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psnet.ahrq.gov/node/847718/psn-pdf
April 19, 2023 - Effect of a Veterans Health Administration mandate to
case review patients with opioid prescriptions on
mortality among patients with opioid use disorder: a
secondary analysis of the STORM randomized control
trial.
April 19, 2023
Auty SG, Barr KD, Frakt AB, et al. Effect of a Veterans Health Administration mandat…
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psnet.ahrq.gov/node/45405/psn-pdf
November 18, 2016 - Relationship between operating room teamwork,
contextual factors, and safety checklist performance.
November 18, 2016
Singer SJ, Molina G, Li Z, et al. Relationship Between Operating Room Teamwork, Contextual Factors,
and Safety Checklist Performance. J Am Coll Surg. 2016;223(4):568-580.e2.
doi:10.1016/j.jamcollsu…
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psnet.ahrq.gov/node/47088/psn-pdf
May 02, 2018 - Medical Office Survey on Patient Safety Culture: 2018
User Database Report.
May 2, 2018
Famolaro T, Yount N, Hare R, et al. Rockville, MD: Agency for Healthcare Research and Quality; April
2018. AHRQ Publication No. 18-0030-EF.
https://psnet.ahrq.gov/issue/medical-office-survey-patient-safety-culture-2018-user-dat…
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psnet.ahrq.gov/node/847717/psn-pdf
April 19, 2023 - Quality improvement initiative to decrease central line-
associated bloodstream infections during the COVID-19
pandemic: a "zero harm" approach.
April 19, 2023
Redstone CS, Zadeh M, Wilson M-A, et al. Quality improvement initiative to decrease central line-
associated bloodstream infections during the COVID-19 pan…
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psnet.ahrq.gov/node/45356/psn-pdf
May 09, 2017 - Screening for medication errors using an outlier detection
system.
May 9, 2017
Schiff G, Volk LA, Volodarskaya M, et al. Screening for medication errors using an outlier detection system.
J Am Med Inform Assoc. 2017;24(2):281-287. doi:10.1093/jamia/ocw171.
https://psnet.ahrq.gov/issue/screening-medication-errors-u…
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psnet.ahrq.gov/node/38120/psn-pdf
June 16, 2011 - Organizational culture, team climate and diabetes care in
small office-based practices.
June 16, 2011
Bosch M, Dijkstra R, Wensing M, et al. Organizational culture, team climate and diabetes care in small
office-based practices. BMC Health Serv Res. 2008;8:180. doi:10.1186/1472-6963-8-180.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/37908/psn-pdf
June 10, 2010 - Incidence and characteristics of potential and actual
retained foreign object events in surgical patients.
June 10, 2010
Cima RR, Kollengode A, Garnatz J, et al. Incidence and characteristics of potential and actual retained
foreign object events in surgical patients. J Am Coll Surg. 2008;207(1):80-7.
doi:10.1016/…
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psnet.ahrq.gov/node/38076/psn-pdf
February 15, 2011 - Consequences of inadequate sign-out for patient care.
February 15, 2011
Horwitz LI, Moin T, Krumholz HM, et al. Consequences of inadequate sign-out for patient care. Arch Intern
Med. 2008;168(16):1755-60. doi:10.1001/archinte.168.16.1755.
https://psnet.ahrq.gov/issue/consequences-inadequate-sign-out-patient-care
W…
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psnet.ahrq.gov/node/844801/psn-pdf
January 01, 2021 - A mixed-methods study of challenges experienced by
clinical teams in measuring improvement.
September 11, 2019
Woodcock T, Liberati EG, Dixon-Woods M. A mixed-methods study of challenges experienced by clinical
teams in measuring improvement. BMJ Qual Saf. 2021;30(2):106-115. doi:10.1136/bmjqs-2018-009048.
https:/…
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psnet.ahrq.gov/node/42653/psn-pdf
January 07, 2015 - Exploring the sociotechnical intersection of patient safety
and electronic health record implementation.
January 7, 2015
Meeks DW, Takian A, Sittig DF, et al. Exploring the sociotechnical intersection of patient safety and
electronic health record implementation. J Am Med Inform Assoc. 2014;21(e1):e28-e34.
doi:10.…
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psnet.ahrq.gov/node/45323/psn-pdf
June 28, 2017 - Effects of health information technology on patient
outcomes: a systematic review.
June 28, 2017
Brenner SK, Kaushal R, Grinspan Z, et al. Effects of health information technology on patient outcomes: a
systematic review. J Am Med Inform Assoc. 2016;23(5):1016-36. doi:10.1093/jamia/ocv138.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/46856/psn-pdf
June 20, 2018 - Visual acuity, literacy, and unintentional misuse of
nonprescription medications.
June 20, 2018
Mullen RJ, Curtis LM, O'Conor R, et al. Visual acuity, literacy, and unintentional misuse of nonprescription
medications. Am J Health-Syst Pharm. 2018;75(9):e213-e220. doi:10.2146/ajhp170303.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/37254/psn-pdf
January 02, 2017 - Creating a fair and just culture: one institution's path
toward organizational change.
January 2, 2017
Connor M, Duncombe D, Barclay E, et al. Creating a fair and just culture: one institution's pat toward
organizational change. Jt Comm J Qual Patient Saf. 2007;33(10):617-24.
https://psnet.ahrq.gov/issue/creating-…
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psnet.ahrq.gov/node/38449/psn-pdf
March 04, 2009 - A model for increasing patient safety in the intensive care
unit: increasing the implementation rates of proven safety
measures.
March 4, 2009
Krimsky WS, Mroz IB, McIlwaine JK, et al. A model for increasing patient safety in the intensive care unit:
increasing the implementation rates of proven safety measures. Q…
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psnet.ahrq.gov/node/40562/psn-pdf
July 03, 2014 - Paid malpractice claims for adverse events in inpatient
and outpatient settings.
July 3, 2014
Bishop TF, Ryan AM, Ryan AK, et al. Paid malpractice claims for adverse events in inpatient and outpatient
settings. JAMA. 2011;305(23):2427-31. doi:10.1001/jama.2011.813.
https://psnet.ahrq.gov/issue/paid-malpractice-cla…
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psnet.ahrq.gov/node/39951/psn-pdf
October 27, 2010 - Making inpatient medication reconciliation patient
centered, clinically relevant and implementable: a
consensus statement on key principles and necessary
first steps.
October 27, 2010
Greenwald JL, Halasyamani L, Greene J, et al. Making inpatient medication reconciliation patient centered,
clinically relevant and…
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psnet.ahrq.gov/node/44034/psn-pdf
January 19, 2016 - Surgical checklist implementation project: the impact of
variable WHO checklist compliance on risk-adjusted
clinical outcomes after national implementation: a
longitudinal study.
January 19, 2016
Mayer EK, Sevdalis N, Rout S, et al. Surgical Checklist Implementation Project: The Impact of Variable
WHO Checklist C…
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psnet.ahrq.gov/node/42396/psn-pdf
July 31, 2013 - Developing and implementing a standardized process for
Global Trigger Tool application across a large health
system.
July 31, 2013
Garrett PR, Sammer C, Nelson A, et al. Developing and implementing a standardized process for global
trigger tool application across a large health system. Jt Comm J Qual Saf. 2013;39(…
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psnet.ahrq.gov/node/38077/psn-pdf
January 31, 2011 - Building physician work hour regulations from first
principles and best evidence.
January 31, 2011
Volpp KG, Landrigan CP. Building physician work hour regulations from first principles and best evidence.
JAMA. 2008;300(10):1197-9. doi:10.1001/jama.300.10.1197.
https://psnet.ahrq.gov/issue/building-physician-work-…
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psnet.ahrq.gov/node/38616/psn-pdf
June 08, 2009 - Cost and workforce implications of subjecting all
physicians to aviation industry work-hour restrictions.
June 8, 2009
Payette M, Chatterjee A, Weeks WB. Cost and workforce implications of subjecting all physicians to
aviation industry work-hour restrictions. Am J Surg. 2009;197(6):820-5; discussion 826-7.
doi:1…