart infusion pump work arounds: a study of 3 U.S. health systems. | PSNet

psnet.ahrq.gov/issue/organizational-cultural-and-psychological-determinants-smart-infusion-pump-work-arounds-study

May 18, 2022 - Study Organizational, cultural, and psychological determinants of smart infusion pump work arounds: a study of 3 U.S. health systems. Citation Text: Dunford BB, Perrigino M, Tucker SJ, et al. Organizational, Cultural, and Psychological Determinants of Smart Infusion Pump Work Arounds: A …

Exploring new avenues to assess the sharp end of patient safety: an analysis of nationally aggregated peer review data. | PSNet

psnet.ahrq.gov/issue/exploring-new-avenues-assess-sharp-end-patient-safety-analysis-nationally-aggregated-peer

December 21, 2014 - Study Exploring new avenues to assess the sharp end of patient safety: an analysis of nationally aggregated peer review data. Citation Text: Meeks DW, Meyer AND, Rose B, et al. Exploring new avenues to assess the sharp end of patient safety: an analysis of nationally aggregated peer revi…

Patient safety implications of wearing a face mask for prevention in the era of COVID-19 pandemic: a systematic review and consensus recommendations. | PSNet

psnet.ahrq.gov/issue/patient-safety-implications-wearing-face-mask-prevention-era-covid-19-pandemic-systematic

September 16, 2020 - Review Patient safety implications of wearing a face mask for prevention in the era of COVID-19 pandemic: a systematic review and consensus recommendations. Citation Text: Balestracci B, La Regina M, Di Sessa D, et al. Patient safety implications of wearing a face mask for prevention in …

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