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  1. Improvement in the detection of adverse drug events by the use of electronic health and prescription records: an evaluation of two trigger tools. | PSNet

    psnet.ahrq.gov/issue/improvement-detection-adverse-drug-events-use-electronic-health-and-prescription-records
    September 23, 2020 - Study Improvement in the detection of adverse drug events by the use of electronic health and prescription records: an evaluation of two trigger tools. Citation Text: Nwulu U, Nirantharakumar K, Odesanya R, et al. Improvement in the detection of adverse drug events by the use of electr…

  2. Failures in Care Coordination and Reviewing a Patient's Death at the VA Salt Lake City Healthcare System in Utah. | PSNet

    psnet.ahrq.gov/issue/failures-care-coordination-and-reviewing-patients-death-va-salt-lake-city-healthcare-system
    April 19, 2023 - Book/Report Failures in Care Coordination and Reviewing a Patient's Death at the VA Salt Lake City Healthcare System in Utah. Citation Text: Failures in Care Coordination and Reviewing a Patient's Death at the VA Salt Lake City Healthcare System in Utah. Washington, DC: Department of Vet…

  3. Estimating breast cancer overdiagnosis after screening mammography among older women in the United States. | PSNet

    psnet.ahrq.gov/issue/estimating-breast-cancer-overdiagnosis-after-screening-mammography-among-older-women-united
    October 19, 2022 - Study Estimating breast cancer overdiagnosis after screening mammography among older women in the United States. Citation Text: Richman IB, Long JB, Soulos PR, et al. Estimating breast cancer overdiagnosis after screening mammography among older women in the United States. Ann Intern Med…

  4. Rapidly increasing rapid response team activation rates. | PSNet

    psnet.ahrq.gov/issue/rapidly-increasing-rapid-response-team-activation-rates
    February 18, 2015 - Study Rapidly increasing rapid response team activation rates. Citation Text: Braaten JS, deGunst G, Bilys K. Rapidly Increasing Rapid Response Team Activation Rates. Jt Comm J Qual Patient Saf. 2015;41(9):421-427. Copy Citation Format: Google Scholar PubMed BibTeX EndNote …

  5. How effective is teamwork really? The relationship between teamwork and performance in healthcare teams: a systematic review and meta-analysis. | PSNet

    psnet.ahrq.gov/issue/how-effective-teamwork-really-relationship-between-teamwork-and-performance-healthcare-teams
    February 14, 2017 - Review Classic How effective is teamwork really? The relationship between teamwork and performance in healthcare teams: a systematic review and meta-analysis. Citation Text: Schmutz JB, Meier LL, Manser T. How effective is teamwork really? The relationship betwe…

  6. Errors in laboratory medicine: practical lessons to improve patient safety. | PSNet

    psnet.ahrq.gov/issue/errors-laboratory-medicine-practical-lessons-improve-patient-safety
    February 14, 2024 - Commentary Classic Errors in laboratory medicine: practical lessons to improve patient safety. Citation Text: Howanitz PJ. Errors in laboratory medicine: practical lessons to improve patient safety. Arch Pathol Lab Med. 2005;129(10):1252-1261. Copy Citation …

  7. What kinds of insights do Safety-I and Safety-II approaches provide? A critical reflection on the use of SHERPA and FRAM in healthcare. | PSNet

    psnet.ahrq.gov/issue/what-kinds-insights-do-safety-i-and-safety-ii-approaches-provide-critical-reflection-use
    February 02, 2022 - Commentary What kinds of insights do Safety-I and Safety-II approaches provide? A critical reflection on the use of SHERPA and FRAM in healthcare. Citation Text: Sujan M, Lounsbury O, Pickup L, et al. What kinds of insights do Safety-I and Safety-II approaches provide? A critical reflect…

  8. Adverse events in patients with return emergency department visits. | PSNet

    psnet.ahrq.gov/issue/adverse-events-patients-return-emergency-department-visits
    May 31, 2017 - Study Adverse events in patients with return emergency department visits. Citation Text: Calder LA, Pozgay A, Riff S, et al. Adverse events in patients with return emergency department visits. BMJ Qual Saf. 2015;24(2):142-148. doi:10.1136/bmjqs-2014-003194. Copy Citation Format: …

  9. 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…

  10. Safety participation at the direct care level: results of a patient questionnaire. | PSNet

    psnet.ahrq.gov/issue/safety-participation-direct-care-level-results-patient-questionnaire
    August 26, 2020 - Study Safety participation at the direct care level: results of a patient questionnaire. Citation Text: Duhn L, Gumapac N, Medves J. Safety participation at the direct care level: results of a patient questionnaire. Patient Exp J. 2021;8(1):59-68. doi:10.35680/2372-0247.1506. Copy Cita…

  11. Discrepancies in written versus calculated durations in opioid prescriptions: pre-post study. | PSNet

    psnet.ahrq.gov/issue/discrepancies-written-versus-calculated-durations-opioid-prescriptions-pre-post-study
    October 19, 2022 - Study Discrepancies in written versus calculated durations in opioid prescriptions: pre-post study. Citation Text: Slovis BH, Kairys J, Babula B, et al. Discrepancies in written versus calculated durations in opioid prescriptions: pre-post study. JMIR Med Inform. 2020;8(3). doi:10.2196/1…

  12. The relationship between hospital patient safety culture and performance on Centers for Medicare & Medicaid Services value-based purchasing metrics. | PSNet

    psnet.ahrq.gov/issue/relationship-between-hospital-patient-safety-culture-and-performance-centers-medicare
    December 11, 2024 - Study The relationship between hospital patient safety culture and performance on Centers for Medicare & Medicaid Services value-based purchasing metrics. Citation Text: Noghrehchi P, Hefner JL, Walker DM. The relationship between hospital patient safety culture and performance on Center…

  13. The impact of post-fall huddles on repeat fall rates and perceptions of safety culture: a quasi-experimental evaluation of a patient safety demonstration project | PSNet

    psnet.ahrq.gov/issue/impact-post-fall-huddles-repeat-fall-rates-and-perceptions-safety-culture-quasi-experimental
    December 30, 2014 - Journal Article The impact of post-fall huddles on repeat fall rates and perceptions of safety culture: a quasi-experimental evaluation of a patient safety demonstration project Citation Text: Jones KJ, Crowe J, Allen JA, et al. The impact of post-fall huddles on repeat fall rates and pe…

  14. Hospital inpatient falls across clinical departments. | PSNet

    psnet.ahrq.gov/issue/hospital-inpatient-falls-across-clinical-departments
    September 15, 2021 - Study Hospital inpatient falls across clinical departments. Citation Text: Mikos M, Banas T, Czerw A, et al. Hospital inpatient falls across clinical departments. Int J Environ Res Public Health. 2021;18(15):8167. doi:10.3390/ijerph18158167. Copy Citation Format: DOI Google…

  15. Digital maturity as a predictor of quality and safety outcomes in US hospitals: cross-sectional observational study. | PSNet

    psnet.ahrq.gov/issue/digital-maturity-predictor-quality-and-safety-outcomes-us-hospitals-cross-sectional
    September 04, 2024 - Study Digital maturity as a predictor of quality and safety outcomes in US hospitals: cross-sectional observational study. Citation Text: Snowdon A, Hussein A, Danforth M, et al. Digital maturity as a predictor of quality and safety outcomes in US hospitals: cross-sectional observational…

  16. Exploring the causes of COPD misdiagnosis in primary care: a mixed methods study. | PSNet

    psnet.ahrq.gov/issue/exploring-causes-copd-misdiagnosis-primary-care-mixed-methods-study
    September 23, 2020 - Study Exploring the causes of COPD misdiagnosis in primary care: a mixed methods study. Citation Text: Patel K, Smith DJ, Huntley CC, et al. Exploring the causes of COPD misdiagnosis in primary care: a mixed methods study. PLoS ONE. 2024;19(3):e0298432. doi:10.1371/journal.pone.0298432. …

  17. A reduced duty hours model for senior internal medicine residents: a qualitative analysis of residents' experiences and perceptions. | PSNet

    psnet.ahrq.gov/issue/reduced-duty-hours-model-senior-internal-medicine-residents-qualitative-analysis-residents
    June 25, 2014 - Study A reduced duty hours model for senior internal medicine residents: a qualitative analysis of residents' experiences and perceptions. Citation Text: Mathew R, Gundy S, Ulic D, et al. A Reduced Duty Hours Model for Senior Internal Medicine Residents: A Qualitative Analysis of Residen…

  18. Double reading in breast cancer screening: cohort evaluation in the CO-OPS trial. | PSNet

    psnet.ahrq.gov/issue/double-reading-breast-cancer-screening-cohort-evaluation-co-ops-trial
    July 10, 2017 - Study Double reading in breast cancer screening: cohort evaluation in the CO-OPS trial. Citation Text: Taylor-Phillips S, Jenkinson D, Stinton C, et al. Double Reading in Breast Cancer Screening: Cohort Evaluation in the CO-OPS Trial. Radiology. 2018;287(3):749-757. doi:10.1148/radiol.20…

  19. Enhancing patient safety in the pediatric emergency department: teams, communication, and lessons from crew resource management. | PSNet

    psnet.ahrq.gov/issue/enhancing-patient-safety-pediatric-emergency-department-teams-communication-and-lessons-crew
    April 26, 2023 - Commentary Enhancing patient safety in the pediatric emergency department: teams, communication, and lessons from crew resource management. Citation Text: Pruitt CM, Liebelt EL. Enhancing patient safety in the pediatric emergency department: teams, communication, and lessons from crew …

  20. Improving organizational climate for quality and quality of care: does membership in a collaborative help? | PSNet

    psnet.ahrq.gov/issue/improving-organizational-climate-quality-and-quality-care-does-membership-collaborative-help
    December 14, 2016 - Study Improving organizational climate for quality and quality of care: does membership in a collaborative help? Citation Text: Nembhard IM, Northrup V, Shaller D, et al. Improving organizational climate for quality and quality of care: does membership in a collaborative help? Med Car…
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