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  1. Root cause analyses of suicides of mental health clients. | PSNet

    psnet.ahrq.gov/issue/root-cause-analyses-suicides-mental-health-clients
    March 16, 2016 - Study Root cause analyses of suicides of mental health clients. Citation Text: Gillies D, Chicop D, O'Halloran P. Root Cause Analyses of Suicides of Mental Health Clients: Identifying Systematic Processes and Service-Level Prevention Strategies. Crisis. 2015;36(5):316-324. doi:10.1027/02…

  2. Discrepancies between home medications listed at hospital admission and reported medical conditions. | PSNet

    psnet.ahrq.gov/issue/discrepancies-between-home-medications-listed-hospital-admission-and-reported-medical
    November 03, 2021 - Study Discrepancies between home medications listed at hospital admission and reported medical conditions. Citation Text: Slain D, Kincaid SE, Dunsworth TS. Discrepancies between home medications listed at hospital admission and reported medical conditions. Am J Geriatr Pharmacother.…

  3. Who applies an intervention to influence cultural attributes in a quality improvement collaborative? | PSNet

    psnet.ahrq.gov/issue/who-applies-intervention-influence-cultural-attributes-quality-improvement-collaborative
    January 22, 2016 - Study Who applies an intervention to influence cultural attributes in a quality improvement collaborative? Citation Text: Hsu Y-J, Marsteller JA. Who Applies an Intervention to Influence Cultural Attributes in a Quality Improvement Collaborative? J Patient Saf. 2020;16(1):1-6. Copy Cit…

  4. Drug calculation ability of qualified paramedics: a pilot study. | PSNet

    psnet.ahrq.gov/issue/drug-calculation-ability-qualified-paramedics-pilot-study
    June 25, 2018 - Study Drug calculation ability of qualified paramedics: a pilot study. Citation Text: Boyle MJ, Eastwood K. Drug calculation ability of qualified paramedics: A pilot study. World J Emerg Med. 2018;9(1):41-45. doi:10.5847/wjem.j.1920-8642.2018.01.006. Copy Citation Format: D…

  5. TRIAD XII: are patients aware of and agree with DNR or POLST orders in their medical records. | PSNet

    psnet.ahrq.gov/issue/triad-xii-are-patients-aware-and-agree-dnr-or-polst-orders-their-medical-records
    September 15, 2021 - Study TRIAD XII: are patients aware of and agree with DNR or POLST orders in their medical records. Citation Text: Mirarchi FL, Juhasz K, Cooney TE, et al. TRIAD XII: Are Patients Aware of and Agree With DNR or POLST Orders in Their Medical Records. J Patient Saf. 2019;15(3):230-237. doi…

  6. Competition and health plan performance: evidence from health maintenance organization insurance markets. | PSNet

    psnet.ahrq.gov/issue/competition-and-health-plan-performance-evidence-health-maintenance-organization-insurance
    July 14, 2009 - Study Competition and health plan performance: evidence from health maintenance organization insurance markets. Citation Text: Scanlon D, Swaminathan S, Chernew M, et al. Competition and health plan performance: evidence from health maintenance organization insurance markets. Med Care.…

  7. Addressing adultification of black pediatric patients in the emergency department: a framework to decrease disparities. | PSNet

    psnet.ahrq.gov/issue/addressing-adultification-black-pediatric-patients-emergency-department-framework-decrease
    October 27, 2021 - Commentary Addressing adultification of black pediatric patients in the emergency department: a framework to decrease disparities. Citation Text: Koch A, Kozhumam A. Addressing adultification of black pediatric patients in the emergency department: a framework to decrease disparities. He…

  8. Handoff tool improves transitions from the operating room to the neonatal intensive care unit. | PSNet

    psnet.ahrq.gov/issue/handoff-tool-improves-transitions-operating-room-neonatal-intensive-care-unit
    November 16, 2022 - Study Handoff tool improves transitions from the operating room to the neonatal intensive care unit. Citation Text: Gallois JB, Zagory JA, Barkemeyer B, et al. Handoff tool improves transitions from the operating room to the neonatal intensive care unit. Pediatr Qual Saf. 2023;8(5):e695.…

  9. Risk factors for hospital admissions associated with adverse drug events. | PSNet

    psnet.ahrq.gov/issue/risk-factors-hospital-admissions-associated-adverse-drug-events
    October 18, 2018 - Study Risk factors for hospital admissions associated with adverse drug events. Citation Text: Kongkaew C, Hann M, Mandal J, et al. Risk factors for hospital admissions associated with adverse drug events. Pharmacotherapy. 2013;33(8):827-37. doi:10.1002/phar.1287. Copy Citation Fo…

  10. Blood and blood products transfusion errors: what can we do to improve patient safety. | PSNet

    psnet.ahrq.gov/issue/blood-and-blood-products-transfusion-errors-what-can-we-do-improve-patient-safety
    September 23, 2020 - Review Blood and blood products transfusion errors: what can we do to improve patient safety. Citation Text: Brown C, Brown M. Blood and blood products transfusion errors: what can we do to improve patient safety? Br J Nurs. 2023;32(7):326-332. doi:10.12968/bjon.2023.32.7.326. Copy Cit…

  11. Developing agreement on never events in primary care dentistry: an international eDelphi study. | PSNet

    psnet.ahrq.gov/issue/developing-agreement-never-events-primary-care-dentistry-international-edelphi-study
    October 05, 2016 - Study Developing agreement on never events in primary care dentistry: an international eDelphi study. Citation Text: Ensaldo-Carrasco E, Carson-Stevens A, Cresswell K, et al. Developing agreement on never events in primary care dentistry: an international eDelphi study. Br Dent J. 2018;2…

  12. Can patients report patient safety incidents in a hospital setting? A systematic review. | PSNet

    psnet.ahrq.gov/issue/can-patients-report-patient-safety-incidents-hospital-setting-systematic-review
    December 21, 2016 - Review Can patients report patient safety incidents in a hospital setting? A systematic review. Citation Text: Ward JK, Armitage G. Can patients report patient safety incidents in a hospital setting? A systematic review. BMJ Qual Saf. 2012;21(8):685-99. doi:10.1136/bmjqs-2011-000213. …

  13. 'If no-one stops me, I'll make the mistake again': changing prescribing behaviours through feedback; a Perceptual Control Theory perspective. | PSNet

    psnet.ahrq.gov/issue/if-no-one-stops-me-ill-make-mistake-again-changing-prescribing-behaviours-through-feedback
    July 01, 2017 - Study 'If no-one stops me, I'll make the mistake again': changing prescribing behaviours through feedback; a Perceptual Control Theory perspective. Citation Text: Ferguson J, Keyworth C, Tully MP. 'If no-one stops me, I'll make the mistake again': Changing prescribing behaviours through …

  14. Opioids prescribed after low-risk surgical procedures in the United States, 2004–2012. | PSNet

    psnet.ahrq.gov/issue/opioids-prescribed-after-low-risk-surgical-procedures-united-states-2004-2012
    May 29, 2024 - Study Opioids prescribed after low-risk surgical procedures in the United States, 2004–2012. Citation Text: Wunsch H, Wijeysundera DN, Passarella MA, et al. Opioids Prescribed After Low-Risk Surgical Procedures in the United States, 2004-2012. JAMA. 2016;315(15):1654-7. doi:10.1001/jama.…

  15. Innovative approach to reconstruct bedside handoff: using simple rules of complexity science to promote partnership with patients. | PSNet

    psnet.ahrq.gov/issue/innovative-approach-reconstruct-bedside-handoff-using-simple-rules-complexity-science-promote
    November 16, 2022 - Commentary Innovative approach to reconstruct bedside handoff: using simple rules of complexity science to promote partnership with patients. Citation Text: Anthony MK, Kloos J, Beam P, et al. Innovative Approach to Reconstruct Bedside Handoff: Using Simple Rules of Complexity Science to…

  16. Efficacy of an incident-reporting system in cellular pathology: a practical experience. | PSNet

    psnet.ahrq.gov/issue/efficacy-incident-reporting-system-cellular-pathology-practical-experience
    August 21, 2024 - Study Efficacy of an incident-reporting system in cellular pathology: a practical experience. Citation Text: Rakha EA, Clark D, Chohan BS, et al. Efficacy of an incident-reporting system in cellular pathology: a practical experience. J Clin Pathol. 2012;65(7):643-8. doi:10.1136/jclinpa…

  17. Patient misidentifications caused by errors in standard barcode technology. | PSNet

    psnet.ahrq.gov/issue/patient-misidentifications-caused-errors-standard-barcode-technology
    June 13, 2012 - Study Patient misidentifications caused by errors in standard barcode technology. Citation Text: Snyder ML, Carter A, Jenkins K, et al. Patient misidentifications caused by errors in standard bar code technology. Clin Chem. 2010;56(10):1554-60. doi:10.1373/clinchem.2010.150094. Copy …

  18. Clinical and financial effects of smart pump-electronic medical record interoperability at a hospital in a regional health system. | PSNet

    psnet.ahrq.gov/issue/clinical-and-financial-effects-smart-pump-electronic-medical-record-interoperability-hospital
    November 16, 2022 - Study Clinical and financial effects of smart pump-electronic medical record interoperability at a hospital in a regional health system. Citation Text: Biltoft J, Finneman L. Clinical and financial effects of smart pump-electronic medical record interoperability at a hospital in a region…

  19. Contributing factors identified by hospital incident report narratives. | PSNet

    psnet.ahrq.gov/issue/contributing-factors-identified-hospital-incident-report-narratives
    January 02, 2017 - Study Contributing factors identified by hospital incident report narratives. Citation Text: Nuckols TK, Bell DS, Paddock SM, et al. Contributing factors identified by hospital incident report narratives. Qual Saf Health Care. 2008;17(5):368-72. doi:10.1136/qshc.2007.023721. Copy Cit…

  20. Patient safety and image transfer between referring hospitals and neuroscience centres: could we do better? | PSNet

    psnet.ahrq.gov/issue/patient-safety-and-image-transfer-between-referring-hospitals-and-neuroscience-centres-could
    July 19, 2023 - Study Patient safety and image transfer between referring hospitals and neuroscience centres: could we do better? Citation Text: Crocker M, Cato-Addison WB, Pushpananthan S, et al. Patient safety and image transfer between referring hospitals and neuroscience centres: could we do bette…
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