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psnet.ahrq.gov/node/36834/psn-pdf
August 26, 2011 - effective leadership initiatives, may improve patient
outcomes, though they acknowledge that their study evaluated
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psnet.ahrq.gov/node/35134/psn-pdf
June 22, 2009 - The 23-hospital Australian
study evaluated the availability of METs at designated hospitals and collected
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psnet.ahrq.gov/issue/adverse-events-robotic-surgery-retrospective-study-14-years-fda-data
June 24, 2020 - Using an automated natural language processing tool, this retrospective study evaluated adverse events
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psnet.ahrq.gov/issue/impact-electronic-health-record-transition-chemotherapy-error-reporting
June 17, 2020 - This study evaluated trends in chemotherapy error reporting before and after EHR implementation.
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psnet.ahrq.gov/issue/structured-patient-handoff-internal-medicine-ward-cluster-randomized-control-trial
September 23, 2020 - This cluster-randomized trial evaluated the effectiveness of a standardized handoff process at preventing
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psnet.ahrq.gov/issue/evidence-base-us-joint-commission-hospital-accreditation-standards-cross-sectional-study
June 09, 2021 - Investigators evaluated the evidence base for 20 actionable standards issued by The Joint Commission
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psnet.ahrq.gov/issue/relationship-between-patient-safety-culture-and-patient-outcomes-systematic-review
March 11, 2020 - This systematic review evaluated the evidence linking safety culture and patient outcomes, including
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psnet.ahrq.gov/issue/how-often-do-physicians-review-medication-charts-ward-rounds
September 23, 2020 - authors suggest that prescribing errors may result from these practices, though this was not explicitly evaluated
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psnet.ahrq.gov/sites/default/files/2023-03/challenging_case_of_multiple_suicide_attempts_in_a_complex_patient_with_psychiatric_comorbidities.pdf
January 01, 2023 - of lorazepam to relieve anxiety.
5
Case Details (2)
• A consulting psychiatrist at the hospital evaluated … • The patient was discharged to her mother’s care the same day that she
was evaluated by the consulting … after her mother promised to
monitor the patient and control her medications until she could be re-
evaluated … • A consulting psychiatrist evaluated the patient but recommended sending
her home on a benzodiazepine
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psnet.ahrq.gov/issue/psychosocial-factors-and-safety-high-risk-industries-systematic-literature-review
July 15, 2020 - point, associations between job demands and resources, and between safety behaviors and outcomes were evaluated
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psnet.ahrq.gov/issue/quantifying-discharge-medication-reconciliation-errors-2-pediatric-hospitals
October 20, 2021 - The authors evaluated the prevalence of these errors at two pediatric hospitals and found that duplication
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psnet.ahrq.gov/issue/rating-raters-evaluation-publicly-reported-hospital-quality-rating-systems
April 06, 2022 - This article evaluated four widely used hospital rating systems and found that all suffered from methodological
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psnet.ahrq.gov/issue/intraoperative-code-blue-improving-teamwork-and-code-response-through-interprofessional-situ
April 28, 2021 - This study evaluated the impact of a one-hour interdisciplinary in situ simulation training on code response
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psnet.ahrq.gov/issue/detecting-adverse-drug-reactions-paediatric-wards-intensified-surveillance-versus
May 10, 2023 - approaches to collect data, an intensified surveillance system and computer-assisted screening, the authors evaluated
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psnet.ahrq.gov/issue/improving-adverse-drug-event-reporting-healthcare-professionals
April 12, 2019 - This Cochrane review, including 15 studies with over 62,000 participants, evaluated the effectiveness
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psnet.ahrq.gov/issue/crowdsourced-feedback-improve-resident-physician-error-disclosure-skills-randomized-clinical
May 18, 2022 - This randomized trial evaluated the effectiveness of video-based communication assessment (VCA) feedback
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psnet.ahrq.gov/issue/delayed-admissions-pediatric-intensive-care-unit-progression-disease-or-errors-emergency
June 14, 2019 - This study evaluated the impact of errors in the emergency department management of pediatric patients
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psnet.ahrq.gov/issue/communication-during-trauma-resuscitation-do-we-know-what-happening
February 03, 2021 - Investigators evaluated more than 200 resuscitations and discovered that communication was audible only
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psnet.ahrq.gov/issue/adverse-events-and-near-miss-reporting-nhs
August 30, 2023 - This study evaluated the utility of a voluntary reporting system from several National Health Service
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psnet.ahrq.gov/issue/adopting-system-models-multiple-incident-analysis-utility-and-usability
May 19, 2021 - This qualitative study conducted in the United Kingdom evaluated the utility of two system models –