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Deficiencies in Emergency Department Care for a Patient Who Died by Suicide at the John Cochran Division of the VA St. Louis Health Care System in Missouri. | PSNet

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July 26, 2023 - Book/Report Deficiencies in Emergency Department Care for a Patient Who Died by Suicide at the John Cochran Division of the VA St. Louis Health Care System in Missouri. Citation Text: Deficiencies in Emergency Department Care for a Patient Who Died by Suicide at the John Cochran Division…

Optimizing Medication Management During the Covid-19 Pandemic: Implementation Guide for Post-acute and Long Term Care. | PSNet

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August 16, 2023 - Study Optimizing Medication Management During the Covid-19 Pandemic: Implementation Guide for Post-acute and Long Term Care. Citation Text: Brandt N, Steinman MA. Optimizing Medication Management During the COVID‐19 Pandemic: An Implementation Guide for Post‐Acute and Long‐Term Care. J A…

Changing and sustaining medical students' knowledge, skills, and attitudes about patient safety and medical fallibility. | PSNet

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December 19, 2012 - Study Changing and sustaining medical students' knowledge, skills, and attitudes about patient safety and medical fallibility. Citation Text: Madigosky WS, Headrick LA, Nelson K, et al. Changing and sustaining medical students' knowledge, skills, and attitudes about patient safety and …

Crossover of the patient satisfaction surveys, adverse events and patient complaints for continuous improvement in radiotherapy department. | PSNet

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July 27, 2022 - Study Crossover of the patient satisfaction surveys, adverse events and patient complaints for continuous improvement in radiotherapy department. Citation Text: Cucchiaro SÉ, Princen F, Goreux JË, et al. Crossover of the patient satisfaction surveys, adverse events and patient complaints…

Multicomponent pharmacist intervention did not reduce clinically important medication errors for ambulatory patients initiating direct oral anticoagulants. | PSNet

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March 17, 2021 - Study Multicomponent pharmacist intervention did not reduce clinically important medication errors for ambulatory patients initiating direct oral anticoagulants. Citation Text: Kapoor A, Patel P, Mbusa D, et al. Multicomponent pharmacist intervention did not reduce clinically important m…

Interventions to reduce medication dispensing, administration, and monitoring errors in pediatric professional healthcare settings: a systematic review. | PSNet

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June 23, 2021 - Review Interventions to reduce medication dispensing, administration, and monitoring errors in pediatric professional healthcare settings: a systematic review. Citation Text: Koeck JA, Young NJ, Kontny U, et al. Interventions to reduce medication dispensing, administration, and monitorin…

Root cause analysis to identify contributing factors for the development of hospital acquired pressure injuries. | PSNet

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July 20, 2022 - Study Root cause analysis to identify contributing factors for the development of hospital acquired pressure injuries. Citation Text: Abela G. Root cause analysis to identify contributing factors for the development of hospital acquired pressure injuries. J Tissue Viability. 2021;30(3):3…

A qualitative analysis of outpatient medication use in community settings: observed safety vulnerabilities and recommendations for improved patient safety. | PSNet

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October 26, 2022 - Study A qualitative analysis of outpatient medication use in community settings: observed safety vulnerabilities and recommendations for improved patient safety. Citation Text: Lyson HC, Sharma AE, Cherian R, et al. A Qualitative Analysis of Outpatient Medication Use in Community Setting…

Chief of Residents for Quality Improvement and Patient Safety: a recipe for a new role in graduate medical education. | PSNet

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August 13, 2014 - Commentary Chief of Residents for Quality Improvement and Patient Safety: a recipe for a new role in graduate medical education. Citation Text: Ferraro K, Zernzach R, Maturo S, et al. Chief of Residents for Quality Improvement and Patient Safety: A Recipe for a New Role in Graduate Medic…

It’s time to consider national culture when designing team training initiatives in healthcare. | PSNet

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January 26, 2022 - Commentary It’s time to consider national culture when designing team training initiatives in healthcare. Citation Text: Rice JC, Daouk-Öyry L, Hitti E. It’s time to consider national culture when designing team training initiatives in healthcare. BMJ Qual Saf. 2021;30(5):412-417. doi:10…

The dollar or disease burden: caps on healthcare spending may save money, but at what "cost" to patients? | PSNet

psnet.ahrq.gov/issue/dollar-or-disease-burden-caps-healthcare-spending-may-save-money-what-cost-patients

March 01, 2011 - Study The dollar or disease burden: caps on healthcare spending may save money, but at what "cost" to patients? Citation Text: Ciarametaro M, Houghton K, Wamble D, et al. The dollar or disease burden: caps on healthcare spending may save money, but at what "cost" to patients? Value Healt…

The effect of a clinical decision support for pending laboratory results at emergency department discharge. | PSNet

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April 24, 2018 - Study The effect of a clinical decision support for pending laboratory results at emergency department discharge. Citation Text: Driver BE, Scharber SK, Fagerstrom ET, et al. The Effect of a Clinical Decision Support for Pending Laboratory Results at Emergency Department Discharge. J Eme…

Sex differences in operating room care giver perceptions of patient safety: a pilot study from the Veterans Health Administration Medical Team Training Program. | PSNet

psnet.ahrq.gov/issue/sex-differences-operating-room-care-giver-perceptions-patient-safety-pilot-study-veterans

June 14, 2011 - Study Sex differences in operating room care giver perceptions of patient safety: a pilot study from the Veterans Health Administration Medical Team Training Program. Citation Text: Carney BT, Mills PD, Bagian JP, et al. Sex differences in operating room care giver perceptions of patie…

Systems engineering analysis of diagnostic referral closed-loop processes. | PSNet

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December 07, 2022 - Study Systems engineering analysis of diagnostic referral closed-loop processes. Citation Text: Nehls N, Yap TS, Salant T, et al. Systems engineering analysis of diagnostic referral closed-loop processes. BMJ Open Qual. 2021;10(4):e001603. doi:10.1136/bmjoq-2021-001603. Copy Citation …

Inadequate Outpatient Mental Health Triage and Care of a Patient at the Chico Community-Based Outpatient Clinic in California. | PSNet

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November 29, 2023 - Book/Report Inadequate Outpatient Mental Health Triage and Care of a Patient at the Chico Community-Based Outpatient Clinic in California. Citation Text: Inadequate Outpatient Mental Health Triage and Care of a Patient at the Chico Community-Based Outpatient Clinic in California. Washing…

Reported medication errors after introducing an electronic medication management system. | PSNet

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November 18, 2016 - Study Reported medication errors after introducing an electronic medication management system. Citation Text: Redley B, Botti M. Reported medication errors after introducing an electronic medication management system. J Clin Nurs. 2013;22(3-4):579-89. doi:10.1111/j.1365-2702.2012.04326.…

The New Electronic Health Record’s Unknown Queue Caused Multiple Events of Patient Harm. | PSNet

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October 12, 2022 - Book/Report The New Electronic Health Record’s Unknown Queue Caused Multiple Events of Patient Harm. Citation Text: The New Electronic Health Record’s Unknown Queue Caused Multiple Events of Patient Harm. Washington, DC: VA Office of the Inspector General; July 14 2022. Report No. 22-011…

Patient Suicide on a Locked Mental Health Unit at the West Palm Beach VA Medical Center, Florida. | PSNet

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January 24, 2024 - Book/Report Patient Suicide on a Locked Mental Health Unit at the West Palm Beach VA Medical Center, Florida. Citation Text: Patient Suicide on a Locked Mental Health Unit at the West Palm Beach VA Medical Center, Florida. Washington, DC: Department of Veterans Affairs, Office of Inspect…

Engaging residents and fellows to improve institution-wide quality: the first six years of a novel financial incentive program. | PSNet

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May 05, 2010 - Study Engaging residents and fellows to improve institution-wide quality: the first six years of a novel financial incentive program. Citation Text: Vidyarthi A, Green AL, Rosenbluth G, et al. Engaging residents and fellows to improve institution-wide quality: the first six years of a no…

Prescribers' interactions with medication alerts at the point of prescribing: a multi-method, in situ investigation of the human–computer interaction. | PSNet

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January 07, 2015 - Study Prescribers' interactions with medication alerts at the point of prescribing: a multi-method, in situ investigation of the human–computer interaction. Citation Text: Russ AL, Zillich AJ, McManus S, et al. Prescribers' interactions with medication alerts at the point of prescribin…

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