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421. Unexpected Death of a Patient During Treatment With Multiple Medications, Tomah VA Medical Center, Tomah, Wisconsin. | PSNet
     psnet.ahrq.gov/issue/unexpected-death-patient-during-treatment-multiple-medications-tomah-va-medical-center-tomah
     October 12, 2022 - Related Resources From the Same Author(s) Comprehensive Healthcare Inspection Summary

422. Systematically improving physician assignment during in-hospital transitions of care by enhancing a preexisting hospital electronic health record. | PSNet
     psnet.ahrq.gov/issue/systematically-improving-physician-assignment-during-hospital-transitions-care-enhancing
     March 14, 2022 - Study Systematically improving physician assignment during in-hospital transitions of care by enhancing a preexisting hospital electronic health record. Citation Text: Zsenits B, Polashenski WA, Sterns RH, et al. Systematically improving physician assignment during in-hospital transiti…

423. Applying decision science to the prioritization of healthcare-associated infection initiatives. | PSNet
     psnet.ahrq.gov/issue/applying-decision-science-prioritization-healthcare-associated-infection-initiatives
     October 20, 2021 - The impact of coronavirus disease 2019 (COVID-19) on healthcare-associated infections in 2020: a summary

424. Is disruptive behavior inherent to the surgeon or the environment? Analysis of 314 events at a single academic medical center. | PSNet
     psnet.ahrq.gov/issue/disruptive-behavior-inherent-surgeon-or-environment-analysis-314-events-single-academic
     October 19, 2022 - Patient Safety Innovations Rescue Improvement Conference Innovation Summary

425. The COVID-19 pandemic: resilient organisational response to a low-chance, high-impact event. | PSNet
     psnet.ahrq.gov/issue/covid-19-pandemic-resilient-organisational-response-low-chance-high-impact-event
     October 07, 2020 - The impact of coronavirus disease 2019 (COVID-19) on healthcare-associated infections in 2020: a summary

426. Evaluating a patient safety learning laboratory to create an interdisciplinary ecosystem for health care innovation. | PSNet
     psnet.ahrq.gov/issue/evaluating-patient-safety-learning-laboratory-create-interdisciplinary-ecosystem-health-care
     December 21, 2022 - Patient Safety Innovations Rescue Improvement Conference Innovation Summary

427. Slow progress on meeting hospital safety standards: learning from the Leapfrog Group's efforts. | PSNet
     psnet.ahrq.gov/issue/slow-progress-meeting-hospital-safety-standards-learning-leapfrog-groups-efforts
     May 13, 2020 - View More Related Resources Hospital Reporting Program: Annual Summary

428. The association of acute COVID-19 infection with Patient Safety Indicator-12 events in a multisite healthcare system. | PSNet
     psnet.ahrq.gov/issue/association-acute-covid-19-infection-patient-safety-indicator-12-events-multisite-healthcare
     January 18, 2023 - The impact of coronavirus disease 2019 (COVID-19) on healthcare-associated infections in 2020: a summary

429. Unintended adverse consequences of introducing electronic health records in residential aged care homes. | PSNet
     psnet.ahrq.gov/issue/unintended-adverse-consequences-introducing-electronic-health-records-residential-aged-care
     March 24, 2019 - Study Unintended adverse consequences of introducing electronic health records in residential aged care homes. Citation Text: Yu P, Zhang Y, Gong Y, et al. Unintended adverse consequences of introducing electronic health records in residential aged care homes. Int J Med Inform. 2013;82…

430. Automation of the I-PASS tool to improve transitions of care. | PSNet
     psnet.ahrq.gov/issue/automation-i-pass-tool-improve-transitions-care
     August 04, 2021 - Study Automation of the I-PASS tool to improve transitions of care. Citation Text: Skaret MM, Weaver TD, Humes RJ, et al. Automation of the I-PASS Tool to Improve Transitions of Care. J Healthc Qual. 2019;41(5):274-280. doi:10.1097/JHQ.0000000000000174. Copy Citation Format: …

431. Characteristics of morbidity and mortality conferences associated with the implementation of patient safety improvement initiatives, an observational study. | PSNet
     psnet.ahrq.gov/issue/characteristics-morbidity-and-mortality-conferences-associated-implementation-patient-safety
     March 18, 2020 - Patient Safety Innovations Rescue Improvement Conference Innovation Summary

432. Early cost and safety benefits of an inpatient electronic health record. | PSNet
     psnet.ahrq.gov/issue/early-cost-and-safety-benefits-inpatient-electronic-health-record
     August 04, 2021 - Study Early cost and safety benefits of an inpatient electronic health record. Citation Text: Zlabek JA, Wickus JW, Mathiason MA. Early cost and safety benefits of an inpatient electronic health record. Journal of the American Medical Informatics Association. 2011;18(2). doi:10.1136/ja…

433. Anatomy of a failure: a sociotechnical evaluation of a laboratory physician order entry system implementation. | PSNet
     psnet.ahrq.gov/issue/anatomy-failure-sociotechnical-evaluation-laboratory-physician-order-entry-system
     April 13, 2022 - Study Anatomy of a failure: a sociotechnical evaluation of a laboratory physician order entry system implementation. Citation Text: Peute LW, Aarts J, Bakker PJM, et al. Anatomy of a failure: a sociotechnical evaluation of a laboratory physician order entry system implementation. Int J…

434. Day of discharge does not impact hospital readmission after major cardiac surgery. | PSNet
     psnet.ahrq.gov/issue/day-discharge-does-not-impact-hospital-readmission-after-major-cardiac-surgery
     October 16, 2019 - June 29, 2022 Evaluation of an electronic health record structured discharge summary

435. Positive approaches to safety: learning from what we do well. | PSNet
     psnet.ahrq.gov/issue/positive-approaches-safety-learning-what-we-do-well
     September 15, 2021 - Innovations Combined Proactive Risk Assessment (CPRA) – 4-Step Technique Innovation Summary

436. Race differences in reported harmful patient safety events in healthcare system high reliability organizations. | PSNet
     psnet.ahrq.gov/issue/race-differences-reported-harmful-patient-safety-events-healthcare-system-high-reliability
     March 01, 2023 - Innovations Combined Proactive Risk Assessment (CPRA) – 4-Step Technique Innovation Summary

437. AHRQ Nursing Home Survey on Patient Safety Culture: 2019 User Comparative Database Report. | PSNet
     psnet.ahrq.gov/issue/ahrq-nursing-home-survey-patient-safety-culture-2019-user-comparative-database-report
     April 17, 2019 - Available at Free full text (PDF) Summary (PDF) Save Save to your library Print

438. Mind the gap between recommendation and implementation—principles and lessons in the aftermath of incident investigations: a semi-quantitative and qualitative study of factors leading to the successful implementation of recommendations. | PSNet
     psnet.ahrq.gov/issue/mind-gap-between-recommendation-and-implementation-principles-and-lessons-aftermath-incident
     March 11, 2020 - Innovations Combined Proactive Risk Assessment (CPRA) – 4-Step Technique Innovation Summary

439. Transformational improvement in quality care and health systems: the next decade. | PSNet
     psnet.ahrq.gov/issue/transformational-improvement-quality-care-and-health-systems-next-decade
     October 14, 2020 - Innovations Combined Proactive Risk Assessment (CPRA) – 4-Step Technique Innovation Summary

440. Development of trigger tools for surveillance of adverse events in ambulatory surgery. | PSNet
     psnet.ahrq.gov/issue/development-trigger-tools-surveillance-adverse-events-ambulatory-surgery
     October 01, 2014 - March 27, 2019 Evaluation of an electronic health record structured discharge summary