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  1. How often are potential patient safety events present on admission? | PSNet

    psnet.ahrq.gov/issue/how-often-are-potential-patient-safety-events-present-admission
    January 26, 2022 - Study Classic How often are potential patient safety events present on admission? Citation Text: Houchens RL, Elixhauser A, Romano PS. How often are potential patient safety events present on admission? Jt Comm J Qual Patient Saf. 2008;34(3):154-63. Copy Citat…

  2. An international perspective on definitions and terminology used to describe serious reportable patient safety incidents: a systematic review. | PSNet

    psnet.ahrq.gov/issue/international-perspective-definitions-and-terminology-used-describe-serious-reportable
    August 04, 2021 - Review An international perspective on definitions and terminology used to describe serious reportable patient safety incidents: a systematic review. Citation Text: Hegarty J, Flaherty SJ, Saab MM, et al. An international perspective on definitions and terminology used to describe seri…

  3. The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving US adult populations. | PSNet

    psnet.ahrq.gov/issue/frequency-diagnostic-errors-outpatient-care-estimations-three-large-observational-studies
    April 09, 2013 - Study Classic The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving US adult populations. Citation Text: Singh H, Meyer AND, Thomas EJ. The frequency of diagnostic errors in outpatient care: estimatio…

  4. Preliminary study of patient safety and quality use cases for ICD-11 MMS. | PSNet

    psnet.ahrq.gov/issue/preliminary-study-patient-safety-and-quality-use-cases-icd-11-mms
    July 22, 2020 - Study Preliminary study of patient safety and quality use cases for ICD-11 MMS. Citation Text: Fenton SH, Giannangelo KL, Stanfill MH. Preliminary study of patient safety and quality use cases for ICD-11 MMS. J Am Med Inform Assoc. 2021;28(11):2346-2353. doi:10.1093/jamia/ocab163. Copy…

  5. Nurse workarounds in the electronic health record: an integrative review. | PSNet

    psnet.ahrq.gov/issue/nurse-workarounds-electronic-health-record-integrative-review
    November 18, 2020 - Review Nurse workarounds in the electronic health record: an integrative review. Citation Text: Fraczkowski D, Matson J, Lopez KD. Nurse workarounds in the electronic health record: an integrative review. J Am Med Inform Assoc. 2020;27(7):1149-1165. doi:10.1093/jamia/ocaa050. Copy Cita…

  6. Prevalence, patterns and predictors of nursing care left undone in European hospitals: results from the multicountry cross-sectional RN4CAST study. | PSNet

    psnet.ahrq.gov/issue/prevalence-patterns-and-predictors-nursing-care-left-undone-european-hospitals-results
    January 04, 2015 - Study Prevalence, patterns and predictors of nursing care left undone in European hospitals: results from the multicountry cross-sectional RN4CAST study. Citation Text: Ausserhofer D, Zander B, Busse R, et al. Prevalence, patterns and predictors of nursing care left undone in European h…

  7. Adverse drug events in U.S. adult ambulatory medical care. | PSNet

    psnet.ahrq.gov/issue/adverse-drug-events-us-adult-ambulatory-medical-care
    June 21, 2010 - Study Classic Adverse drug events in U.S. adult ambulatory medical care. Citation Text: Sarkar U, Lopez A, Maselli JH, et al. Adverse drug events in U.S. adult ambulatory medical care. Health Serv Res. 2011;46(5):1517-1533. doi:10.1111/j.1475-6773.2011.01269.x…

  8. Patient safety monitoring in acute care in a decentralized national health care system: conceptual framework and initial set of actionable indicators. | PSNet

    psnet.ahrq.gov/issue/patient-safety-monitoring-acute-care-decentralized-national-health-care-system-conceptual
    July 27, 2022 - Study Patient safety monitoring in acute care in a decentralized national health care system: conceptual framework and initial set of actionable indicators. Citation Text: Barbara L, Roberta DB, Vanda R, et al. Patient safety monitoring in acute care in a decentralized national health ca…

  9. Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients. | PSNet

    psnet.ahrq.gov/issue/root-cause-analysis-reports-help-identify-common-factors-delayed-diagnosis-and-treatment
    October 24, 2018 - Study Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients. Citation Text: Giardina TD, King BJ, Ignaczak AP, et al. Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients. Health A…

  10. Association between workarounds and medication administration errors in bar-code-assisted medication administration in hospitals. | PSNet

    psnet.ahrq.gov/issue/association-between-workarounds-and-medication-administration-errors-bar-code-assisted
    August 26, 2020 - Study Classic Association between workarounds and medication administration errors in bar-code-assisted medication administration in hospitals. Citation Text: van der Veen W, van den Bemt PMLA, Wouters H, et al. Association between workarounds and medication adm…

  11. Impact of the Comprehensive Unit-Based Safety Program (CUSP) on safety culture in a surgical inpatient unit. | PSNet

    psnet.ahrq.gov/issue/impact-comprehensive-unit-based-safety-program-cusp-safety-culture-surgical-inpatient-unit
    January 03, 2017 - Study Impact of the Comprehensive Unit-Based Safety Program (CUSP) on safety culture in a surgical inpatient unit. Citation Text: Timmel J, Kent P, Holzmueller CG, et al. Impact of the Comprehensive Unit-based Safety Program (CUSP) on safety culture in a surgical inpatient unit. Jt Comm …

  12. Effectiveness of pharmacist intervention to reduce medication errors and health-care resources utilization after transitions of care: a meta-analysis of randomized controlled trials. | PSNet

    psnet.ahrq.gov/issue/effectiveness-pharmacist-intervention-reduce-medication-errors-and-health-care-resources
    August 04, 2021 - Review Effectiveness of pharmacist intervention to reduce medication errors and health-care resources utilization after transitions of care: a meta-analysis of randomized controlled trials. Citation Text: De Oliveira GS, Castro-Alves LJ, Kendall MC, et al. Effectiveness of Pharmacist Int…

  13. Stakeholder perspectives on contributors to delayed and inaccurate diagnosis of cardiovascular disease and their implications for digital health technologies: a UK-based qualitative study. | PSNet

    psnet.ahrq.gov/issue/stakeholder-perspectives-contributors-delayed-and-inaccurate-diagnosis-cardiovascular-disease
    August 18, 2021 - Study Stakeholder perspectives on contributors to delayed and inaccurate diagnosis of cardiovascular disease and their implications for digital health technologies: a UK-based qualitative study. Citation Text: Abdullayev K, Gorvett O, Sochiera A, et al. Stakeholder perspectives on contri…

  14. Disparities after discharge: the association of limited English proficiency and postdischarge patient-reported issues. | PSNet

    psnet.ahrq.gov/issue/disparities-after-discharge-association-limited-english-proficiency-and-postdischarge-patient
    October 14, 2020 - Study Disparities after discharge: the association of limited English proficiency and postdischarge patient-reported issues. Citation Text: Malevanchik L, Wheeler M, Gagliardi K, et al. Disparities after discharge: the association of limited English proficiency and postdischarge patient…

  15. How safe is primary care? A systematic review. | PSNet

    psnet.ahrq.gov/issue/how-safe-primary-care-systematic-review
    December 18, 2013 - Review Classic How safe is primary care? A systematic review. Citation Text: Panesar SS, deSilva D, Carson-Stevens A, et al. How safe is primary care? A systematic review. BMJ Qual Saf. 2016;25(7):544-53. doi:10.1136/bmjqs-2015-004178. Copy Citation Format…

  16. Evaluating efforts to optimize TeamSTEPPS implementation in surgical and pediatric intensive care units. | PSNet

    psnet.ahrq.gov/issue/evaluating-efforts-optimize-teamstepps-implementation-surgical-and-pediatric-intensive-care
    April 12, 2014 - Study Evaluating efforts to optimize TeamSTEPPS implementation in surgical and pediatric intensive care units. Citation Text: Mayer CM, Cluff L, Lin W-T, et al. Evaluating efforts to optimize TeamSTEPPS implementation in surgical and pediatric intensive care units. Jt Comm J Qual Patie…

  17. Symptom–Disease Pair Analysis of Diagnostic Error (SPADE): a conceptual framework and methodological approach for unearthing misdiagnosis-related harms using big data. | PSNet

    psnet.ahrq.gov/issue/symptom-disease-pair-analysis-diagnostic-error-spade-conceptual-framework-and-methodological
    October 23, 2019 - Review Classic Symptom–Disease Pair Analysis of Diagnostic Error (SPADE): a conceptual framework and methodological approach for unearthing misdiagnosis-related harms using big data. Citation Text: Liberman AL, Newman-Toker DE. Symptom-Disease Pair Analysis of D…

  18. Optimizing measurement of misdiagnosis-related harms using symptom-disease pair analysis of diagnostic error (SPADE): comparison groups to maximize SPADE validity. | PSNet

    psnet.ahrq.gov/issue/optimizing-measurement-misdiagnosis-related-harms-using-symptom-disease-pair-analysis
    July 21, 2021 - Commentary Optimizing measurement of misdiagnosis-related harms using symptom-disease pair analysis of diagnostic error (SPADE): comparison groups to maximize SPADE validity. Citation Text: Liberman AL, Wang Z, Zhu Y, et al. Optimizing measurement of misdiagnosis-related harms using symp…

  19. Inpatient fall prevention programs as a patient safety strategy: a systematic review. | PSNet

    psnet.ahrq.gov/issue/inpatient-fall-prevention-programs-patient-safety-strategy-systematic-review
    May 26, 2016 - Review Inpatient fall prevention programs as a patient safety strategy: a systematic review. Citation Text: Miake-Lye IM, Hempel S, Ganz DA, et al. Inpatient fall prevention programs as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):390-396. doi:10.732…

  20. Diagnostic error experiences of patients and families with limited English-language health literacy or disadvantaged socioeconomic position in a cross-sectional US population-based survey. | PSNet

    psnet.ahrq.gov/issue/diagnostic-error-experiences-patients-and-families-limited-english-language-health-literacy
    October 27, 2021 - Study Diagnostic error experiences of patients and families with limited English-language health literacy or disadvantaged socioeconomic position in a cross-sectional US population-based survey. Citation Text: Bell SK, Dong J, Ngo L, et al. Diagnostic error experiences of patients and fa…
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