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psnet.ahrq.gov/node/44599/psn-pdf
December 09, 2015 - Association between day of delivery and obstetric
outcomes: observational study.
December 9, 2015
Palmer WL, Bottle A, Aylin P. Association between day of delivery and obstetric outcomes: observational
study. BMJ. 2015;351:h5774. doi:10.1136/bmj.h5774.
https://psnet.ahrq.gov/issue/association-between-day-delivery-…
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psnet.ahrq.gov/node/50866/psn-pdf
February 05, 2020 - Effectiveness of acute care remote triage systems: a
systematic review.
February 5, 2020
Boggan JC, Shoup JP, Whited JD, et al. Effectiveness of acute care remote triage systems: a systematic
review. J Gen Intern Med. 2020;35(7):2136-2145. doi:10.1007/s11606-019-05585-4.
https://psnet.ahrq.gov/issue/effectiveness-…
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psnet.ahrq.gov/node/837677/psn-pdf
July 13, 2022 - Multiple Failures in Test Results Follow-up for a Patient
Diagnosed with Prostate Cancer at the Hampton VA
Medical Center in Virginia.
July 13, 2022
Washington, DC: VA Office of the Inspector General; June 28, 2022. Report No 21-03349-186.
https://psnet.ahrq.gov/issue/multiple-failures-test-results-follow-patient-…
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psnet.ahrq.gov/node/73438/psn-pdf
June 30, 2021 - Implementation of patient safety structures and
processes in the patient-centered medical home.
June 30, 2021
Oberlander T, Scholle SH, Marsteller JA, et al. Implementation of patient safety structures and processes in
the patient-centered medical home. J Healthc Qual. 2021;43(6):324-339.
doi:10.1097/jhq.000000000…
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psnet.ahrq.gov/node/845630/psn-pdf
March 08, 2023 - The effect of transitions intervention to ensure patient
safety and satisfaction when transferred from hospital to
home health care-a systematic review.
March 8, 2023
Oksholm T, Gissum KR, Hunskår I, et al. The effect of transitions intervention to ensure patient safety and
satisfaction when transferred from hospi…
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psnet.ahrq.gov/node/34829/psn-pdf
April 06, 2011 - Use of medical emergency team responses to reduce
hospital cardiopulmonary arrests.
April 6, 2011
Devita MA, Braithwaite RS, Mahidhara R, et al. Use of medical emergency team responses to reduce
hospital cardiopulmonary arrests. Qual Saf Health Care. 2004;13(4):251-4.
https://psnet.ahrq.gov/issue/use-medical-emerg…
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psnet.ahrq.gov/node/836966/psn-pdf
April 20, 2022 - Performance variability in perioperative sentinel events:
report on a nationwide data set.
April 20, 2022
Reijmerink IM, Bos K, Leistikow IP, et al. Performance variability in perioperative sentinel events: report on
a nationwide data set. Br J Surg. 2022;109(7):573-575. doi:10.1093/bjs/znac067.
https://psnet.ahrq…
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psnet.ahrq.gov/node/47250/psn-pdf
September 26, 2018 - Hospital-acquired infections under pay-for-performance
systems: an administrative perspective on management
and change.
September 26, 2018
Vokes RA, Bearman G, Bazzoli GJ. Hospital-Acquired Infections Under Pay-for-Performance Systems: an
Administrative Perspective on Management and Change. Curr Infect Dis Rep. 20…
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psnet.ahrq.gov/node/855422/psn-pdf
November 15, 2023 - An exploratory analysis of the association between
hospital quality measures and financial performance.
November 15, 2023
Beauvais B, Dolezel D, Ramamonjiarivelo Z. An exploratory analysis of the association between hospital
quality measures and financial performance. Healthcare (Basel). 2023;11(20):2758.
doi:10.3…
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psnet.ahrq.gov/node/74695/psn-pdf
January 26, 2022 - Impact of teamwork and communication training
interventions on safety culture and patient safety in
emergency departments: a systematic review.
January 26, 2022
Alsabri M, Boudi Z, Lauque D, et al. Impact of teamwork and communication training interventions on
safety culture and patient safety in emergency departm…
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psnet.ahrq.gov/node/47489/psn-pdf
November 21, 2018 - Impact of the Care Quality Commission on Provider
Performance: Room for Improvement?
November 21, 2018
Smithson R, Richardson E, Roberts J, et al. The King's Fund, Alliance Manchester Business School;
September 2018. ISBN: 9781909029880.
https://psnet.ahrq.gov/issue/impact-care-quality-commission-provider-performa…
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psnet.ahrq.gov/node/47251/psn-pdf
July 25, 2018 - Fail-safe patient ID matching remains just out of reach.
July 25, 2018
Arndt RZ. Mod Healthc. July 14, 2018.
https://psnet.ahrq.gov/issue/fail-safe-patient-id-matching-remains-just-out-reach
Similarities in patient names and clinical situations can result in medical errors. Discussing how digital
technologies can …
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psnet.ahrq.gov/node/60232/psn-pdf
April 15, 2020 - Sustaining innovations in complex health care
environments: a multiple-case study of rapid response
teams.
April 15, 2020
Stolldorf DP, Havens DS, Jones CB. Sustaining innovations in complex health care environments: a
multiple-case study of rapid response teams. J Patient Saf. 2020;16(1).
doi:10.1097/pts.0000000…
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psnet.ahrq.gov/node/60662/psn-pdf
January 01, 2022 - Medication order errors at hospital admission among
children with medical complexity
July 8, 2020
Blaine K, Wright J, Pinkham A, et al. Medication Order Errors at Hospital Admission Among Children With
Medical Complexity. J Patient Saf. 2022;18(1):e156-e162. doi:10.1097/pts.0000000000000719.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/72664/psn-pdf
January 20, 2021 - Delayed flow is a risk to patient safety: a mixed method
analysis of emergency department patient flow.
January 20, 2021
Pryce A, Unwin M, Kinsman L, et al. Delayed flow is a risk to patient safety: A mixed method analysis of
emergency department patient flow. Int Emerg Nurs. 2020;54:100956. doi:10.1016/j.ienj.2020…
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psnet.ahrq.gov/node/60991/psn-pdf
October 07, 2020 - Nonfatal opioid overdoses at an urban emergency
department during the COVID-19 pandemic.
October 7, 2020
Ochalek TA, Cumpston KL, Wills BK, et al. Nonfatal opioid overdoses at an urban emergency department
during the COVID-19 pandemic. JAMA. 2020;324(16):1673-1674. doi:10.1001/jama.2020.17477.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/47952/psn-pdf
January 01, 2020 - Overlooked guide wire: a multicomplicated Swiss Cheese
Model example. Analysis of a case and review of the
literature.
May 15, 2019
Thonon H, Espeel F, Frederic F, et al. Overlooked guide wire: a multicomplicated Swiss Cheese Model
example. Analysis of a case and review of the literature. Acta Clin Belg. 2020;75(3…
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psnet.ahrq.gov/node/34795/psn-pdf
December 23, 2008 - Preventable adverse drug events in hospitalized patients:
a comparative study of intensive care and general care
units.
December 23, 2008
Cullen DJ, Sweitzer BJ, Bates DW, et al. Preventable adverse drug events in hospitalized patients. Crit
Care Med. 1997;25(8):1289-1297. doi:10.1097/00003246-199708000-00014.
ht…
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psnet.ahrq.gov/node/36700/psn-pdf
July 20, 2011 - Adverse drug events resulting from patient errors in older
adults.
July 20, 2011
Field TS, Mazor KM, Briesacher BA, et al. Adverse Drug Events Resulting from Patient Errors in Older
Adults. J Am Geriatr Soc. 2007;55(2):271-276. doi:10.1111/j.1532-5415.2007.01047.x.
https://psnet.ahrq.gov/issue/adverse-drug-events-…
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psnet.ahrq.gov/node/34067/psn-pdf
January 04, 2017 - Does full disclosure of medical errors affect malpractice
liability? The jury is still out.
January 4, 2017
Kachalia A, Shojania KG, Hofer TP, et al. Does full disclosure of medical errors affect malpractice liability?
The jury is still out. Jt Comm J Qual Saf. 2003;29(10):503-11.
https://psnet.ahrq.gov/issue/does…