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psnet.ahrq.gov/issue/does-implementation-electronic-prescribing-system-create-unintended-medication-errors-study
August 24, 2016 - Study
Does the implementation of an electronic prescribing system create unintended medication errors? A study of the sociotechnical context through the analysis of reported medication incidents.
Citation Text:
Redwood S, Rajakumar A, Hodson J, et al. Does the implementation of an elec…
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psnet.ahrq.gov/issue/systematic-review-safety-checklists-use-medical-care-teams-acute-hospital-settings-limited
July 29, 2020 - Review
Systematic review of safety checklists for use by medical care teams in acute hospital settings—limited evidence of effectiveness.
Citation Text:
Ko HCH, Turner TJ, Finnigan MA. Systematic review of safety checklists for use by medical care teams in acute hospital settings--limi…
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psnet.ahrq.gov/issue/high-rates-adverse-drug-events-highly-computerized-hospital
August 04, 2021 - Study
Classic
High rates of adverse drug events in a highly computerized hospital.
Citation Text:
Nebeker JR, Hoffman JM, Weir C, et al. High rates of adverse drug events in a highly computerized hospital. Arch Intern Med. 2005;165(10):1111-6.
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psnet.ahrq.gov/issue/nurses-achilles-heel-using-big-data-determine-workload-factors-impact-near-misses
July 28, 2021 - Study
Nurse's Achilles Heel: using big data to determine workload factors that impact near misses.
Citation Text:
Campbell AA, Harlan T, Campbell M, et al. Nurse's Achilles Heel: using big data to determine workload factors that impact near misses. J Nurs Scholarsh. 2021;53(3):333-342. d…
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psnet.ahrq.gov/issue/how-best-measure-surgical-quality-comparison-agency-healthcare-research-and-quality-patient
December 21, 2014 - Study
How best to measure surgical quality? Comparison of the Agency for Healthcare Research and Quality Patient Safety Indicators (AHRQ-PSI) and the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) postoperative adverse events at a single institution.
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psnet.ahrq.gov/issue/deriving-framework-systems-approach-agitated-patient-care-emergency-department
June 13, 2018 - Study
Deriving a framework for a systems approach to agitated patient care in the emergency department.
Citation Text:
Wong AH, Ruppel H, Crispino LJ, et al. Deriving a Framework for a Systems Approach to Agitated Patient Care in the Emergency Department. Jt Comm J Qual Patient Saf. 2018…
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psnet.ahrq.gov/issue/integration-prospective-and-retrospective-methods-risk-analysis-hospitals
June 23, 2010 - Study
Integration of prospective and retrospective methods for risk analysis in hospitals.
Citation Text:
Kessels-Habraken M, van der Schaaf TW, De Jonge J, et al. Integration of prospective and retrospective methods for risk analysis in hospitals. Int J Qual Health Care. 2009;21(6):42…
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psnet.ahrq.gov/issue/central-venous-catheter-guidewire-retention-lessons-englands-never-event-database
September 15, 2021 - Study
Central venous catheter guidewire retention: lessons from England's never event database.
Citation Text:
Mariyaselvam MZA, Patel V, Young HE, et al. Central venous catheter guidewire retention: lessons from England's never event database. J Patient Saf. 2022;18(2):e387-e392. doi:10…
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psnet.ahrq.gov/issue/weekly-variation-health-care-quality-day-and-time-admission-nationwide-registry-based
September 24, 2014 - Study
Weekly variation in health-care quality by day and time of admission: a nationwide, registry-based, prospective cohort study of acute stroke care.
Citation Text:
Bray BD, Cloud GC, James MA, et al. Weekly variation in health-care quality by day and time of admission: a nationwide, …
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psnet.ahrq.gov/issue/medication-safety-two-intensive-care-units-community-teaching-hospital-after-electronic
October 31, 2014 - Study
Medication safety in two intensive care units of a community teaching hospital after electronic health record implementation: sociotechnical and human factors engineering considerations.
Citation Text:
Carayon P, Wetterneck TB, Cartmill R, et al. Medication Safety in Two Intensive …
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psnet.ahrq.gov/issue/using-four-phased-unit-based-patient-safety-walkrounds-uncover-correctable-system-flaws
October 05, 2022 - Study
Using four-phased unit-based patient safety walkrounds to uncover correctable system flaws.
Citation Text:
Taylor AM, Chuo J, Figueroa-Altmann A, et al. Using four-phased unit-based patient safety walkrounds to uncover correctable system flaws. Jt Comm J Qual Patient Saf. 2013;39…
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psnet.ahrq.gov/issue/surgical-safety-checklist-and-patient-outcomes-after-surgery-prospective-observational-cohort
May 28, 2015 - Study
Classic
The surgical safety checklist and patient outcomes after surgery: a prospective observational cohort study, systematic review and meta-analysis.
Citation Text:
Abbott TEF, Ahmad T, Phull MK, et al. The surgical safety checklist and patient outcomes…
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psnet.ahrq.gov/issue/relationships-between-comprehensive-characteristics-nurse-work-schedules-and-adverse-patient
October 06, 2010 - Review
Relationships between comprehensive characteristics of nurse work schedules and adverse patient outcomes: a systematic literature review.
Citation Text:
Bae S‐H. Relationships between comprehensive characteristics of nurse work schedules and adverse patient outcomes: a systematic …
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psnet.ahrq.gov/issue/improving-diagnostic-fidelity-approach-standardizing-process-patients-emerging-critical
August 04, 2021 - Journal Article
Improving Diagnostic Fidelity: An Approach to Standardizing the Process in Patients With Emerging Critical Illness
Citation Text:
Jayaprakash N, Chae J, Sabov M, et al. Improving Diagnostic Fidelity: An Approach to Standardizing the Process in Patients With Emerging Criti…
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psnet.ahrq.gov/issue/electromagnetic-interference-radio-frequency-identification-inducing-potentially-hazardous
February 14, 2024 - Study
Electromagnetic interference from radio frequency identification inducing potentially hazardous incidents in critical care medical equipment.
Citation Text:
van der Togt R, van Lieshout EJ, Hensbroek R, et al. Electromagnetic interference from radio frequency identification indu…
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psnet.ahrq.gov/issue/systematic-review-evidence-links-between-patient-experience-and-clinical-safety-and
May 01, 2019 - Review
A systematic review of evidence on the links between patient experience and clinical safety and effectiveness.
Citation Text:
Doyle C, Lennox L, Bell D. A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open. 2013;…
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psnet.ahrq.gov/issue/patient-safety-indicators-england-hospital-administrative-data-case-control-analysis-and
June 15, 2011 - Study
Patient safety indicators for England from hospital administrative data: case-control analysis and comparison with US data.
Citation Text:
Raleigh VS, Cooper J, Bremner SA, et al. Patient safety indicators for England from hospital administrative data: case-control analysis and c…
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psnet.ahrq.gov/issue/multicenter-study-evaluate-benefits-technology-assisted-workflow-iv-room-efficiency-costs-and
July 14, 2009 - Study
Multicenter study to evaluate the benefits of technology-assisted workflow on i.v. room efficiency, costs, and safety.
Citation Text:
Eckel SF, Higgins JP, Hess E, et al. Multicenter study to evaluate the benefits of technology-assisted workflow on i.v. room efficiency, costs, and …
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psnet.ahrq.gov/issue/wrong-site-surgery-pennsylvania-during-2015-2019-study-variables-associated-368-events-178
October 09, 2024 - Study
Wrong-site surgery in Pennsylvania during 2015–2019: a study of variables associated with 368 events from 178 facilities.
Citation Text:
Yonash RA, Taylor M. Wrong-Site Surgery in Pennsylvania During 2015–2019: A Study of Variables Associated With 368 Events From 178 Facilities. …
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psnet.ahrq.gov/issue/improving-safety-and-eliminating-redundant-tests-cutting-costs-us-hospitals
May 27, 2011 - Study
Classic
Improving safety and eliminating redundant tests: cutting costs in U.S. hospitals.
Citation Text:
Jha AK, Chan DC, Ridgway AB, et al. Improving safety and eliminating redundant tests: cutting costs in U.S. hospitals. Health Aff (Millwood). 2009;28(…