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  1. Reducing adverse drug events: lessons from a breakthrough series collaborative. | PSNet

    psnet.ahrq.gov/issue/reducing-adverse-drug-events-lessons-breakthrough-series-collaborative
    August 04, 2021 - Study Classic Reducing adverse drug events: lessons from a breakthrough series collaborative. Citation Text: Leape L, Kabcenell AI, Gandhi TK, et al. Reducing adverse drug events: lessons from a breakthrough series collaborative. Jt Comm J Qual Improv. 2000;26(6…

  2. Improving patient handovers from hospital to primary care: a systematic review. | PSNet

    psnet.ahrq.gov/issue/improving-patient-handovers-hospital-primary-care-systematic-review
    March 06, 2013 - Review Improving patient handovers from hospital to primary care: a systematic review. Citation Text: Hesselink G, Schoonhoven L, Barach P, et al. Improving patient handovers from hospital to primary care: a systematic review. Ann Intern Med. 2013;157(6):417. doi:10.7326/0003-4819-157-6-…

  3. Surgeon and surgical trainee experiences after adverse patient events. | PSNet

    psnet.ahrq.gov/issue/surgeon-and-surgical-trainee-experiences-after-adverse-patient-events
    January 09, 2019 - Study Surgeon and surgical trainee experiences after adverse patient events. Citation Text: Ginzberg SP, Gasior JA, Passman JE, et al. Surgeon and surgical trainee experiences after adverse patient events. JAMA Netw Open. 2024;7(6):e2414329. doi:10.1001/jamanetworkopen.2024.14329. Copy…

  4. One fourth of unplanned transfers to a higher level of care are associated with a highly preventable adverse event: a patient record review in six Belgian hospitals. | PSNet

    psnet.ahrq.gov/issue/one-fourth-unplanned-transfers-higher-level-care-are-associated-highly-preventable-adverse
    May 16, 2018 - Study One fourth of unplanned transfers to a higher level of care are associated with a highly preventable adverse event: a patient record review in six Belgian hospitals. Citation Text: Marquet K, Claes N, De Troy E, et al. One fourth of unplanned transfers to a higher level of care are…

  5. Errors in administration of parenteral drugs in intensive care units: multinational prospective study. | PSNet

    psnet.ahrq.gov/issue/errors-administration-parenteral-drugs-intensive-care-units-multinational-prospective-study
    September 30, 2010 - Study Errors in administration of parenteral drugs in intensive care units: multinational prospective study. Citation Text: Valentin A, Capuzzo M, Guidet B, et al. Errors in administration of parenteral drugs in intensive care units: multinational prospective study. BMJ. 2009;338:b814.…

  6. A checklist to address implicit bias in healthcare settings during the COVID-19 pandemic: The PLACE Strategy. | PSNet

    psnet.ahrq.gov/issue/checklist-address-implicit-bias-healthcare-settings-during-covid-19-pandemic-place-strategy
    July 07, 2021 - Commentary A checklist to address implicit bias in healthcare settings during the COVID-19 pandemic: The PLACE Strategy. Citation Text: Galiatsatos P, O'Conor KJ, Wilson C, et al. A checklist to address implicit bias in healthcare settings during the COVID-19 pandemic: The PLACE Strategy…

  7. Development and implementation of a subcutaneous insulin pen label bar code scanning protocol to prevent wrong-patient insulin pen errors. | PSNet

    psnet.ahrq.gov/issue/development-and-implementation-subcutaneous-insulin-pen-label-bar-code-scanning-protocol
    October 19, 2022 - Study Development and implementation of a subcutaneous insulin pen label bar code scanning protocol to prevent wrong-patient insulin pen errors. Citation Text: MacMaster HW, Gonzalez S, Maruoka A, et al. Development and Implementation of a Subcutaneous Insulin Pen Label Bar Code Scanning…

  8. Assessing the effectiveness of engaging patients and their families in the three-step fall prevention process across modalities of an evidence-based fall prevention toolkit: an implementation science study. | PSNet

    psnet.ahrq.gov/issue/assessing-effectiveness-engaging-patients-and-their-families-three-step-fall-prevention
    February 19, 2020 - Study Assessing the effectiveness of engaging patients and their families in the three-step fall prevention process across modalities of an evidence-based fall prevention toolkit: an implementation science study. Citation Text: Duckworth M, Adelman JS, Belategui K, et al. Assessing the E…

  9. Decisions about critical events in device-related scenarios as a function of expertise. | PSNet

    psnet.ahrq.gov/issue/decisions-about-critical-events-device-related-scenarios-function-expertise
    January 02, 2017 - Study Decisions about critical events in device-related scenarios as a function of expertise. Citation Text: Laxmisan A, Malhotra S, Keselman A, et al. Decisions about critical events in device-related scenarios as a function of expertise. J Biomed Inform. 2005;38(3):200-12. Copy Citat…

  10. Development of a tool within the electronic medical record to facilitate medication reconciliation after hospital discharge. | PSNet

    psnet.ahrq.gov/issue/development-tool-within-electronic-medical-record-facilitate-medication-reconciliation-after
    June 09, 2011 - Study Development of a tool within the electronic medical record to facilitate medication reconciliation after hospital discharge. Citation Text: Schnipper JL, Liang CL, Hamann C, et al. Development of a tool within the electronic medical record to facilitate medication reconciliation …

  11. A qualitative study of prescribing errors among multi-professional prescribers within an e-prescribing system. | PSNet

    psnet.ahrq.gov/issue/qualitative-study-prescribing-errors-among-multi-professional-prescribers-within-e
    December 02, 2020 - Study A qualitative study of prescribing errors among multi-professional prescribers within an e-prescribing system. Citation Text: Alshahrani F, Marriott JF, Cox AR. A qualitative study of prescribing errors among multi-professional prescribers within an e-prescribing system. Int J Clin…

  12. A clinical data warehouse-based process for refining medication orders alerts. | PSNet

    psnet.ahrq.gov/issue/clinical-data-warehouse-based-process-refining-medication-orders-alerts
    March 10, 2011 - Study A clinical data warehouse-based process for refining medication orders alerts. Citation Text: Boussadi A, Caruba T, Zapletal E, et al. A clinical data warehouse-based process for refining medication orders alerts. J Am Med Inform Assoc. 2012;19(5):782-5. doi:10.1136/amiajnl-2012-00…

  13. Differences of reasons for alert overrides on contraindicated co-prescriptions by admitting department. | PSNet

    psnet.ahrq.gov/issue/differences-reasons-alert-overrides-contraindicated-co-prescriptions-admitting-department
    January 23, 2017 - Study Differences of reasons for alert overrides on contraindicated co-prescriptions by admitting department. Citation Text: Ahn EK, Cho S-Y, Shin D, et al. Differences of Reasons for Alert Overrides on Contraindicated Co-prescriptions by Admitting Department. Healthc Inform Res. 2014;20…

  14. "We're not taken seriously": describing the experiences of perceived discrimination in medical settings for Black women. | PSNet

    psnet.ahrq.gov/issue/were-not-taken-seriously-describing-experiences-perceived-discrimination-medical-settings
    August 26, 2020 - Study "We're not taken seriously": describing the experiences of perceived discrimination in medical settings for Black women. Citation Text: Washington A, Randall J. "We're not taken seriously": describing the experiences of perceived discrimination in medical settings for Black women. …

  15. The effect of clinical experience on the error rate of emergency physicians. | PSNet

    psnet.ahrq.gov/issue/effect-clinical-experience-error-rate-emergency-physicians
    November 16, 2022 - Study The effect of clinical experience on the error rate of emergency physicians. Citation Text: Berk WA, Welch RD, Levy PD, et al. The effect of clinical experience on the error rate of emergency physicians. Ann Emerg Med. 2008;52(5):497-501. doi:10.1016/j.annemergmed.2008.01.329. …

  16. Hospitalisation for medication misadventures among older adults with and without dementia: a 5-year retrospective study. | PSNet

    psnet.ahrq.gov/issue/hospitalisation-medication-misadventures-among-older-adults-and-without-dementia-5-year
    August 18, 2021 - Study Hospitalisation for medication misadventures among older adults with and without dementia: a 5-year retrospective study. Citation Text: Mullan J, Burns P, Mohanan L, et al. Hospitalisation for medication misadventures among older adults with and without dementia: A 5-year retrospec…

  17. Adoption of electronic health records grows rapidly, but fewer than half of US hospitals had at least a basic system in 2012. | PSNet

    psnet.ahrq.gov/issue/adoption-electronic-health-records-grows-rapidly-fewer-half-us-hospitals-had-least-basic
    August 07, 2013 - Study Adoption of electronic health records grows rapidly, but fewer than half of US hospitals had at least a basic system in 2012. Citation Text: DesRoches CM, Charles D, Furukawa MF, et al. Adoption of electronic health records grows rapidly, but fewer than half of US hospitals had…

  18. Inappropriate diagnosis of pneumonia among hospitalized adults. | PSNet

    psnet.ahrq.gov/issue/inappropriate-diagnosis-pneumonia-among-hospitalized-adults
    July 17, 2024 - Study Inappropriate diagnosis of pneumonia among hospitalized adults. Citation Text: Gupta AB, Flanders SA, Petty LA, et al. Inappropriate diagnosis of pneumonia among hospitalized adults. JAMA Intern Med. 2024;184(4):548-556. doi:10.1001/jamainternmed.2024.0077. Copy Citation Form…

  19. Improving infusion pump safety through usability testing. | PSNet

    psnet.ahrq.gov/issue/improving-infusion-pump-safety-through-usability-testing
    July 15, 2020 - Commentary Improving infusion pump safety through usability testing. Citation Text: Miller K, Arnold R, Capan M, et al. Improving infusion pump safety through usability testing. J Nurs Care Qual. 2017;32(2):141-149. doi:10.1097/NCQ.0000000000000208. Copy Citation Format: DO…

  20. Wrong-site surgery, retained surgical items, and surgical fires: a systematic review of surgical never events. | PSNet

    psnet.ahrq.gov/issue/wrong-site-surgery-retained-surgical-items-and-surgical-fires-systematic-review-surgical
    March 13, 2013 - Review Wrong-site surgery, retained surgical items, and surgical fires: a systematic review of surgical never events. Citation Text: Hempel S, Maggard-Gibbons M, Nguyen DK, et al. Wrong-Site Surgery, Retained Surgical Items, and Surgical Fires : A Systematic Review of Surgical Never Even…
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