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9361. Weekend mortality for emergency admissions. A large, multicentre study. | PSNet
      psnet.ahrq.gov/issue/weekend-mortality-emergency-admissions-large-multicentre-study
      October 20, 2021 - Study Classic Weekend mortality for emergency admissions. A large, multicentre study. Citation Text: Aylin PP, Yunus A, Bottle A, et al. Weekend mortality for emergency admissions. A large, multicentre study. Qual Saf Health Care. 2010;19(3):213-7. doi:10.1136…

9362. Screening for medication errors using an outlier detection system. | PSNet
      psnet.ahrq.gov/issue/screening-medication-errors-using-outlier-detection-system
      December 18, 2019 - Study Screening for medication errors using an outlier detection system. Citation Text: Schiff G, Volk LA, Volodarskaya M, et al. Screening for medication errors using an outlier detection system. J Am Med Inform Assoc. 2017;24(2):281-287. doi:10.1093/jamia/ocw171. Copy Citation Fo…

9363. Effect of contextual factors on the prevalence of diagnostic errors among patients managed by physicians of the same specialty: a single-centre retrospective observational study. | PSNet
      psnet.ahrq.gov/issue/effect-contextual-factors-prevalence-diagnostic-errors-among-patients-managed-physicians-same
      February 02, 2022 - Study Effect of contextual factors on the prevalence of diagnostic errors among patients managed by physicians of the same specialty: a single-centre retrospective observational study. Citation Text: Harada Y, Otaka Y, Katsukura S, et al. Effect of contextual factors on the prevalence of…

9364. Association of sleep and fatigue with decision regret among critical care nurses. | PSNet
      psnet.ahrq.gov/issue/association-sleep-and-fatigue-decision-regret-among-critical-care-nurses
      July 14, 2021 - Study Association of sleep and fatigue with decision regret among critical care nurses. Citation Text: Scott LD, Arslanian-Engoren C, Engoren MC. Association of sleep and fatigue with decision regret among critical care nurses. Am J Crit Care. 2014;23(1):13-23. doi:10.4037/ajcc2014191. …

9365. Can first-year medical students acquire quality improvement knowledge prior to substantial clinical exposure? A mixed-methods evaluation of a pre-clerkship curriculum that uses education as the context for learning. | PSNet
      psnet.ahrq.gov/issue/can-first-year-medical-students-acquire-quality-improvement-knowledge-prior-substantial
      April 24, 2019 - Study Can first-year medical students acquire quality improvement knowledge prior to substantial clinical exposure? A mixed-methods evaluation of a pre-clerkship curriculum that uses education as the context for learning. Citation Text: Brown A, Nidumolu A, Stanhope A, et al. Can first-y…

9366. Use of prescribing safety quality improvement reports in UK general practices: a qualitative assessment. | PSNet
      psnet.ahrq.gov/issue/use-prescribing-safety-quality-improvement-reports-uk-general-practices-qualitative
      December 08, 2021 - Study Use of prescribing safety quality improvement reports in UK general practices: a qualitative assessment. Citation Text: Khan NF, Booth HP, Myles P, et al. Use of prescribing safety quality improvement reports in UK general practices: a qualitative assessment. BMC Health Serv Res. 2…

9367. Development and preliminary testing of the Coordination Process Error Reporting Tool (CPERT), a prospective clinical surveillance mechanism for teamwork errors in the pediatric cardiac ICU. | PSNet
      psnet.ahrq.gov/issue/development-and-preliminary-testing-coordination-process-error-reporting-tool-cpert
      May 25, 2016 - Study Development and preliminary testing of the Coordination Process Error Reporting Tool (CPERT), a prospective clinical surveillance mechanism for teamwork errors in the pediatric cardiac ICU. Citation Text: Bates KE, Shea JA, Bird GL, et al. Development and Preliminary Testing of the…

9368. Routine failures in the process for blood testing and the communication of results to patients in primary care in the UK: a qualitative exploration of patient and provider perspectives. | PSNet
      psnet.ahrq.gov/issue/routine-failures-process-blood-testing-and-communication-results-patients-primary-care-uk
      November 20, 2015 - Study Routine failures in the process for blood testing and the communication of results to patients in primary care in the UK: a qualitative exploration of patient and provider perspectives. Citation Text: Litchfield I, Bentham L, Hill A, et al. Routine failures in the process for bloo…

9369. AHRQ Evidence Reviews: Catalysts for Practice Change | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/blog/ahrqviews/epc-program-evidence-reviews.html
      January 01, 2022 - AHRQ Views: Blog posts from AHRQ leaders AHRQ Evidence Reviews: Catalysts for Practice Change JAN 19 2022 By Lionel Bañez, M.D., and David Meyers, M.D. Lionel Bañez, M.D. Medical research keeps advancing while clinicians are busy taking care of patients. It is a const…

9370. Experience with a trigger tool for identifying adverse drug events among older adults in ambulatory primary care. | PSNet
      psnet.ahrq.gov/issue/experience-trigger-tool-identifying-adverse-drug-events-among-older-adults-ambulatory-primary
      June 07, 2023 - Study Experience with a trigger tool for identifying adverse drug events among older adults in ambulatory primary care. Citation Text: Singh R, McLean-Plunckett EA, Kee R, et al. Experience with a trigger tool for identifying adverse drug events among older adults in ambulatory primary …

9371. Self-reported patient safety competence among Canadian medical students and postgraduate trainees: a cross-sectional survey. | PSNet
      psnet.ahrq.gov/issue/self-reported-patient-safety-competence-among-canadian-medical-students-and-postgraduate
      December 04, 2015 - Study Self-reported patient safety competence among Canadian medical students and postgraduate trainees: a cross-sectional survey. Citation Text: Doyle P, VanDenKerkhof E, Edge DS, et al. Self-reported patient safety competence among Canadian medical students and postgraduate trainees: a…

9372. Two fatal cases of accidental intrathecal vincristine administration: learning from death events. | PSNet
      psnet.ahrq.gov/issue/two-fatal-cases-accidental-intrathecal-vincristine-administration-learning-death-events
      March 24, 2021 - Commentary Two fatal cases of accidental intrathecal vincristine administration: learning from death events. Citation Text: Chotsampancharoen T, Sripornsawan P, Wongchanchailert M. Two fatal cases of accidental intrathecal vincristine administration: learning from death event. Chemothera…

9373. Prologue: The Shift toward Performance and Tools (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Prologue_Keyes_Vol3.pdf
      June 02, 2025 - Prologue: The Shift toward Performance and Tools Prologue The Shift toward Performance and Tools Margaret A. Keyes, M.A. The articles in this volume provide a number of perspectives on performance and tools used to improve the safe delivery of health care. They include a wide variety of approaches that …

9374. Improving the approach to defining, classifying, reporting and monitoring adverse events in seriously ill older adults: recommendations from a multi-stakeholder convening. | PSNet
      psnet.ahrq.gov/issue/improving-approach-defining-classifying-reporting-and-monitoring-adverse-events-seriously-ill
      July 29, 2020 - Commentary Improving the approach to defining, classifying, reporting and monitoring adverse events in seriously ill older adults: recommendations from a multi-stakeholder convening. Citation Text: Baim-Lance A, Ferreira KB, Cohen HJ, et al. Improving the approach to defining, classifyin…

9375. UChicago Medicine Reduces Perioperative Venous Thromboembolism with AHRQ's Toolkit | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/about/uni-chicago-medicine.html
      February 01, 2024 - UChicago Medicine Reduces Perioperative Venous Thromboembolism with AHRQ's Toolkit UChicago Medicine (UCM) reduced venous thromboembolism (VTE) incidence by 30% in the perioperative patient population with the use of AHRQ’s Preventing Hospital-Associated Venous Thromboembolism Toolkit . Using the toolkit’s Fra…

9376. About the eCare Plan for Multiple Chronic Conditions | Agency for Healthcare Research and Quality
      www.ahrq.gov/ecareplan/about/index.html
      August 01, 2024 - About the eCare Plan for Multiple Chronic Conditions The eCare Plan project aims to build care planning tools that will improve how we do research and provide healthcare for people with multiple chronic conditions (MCC). These tools include data standards and electronic care plan applications that allow all mem…

9377. Implementing Automatic Referral | Agency for Healthcare Research and Quality
      www.ahrq.gov/takeheart/training/implementing-automatic-referral/index.html
      April 01, 2023 - Implementing Automatic Referral This focus area will walk you through the necessary steps for implementing an automatic referral system in your hospital. Automatic referral is a proven, evidence-based strategy to increase participation in cardiac rehabilitation (CR). Automatic referral is the systematic, au…

9378. Benefits of reporting and analyzing nursing students' near-miss medication incidents. | PSNet
      psnet.ahrq.gov/issue/benefits-reporting-and-analyzing-nursing-students-near-miss-medication-incidents
      March 16, 2022 - Study Benefits of reporting and analyzing nursing students' near-miss medication incidents. Citation Text: Dennison S, Freeman M, Giannotti N, et al. Benefits of reporting and analyzing nursing students' near-miss medication incidents. Nurse Educ. 2022;47(4):202-207. doi:10.1097/nne.0000…

9379. Interpretive diagnostic error reduction in surgical pathology and cytology: guideline from the College of American Pathologists Pathology and Laboratory Quality Center and the Association of Directors of Anatomic and Surgical Pathology. | PSNet
      psnet.ahrq.gov/issue/interpretive-diagnostic-error-reduction-surgical-pathology-and-cytology-guideline-college
      February 10, 2012 - Organizational Policy/Guidelines Interpretive diagnostic error reduction in surgical pathology and cytology: guideline from the College of American Pathologists Pathology and Laboratory Quality Center and the Association of Directors of Anatomic and Surgical Pathology. Citation Text: Nak…

9380. 'Providing good and comfortable care by building a bond of trust': nurses views regarding their role in patients' perception of safety in the intensive care unit. | PSNet
      psnet.ahrq.gov/issue/providing-good-and-comfortable-care-building-bond-trust-nurses-views-regarding-their-role
      February 14, 2024 - Study 'Providing good and comfortable care by building a bond of trust': nurses views regarding their role in patients' perception of safety in the intensive care unit. Citation Text: Wassenaar A, van den Boogaard M, van der Hooft T, et al. 'Providing good and comfortable care by buildin…