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1961. A systematic review of falls in hospital for patients with communication disability: highlighting an invisible population. | PSNet
      psnet.ahrq.gov/issue/systematic-review-falls-hospital-patients-communication-disability-highlighting-invisible
      April 15, 2016 - Review A systematic review of falls in hospital for patients with communication disability: highlighting an invisible population. Citation Text: Hemsley B, Steel J, Worrall L, et al. A systematic review of falls in hospital for patients with communication disability: Highlighting an invi…

1962. Letter to Health Care Providers: Safe Use of Surgical Staplers and Staples. | PSNet
      psnet.ahrq.gov/issue/letter-health-care-providers-safe-use-surgical-staplers-and-staples
      October 20, 2021 - Press Release/Announcement Letter to Health Care Providers: Safe Use of Surgical Staplers and Staples. Citation Text: Letter to Health Care Providers: Safe Use of Surgical Staplers and Staples. US Food and Drug Administration. October 7, 2021. Copy Citation Save S…

1963. A comparative analysis of incident reporting lag times in academic medical centres in Japan and the USA. | PSNet
      psnet.ahrq.gov/issue/comparative-analysis-incident-reporting-lag-times-academic-medical-centres-japan-and-usa
      March 23, 2011 - Study A comparative analysis of incident reporting lag times in academic medical centres in Japan and the USA. Citation Text: Regenbogen SE, Hirose M, Imanaka Y, et al. A comparative analysis of incident reporting lag times in academic medical centres in Japan and the USA. Qual Saf Hea…

1964. Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects analysis, and structured communications skills. | PSNet
      psnet.ahrq.gov/issue/key-performance-outcomes-patient-safety-curricula-root-cause-analysis-failure-mode-and
      July 23, 2010 - Commentary Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects analysis, and structured communications skills. Citation Text: Fassett WE. Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects …

1965. Medical error disclosure among pediatricians: choosing carefully what we might say to parents. | PSNet
      psnet.ahrq.gov/issue/medical-error-disclosure-among-pediatricians-choosing-carefully-what-we-might-say-parents
      July 10, 2008 - Study Classic Medical error disclosure among pediatricians: choosing carefully what we might say to parents. Citation Text: Loren DJ, Klein EJ, Garbutt J, et al. Medical Error Disclosure Among Pediatricians. Arch Pediatr Adolesc Med. 2008;162(10):922-927. doi:10…

1966. Reflection on adverse event disclosure in the postsurgical hospital context. | PSNet
      psnet.ahrq.gov/issue/reflection-adverse-event-disclosure-postsurgical-hospital-context
      August 20, 2018 - Commentary Reflection on adverse event disclosure in the postsurgical hospital context. Citation Text: Roberts F, Gettings P, Torbeck L, et al. Reflection on adverse event disclosure in the postsurgical hospital context. J Surg Educ. 2015;72(4):767-70. doi:10.1016/j.jsurg.2014.12.016. …

1967. Interhospital transfer handoff practices among US tertiary care centers: a descriptive survey. | PSNet
      psnet.ahrq.gov/issue/interhospital-transfer-handoff-practices-among-us-tertiary-care-centers-descriptive-survey
      November 02, 2016 - Study Interhospital transfer handoff practices among US tertiary care centers: a descriptive survey. Citation Text: Herrigel DJ, Carroll M, Fanning C, et al. Interhospital transfer handoff practices among US tertiary care centers: A descriptive survey. J Hosp Med. 2016;11(6):413-7. doi:1…

1968. Improving situation awareness to advance patient outcomes: a systematic literature review. | PSNet
      psnet.ahrq.gov/issue/improving-situation-awareness-advance-patient-outcomes-systematic-literature-review
      January 16, 2010 - Review Improving situation awareness to advance patient outcomes: a systematic literature review. Citation Text: Alqarrain Y, Roudsari A, Courtney KL, et al. Improving situation awareness to advance patient outcomes: a systematic literature review. Comput Inform Nurs. 2024;42(4):277-288.…

1969. Epidemiology of adverse events in air medical transport. | PSNet
      psnet.ahrq.gov/issue/epidemiology-adverse-events-air-medical-transport
      July 03, 2014 - Study Epidemiology of adverse events in air medical transport. Citation Text: MacDonald RD, Banks BA, Morrison M. Epidemiology of adverse events in air medical transport. Acad Emerg Med. 2008;15(10):923-931. doi:10.1111/j.1553-2712.2008.00241.x. Copy Citation Format: DOI Go…

1970. Patients' and physicians' attitudes regarding the disclosure of medical errors. | PSNet
      psnet.ahrq.gov/issue/patients-and-physicians-attitudes-regarding-disclosure-medical-errors
      March 21, 2017 - Study Classic Patients' and physicians' attitudes regarding the disclosure of medical errors. Citation Text: Gallagher TH, Waterman AD, Ebers AG, et al. Patients' and physicians' attitudes regarding the disclosure of medical errors. JAMA. 2003;289(8):1001-7. …

1971. Long-term sustainability and adaptation of I-PASS handovers. | PSNet
      psnet.ahrq.gov/issue/long-term-sustainability-and-adaptation-i-pass-handovers
      September 09, 2020 - Study Long-term sustainability and adaptation of I-PASS handovers. Citation Text: Ryan SL, Logan M, Liu X, et al. Long-term sustainability and adaptation of I-PASS handovers. Jt Comm J Qual Patient Saf. 2023;19(12):689-697. doi:10.1016/j.jcjq.2023.07.007. Copy Citation Format: …

1972. Problems after discharge and understanding of communication with their primary care physicians (PCPs) among hospitalized seniors: a mixed methods study. | PSNet
      psnet.ahrq.gov/issue/problems-after-discharge-and-understanding-communication-their-primary-care-physicians-pcps
      March 28, 2018 - Study Problems after discharge and understanding of communication with their primary care physicians (PCPs) among hospitalized seniors: a mixed methods study. Citation Text: Arora V, Prochaska ML, Farnan JM, et al. Problems after discharge and understanding of communication with their p…

1973. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47738/psn-pdf
      February 06, 2019 - ISMP Guidelines for Safe Electronic Communication of Medication Information. February 6, 2019 Horsham, PA: Institute for Safe Medication Practices; January 2019. https://psnet.ahrq.gov/issue/ismp-guidelines-safe-electronic-communication-medication-information Inaccurate or incomplete data in electronic health reco…

1974. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44620/psn-pdf
      November 04, 2015 - Laboratory testing in general practice: a patient safety blind spot. November 4, 2015 Elder NC. Laboratory testing in general practice: a patient safety blind spot. BMJ Qual Saf. 2015;24(11):667-70. doi:10.1136/bmjqs-2015-004644. https://psnet.ahrq.gov/issue/laboratory-testing-general-practice-patient-safety-blind…

1975. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38587/psn-pdf
      May 06, 2009 - Creating a better discharge summary: improvement in quality and timeliness using an electronic discharge summary. May 6, 2009 O'Leary KJ, Liebovitz DM, Feinglass J, et al. Creating a better discharge summary: improvement in quality and timeliness using an electronic discharge summary. J Hosp Med. 2009;4(4):219-225…

1976. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866256/psn-pdf
      July 10, 2024 - Disclosure programmes in the US--an inadequate response to medical error. July 10, 2024 Handley GM. Disclosure programmes in the US—an inadequate response to medical error. BMJ. 2024;385:q1318. doi:10.1136/bmj.q1318. https://psnet.ahrq.gov/issue/disclosure-programmes-us-inadequate-response-medical-error Communica…

1977. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49573/psn-pdf
      January 01, 2009 - Dangerous Shift November 1, 2008 Patterson ES. Dangerous Shift. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/dangerous-shift Case Objectives Review the evidence base on erroneous actions related to shift changes. Understand the limits of standardizing handoffs in preventing errors at shift change. Expla…

1978. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49819/psn-pdf
      February 01, 2018 - Signout Fallout February 1, 2018 Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/signout-fallout Case Objectives Understand the role of communication failures in medical errors and preventable adverse events. Review the evidence in support of handoff improvement pr…

1979. PSNet Curated Library (pdf file)
      psnet.ahrq.gov/print/pdf/node/867461
      January 31, 2024 - PSNet Curated Library AHRQ: Agency for Healthcare Research and Quality Patient and Family Engagement in Long Term Care Curated Library Foundations Long-term Care and Patient Safety Deb Bakerjian PhD, APRN, FAAN, FAANP, FGSA | April, 10 2024 A large and growing number of Americans require care in skilled nursin…

1980. The Unhappy Patient Leaves Against Medical Advice. | PSNet
      psnet.ahrq.gov/web-mm/unhappy-patient-leaves-against-medical-advice
      January 31, 2024 - The Unhappy Patient Leaves Against Medical Advice. Citation Text: Nichols A. The Unhappy Patient Leaves Against Medical Advice.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: Google Scholar …