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Use of recalled devices in new device authorizations under the US Food and Drug Administration's 510(k) pathway and risk of subsequent recalls. | PSNet

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April 13, 2022 - Study Use of recalled devices in new device authorizations under the US Food and Drug Administration's 510(k) pathway and risk of subsequent recalls. Citation Text: Kramer DB, Yeh RW. Use of recalled devices in new device authorizations under the US Food and Drug Administration's 510(k) …

Safety of elderly fallers: identifying associated risk factors for 30-day unplanned readmissions using a clinical data warehouse. | PSNet

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May 04, 2022 - Study Safety of elderly fallers: identifying associated risk factors for 30-day unplanned readmissions using a clinical data warehouse. Citation Text: El Abd A, Schwab C, Clementz A, et al. Safety of elderly fallers: identifying associated risk factors for 30-day unplanned readmissions u…

Examining causes and prevention strategies of adverse events in deceased hospital patients: a retrospective patient record review study in the Netherlands. | PSNet

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June 08, 2022 - Study Examining causes and prevention strategies of adverse events in deceased hospital patients: a retrospective patient record review study in the Netherlands. Citation Text: Smits M, Langelaan M, de Groot J, et al. Examining causes and prevention strategies of adverse events in deceas…

We asked the experts: the WHO Surgical Safety Checklist and the COVID-19 pandemic: recommendations for content and implementation adaptations. | PSNet

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May 19, 2021 - Commentary We asked the experts: the WHO Surgical Safety Checklist and the COVID-19 pandemic: recommendations for content and implementation adaptations. Citation Text: Panda N, Etheridge JC, Singh T, et al. The WHO Surgical Safety Checklist and the COVID-19 pandemic: recommendations for…

Disclosing large scale adverse events in the US Veterans Health Administration: lessons from media responses. | PSNet

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August 18, 2021 - Study Disclosing large scale adverse events in the US Veterans Health Administration: lessons from media responses. Citation Text: Maguire EM, Bokhour BG, Asch SM, et al. Disclosing large scale adverse events in the US Veterans Health Administration: lessons from media responses. Public …

Hospital rating organizations' quality and patient safety scores: analysis of result discrepancies. | PSNet

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February 22, 2017 - Study Hospital rating organizations' quality and patient safety scores: analysis of result discrepancies. Citation Text: Badr S, Nahle T, Rahman S, et al. Hospital rating organizations' quality and patient safety scores: analysis of result discrepancies. J Gen Intern Med. 2025;40(3):525-…

Incident and long-term opioid therapy among patients with psychiatric conditions and medications: a national study of commercial health care claims. | PSNet

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November 16, 2022 - Study Incident and long-term opioid therapy among patients with psychiatric conditions and medications: a national study of commercial health care claims. Citation Text: Quinn PD, Hur K, Chang Z, et al. Incident and long-term opioid therapy among patients with psychiatric conditions and …

Overrides of medication-related clinical decision support alerts in outpatients. | PSNet

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September 01, 2016 - Study Overrides of medication-related clinical decision support alerts in outpatients. Citation Text: Nanji KC, Slight SP, Seger DL, et al. Overrides of medication-related clinical decision support alerts in outpatients. J Am Med Inform Assoc. 2014;21(3):487-91. doi:10.1136/amiajnl-2013-…

Intervention of pharmacist included in multidisciplinary team to reduce adverse drug event: a qualitative systematic review. | PSNet

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February 12, 2020 - Review Intervention of pharmacist included in multidisciplinary team to reduce adverse drug event: a qualitative systematic review. Citation Text: Zaij S, Pereira Maia K, Leguelinel-Blache G, et al. Intervention of pharmacist included in multidisciplinary team to reduce adverse drug even…

Discussion of medical errors in morbidity and mortality conferences. | PSNet

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August 04, 2015 - Study Classic Discussion of medical errors in morbidity and mortality conferences. Citation Text: Pierluissi E, Fischer M, Campbell AR, et al. Discussion of medical errors in morbidity and mortality conferences. JAMA. 2003;290(21):2838-2842. Copy Citation …

Surveying care teams after in-hospital deaths to identify preventable harm and opportunities to improve advance care planning. | PSNet

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April 17, 2024 - Study Surveying care teams after in-hospital deaths to identify preventable harm and opportunities to improve advance care planning. Citation Text: Lucier D, Folcarelli P, Totte C, et al. Surveying Care Teams after in-Hospital Deaths to Identify Preventable Harm and Opportunities to Impr…

Alcoholism and American healthcare: the case for a patient safety approach. | PSNet

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March 30, 2022 - Review Alcoholism and American healthcare: the case for a patient safety approach. Citation Text: Zipperer L, Ryan R, Jones B. Alcoholism and American healthcare: the case for a patient safety approach. J Patient Saf Risk Manag. 2022;27(5):201-208. doi:10.1177/25160435221117952. Copy C…

"My whole room went into chaos because of that thing in the corner": unintended consequences of a central fetal monitoring system. | PSNet

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February 15, 2023 - Study "My whole room went into chaos because of that thing in the corner": unintended consequences of a central fetal monitoring system. Citation Text: Small K, Sidebotham M, Gamble J, et al. “My whole room went into chaos because of that thing in the corner”: unintended consequences of …

"The patient is awake and we need to stay calm": reconsidering indirect communication in the face of medical error and professionalism lapses. | PSNet

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October 11, 2023 - Study "The patient is awake and we need to stay calm": reconsidering indirect communication in the face of medical error and professionalism lapses. Citation Text: Taylor T, Columbus L, Banner H, et al. “The patient is awake and we need to stay calm”: reconsidering indirect communication…

Comparing rates of adverse events detected in incident reporting and the Global Trigger Tool: a systematic review. | PSNet

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December 13, 2023 - Review Comparing rates of adverse events detected in incident reporting and the Global Trigger Tool: a systematic review. Citation Text: Hibbert PD, Molloy CJ, Schultz TJ, et al. Comparing rates of adverse events detected in incident reporting and the Global Trigger Tool: a systematic re…

Interventions to reduce adverse drug event-related outcomes in older adults: a systematic review and meta-analysis. | PSNet

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July 19, 2023 - Review Emerging Classic Interventions to reduce adverse drug event-related outcomes in older adults: a systematic review and meta-analysis. Citation Text: Tecklenborg S, Byrne C, Cahir C, et al. Interventions to Reduce Adverse Drug Event-Related Outcomes in Olde…

Effects of a multifaceted medication reconciliation quality improvement intervention on patient safety: final results of the MARQUIS study. | PSNet

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April 12, 2023 - Study Emerging Classic Effects of a multifaceted medication reconciliation quality improvement intervention on patient safety: final results of the MARQUIS study. Citation Text: Schnipper JL, Mixon A, Stein J, et al. Effects of a multifaceted medication reconcil…

Improving administration and documentation of enteral nutrition support therapy in a Veteran Affairs health care system: use of medication administration record and bar code scanning technology. | PSNet

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September 09, 2020 - Study Improving administration and documentation of enteral nutrition support therapy in a Veteran Affairs health care system: use of medication administration record and bar code scanning technology. Citation Text: Chew MM, Rivas S, Chesser M, et al. Improving administration and documen…

Relationship between patient safety and hospital surgical volume. | PSNet

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May 04, 2012 - Study Relationship between patient safety and hospital surgical volume. Citation Text: Hernandez-Boussard T, Downey JR, McDonald KM, et al. Relationship between Patient Safety and Hospital Surgical Volume. Health Serv Res. 2011;47(2). doi:10.1111/j.1475-6773.2011.01310.x. Copy Citati…

Quality improvement lessons learned from National Implementation of the "Patient Safety Events in Community Care: Reporting, Investigation, and Improvement Guidebook". | PSNet

psnet.ahrq.gov/issue/quality-improvement-lessons-learned-national-implementation-patient-safety-events-community

March 15, 2016 - Study Quality improvement lessons learned from National Implementation of the "Patient Safety Events in Community Care: Reporting, Investigation, and Improvement Guidebook". Citation Text: Sullivan JL, Shin MH, Chan J, et al. Quality improvement lessons learned from National Implementati…

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