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psnet.ahrq.gov/node/34674/psn-pdf
December 23, 2008 - Incidence and preventability of adverse drug events in
hospitalized patients.
December 23, 2008
Bates DW, Leape L, Petrycki S. Incidence and preventability of adverse drug events in hospitalized adults.
J Gen Intern Med. 1993;8(6):289-294.
https://psnet.ahrq.gov/issue/incidence-and-preventability-adverse-drug-even…
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psnet.ahrq.gov/node/73332/psn-pdf
May 26, 2021 - An evolving hospital quality star rating system from CMS:
aligning the stars.
May 26, 2021
Bilimoria KY, Barnard C. An evolving hospital quality star rating system from CMS: aligning the stars.
JAMA. 2021;325(21):2151-2152. doi:10.1001/jama.2021.6946.
https://psnet.ahrq.gov/issue/evolving-hospital-quality-star-rat…
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psnet.ahrq.gov/issue/computer-alert-system-prevent-injury-adverse-drug-events-development-and-evaluation-community
November 01, 2016 - Study
Classic
A computer alert system to prevent injury from adverse drug events: development and evaluation in a community teaching hospital.
Citation Text:
Raschke RA, Gollihare B, Wunderlich TA, et al. A Computer Alert System to Prevent Injury From Adverse …
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psnet.ahrq.gov/issue/hospital-board-and-management-practices-are-strongly-related-hospital-performance-clinical
October 27, 2021 - Study
Classic
Hospital board and management practices are strongly related to hospital performance on clinical quality metrics.
Citation Text:
Tsai TC, Jha AK, Gawande AA, et al. Hospital board and management practices are strongly related to hospital performanc…
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psnet.ahrq.gov/innovation/esimpler-dynamic-electronic-health-record-integrated-checklist-clinical-decision-support
June 16, 2021 - EMERGING INNOVATIONS
eSIMPLER: a dynamic, electronic health record-integrated checklist for clinical decision support during PICU daily rounds.
Citation Text:
Geva A, Albert BD, Hamilton S, et al. eSIMPLER: a dynamic, electronic health record-integrated checklist for clinical decision support duri…
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psnet.ahrq.gov/node/46952/psn-pdf
January 01, 2019 - Perspectives on patient and family engagement with
reduction in harm: the forgotten voice.
December 21, 2018
Schenk EC, Bryant RA, Van Son CR, et al. Perspectives on Patient and Family Engagement With
Reduction in Harm: The Forgotten Voice. J Nurs Care Qual. 2019;34(1):73-79.
doi:10.1097/NCQ.0000000000000333.
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January 26, 2022 - Improving self-reported empathy and communication
skills through harm in healthcare response training.
January 26, 2022
Samuels A, Broome ME, McDonald TB, et al. Improving self-reported empathy and communication skills
through harm in healthcare response training. J Patient Saf Risk Manage. 2021;26(6):251-260.
doi…
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psnet.ahrq.gov/node/854383/psn-pdf
January 01, 2024 - What can safety cases offer for patient safety? A multisite
case study.
October 11, 2023
Liberati EG, Martin GP, Lamé G, et al. What can Safety Cases offer for patient safety? A multisite case
study. BMJ Qual Saf. 2024;33(3):156-165. doi:10.1136/bmjqs-2023-016042.
https://psnet.ahrq.gov/issue/what-can-safety-cases…
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psnet.ahrq.gov/node/60729/psn-pdf
July 29, 2020 - Oncology pharmacist-led medication reconciliation
among cancer patients initiating chemotherapy.
July 29, 2020
Chun DS, Faso A, Muss HB, et al. Oncology pharmacist-led medication reconciliation among cancer
patients initiating chemotherapy. J Oncol Pharm Pract. 2020;26(5):1156-1163.
doi:10.1177/1078155219892066.
…
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psnet.ahrq.gov/node/38027/psn-pdf
October 15, 2008 - Assessing the Evidence Base for Context-Sensitive
Effectiveness and Safety of Patient Safety Practices:
Developing Criteria.
October 15, 2008
US Department of Health and Human Services; HHS; Agency for Healthcare Research and Quality; AHRQ.
https://psnet.ahrq.gov/issue/assessing-evidence-base-context-sensitive-eff…
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psnet.ahrq.gov/node/36888/psn-pdf
November 30, 2016 - Hospital Survey on Patient Safety Culture: 2007
Comparative Database Report.
November 30, 2016
Sorra J, Nieva V, Famolaro T, et al. Rockville, MD: Agency for Healthcare; 2007. AHRQ publication, no. 07-
0025.
https://psnet.ahrq.gov/issue/hospital-survey-patient-safety-culture-2007-comparative-database-report
A key…
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psnet.ahrq.gov/node/47724/psn-pdf
March 20, 2019 - Understanding patient safety and quality outcome data.
March 20, 2019
Easter K, Tamburri LM. Understanding Patient Safety and Quality Outcome Data. Crit Care Nurse.
2018;38(6):58-66. doi:10.4037/ccn2018979.
https://psnet.ahrq.gov/issue/understanding-patient-safety-and-quality-outcome-data
Public reporting of safet…
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psnet.ahrq.gov/node/45736/psn-pdf
February 01, 2017 - Disruptive behaviour in the perioperative setting: a
contemporary review.
February 1, 2017
Villafranca A, Hamlin C, Enns S, et al. Disruptive behaviour in the perioperative setting: a contemporary
review. Canadian J Anaesth. 2017;64(2):128-140. doi:10.1007/s12630-016-0784-x.
https://psnet.ahrq.gov/issue/disruptive…
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psnet.ahrq.gov/node/43142/psn-pdf
June 15, 2014 - Development and sustainability of an inpatient-to-
outpatient discharge handoff tool: a quality improvement
project.
June 15, 2014
Moy NY, Lee SJ, Chan T, et al. Development and sustainability of an inpatient-to-outpatient discharge
handoff tool: a quality improvement project. Jt Comm J Qual Patient Saf. 2014;40(5…
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psnet.ahrq.gov/node/43425/psn-pdf
July 03, 2016 - Graduate medical education's new focus on resident
engagement in quality and safety: will it transform the
culture of teaching hospitals?
July 3, 2016
Myers JS, Nash DB. Graduate Medical Education’s New Focus on Resident Engagement in Quality and
Safety. Acad Med. 2014;89(10):1328-1330. doi:10.1097/acm.00000000000…
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psnet.ahrq.gov/node/74729/psn-pdf
February 02, 2022 - Healing our own: a randomized trial to assess benefits of
peer support.
February 2, 2022
Rivera-Chiauzzi EY, Smith HA, Moore-Murray T, et al. Healing our own: a randomized trial to assess
benefits of peer support. J Patient Saf. 2022;18(1):e308-e314. doi:10.1097/pts.0000000000000771.
https://psnet.ahrq.gov/issue/h…
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psnet.ahrq.gov/node/840144/psn-pdf
November 16, 2022 - Dedicated teams to optimize quality and safety of
surgery: a systematic review.
November 16, 2022
Lentz CM, De Lind Van Wijngaarden RAF, Willeboordse F, et al. Dedicated teams to optimize quality and
safety of surgery: a systematic review. Int J Qual Health Care. 2022;34(4):mzac078.
doi:10.1093/intqhc/mzac078.
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September 09, 2015 - Utilizing pharmacy students in transitions-of-care
services.
September 9, 2015
L'Hommedieu T, DeCoske M, Lababidi RE, et al. Utilizing pharmacy students in transitions-of-care
services. Am J Health Syst Pharm. 2015;72(15):1266-8. doi:10.2146/ajhp140561.
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psnet.ahrq.gov/node/42536/psn-pdf
August 13, 2014 - Levels of reflective thinking and patient safety: an
investigation of the mechanisms that impact on student
learning in a single cohort over a 5 year curriculum.
August 13, 2014
Ambrose LJ, Ker J. Levels of reflective thinking and patient safety: an investigation of the mechanisms that
impact on student learning i…
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psnet.ahrq.gov/node/42672/psn-pdf
October 23, 2013 - SBAR improves nurse–physician communication and
reduces unexpected death: a pre and post intervention
study.
October 23, 2013
De Meester K, Verspuy M, Monsieurs KG, et al. SBAR improves nurse-physician communication and
reduces unexpected death: a pre and post intervention study. Resuscitation. 2013;84(9):1192-6.
…