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A descriptive study of morbidity and mortality conferences and their conformity to medical incident analysis models: results of the morbidity and mortality conference improvement study, phase 1. | PSNet

psnet.ahrq.gov/issue/descriptive-study-morbidity-and-mortality-conferences-and-their-conformity-medical-incident

September 28, 2010 - Study A descriptive study of morbidity and mortality conferences and their conformity to medical incident analysis models: results of the morbidity and mortality conference improvement study, phase 1. Citation Text: Aboumatar HJ, Blackledge CG, Dickson C, et al. A descriptive study of …

Creating a high-reliability health care system: improving performance on core processes of care at Johns Hopkins Medicine. | PSNet

psnet.ahrq.gov/issue/creating-high-reliability-health-care-system-improving-performance-core-processes-care-johns

January 27, 2016 - Study Creating a high-reliability health care system: improving performance on core processes of care at Johns Hopkins Medicine. Citation Text: Pronovost P, Armstrong M, Demski R, et al. Creating a high-reliability health care system: improving performance on core processes of care at Jo…

Potentially preventable 30-day hospital readmissions at a children's hospital. | PSNet

psnet.ahrq.gov/issue/potentially-preventable-30-day-hospital-readmissions-childrens-hospital

July 11, 2017 - Study Potentially preventable 30-day hospital readmissions at a children's hospital. Citation Text: Toomey SL, Peltz A, Loren S, et al. Potentially Preventable 30-Day Hospital Readmissions at a Children's Hospital. Pediatrics. 2016;138(2). doi:10.1542/peds.2015-4182. Copy Citation …

Healthcare failure mode and effect analysis in the chemotherapy preparation process. | PSNet

psnet.ahrq.gov/issue/healthcare-failure-mode-and-effect-analysis-chemotherapy-preparation-process

March 09, 2022 - Study Healthcare failure mode and effect analysis in the chemotherapy preparation process. Citation Text: Pueyo-López C, Sánchez-Cuervo M, Vélez-Díaz-Pallarés M, et al. Healthcare failure mode and effect analysis in the chemotherapy preparation process. J Oncol Pharm Pract. 2021;27(7):15…

Observational evidence of the prevalence and association of polypharmacy and drug administration errors in hospitalized adult patients. | PSNet

psnet.ahrq.gov/issue/observational-evidence-prevalence-and-association-polypharmacy-and-drug-administration-errors

August 11, 2021 - Study Observational evidence of the prevalence and association of polypharmacy and drug administration errors in hospitalized adult patients. Citation Text: Savva G, Papastavrou E, Charalambous A, et al. Observational evidence of the prevalence and association of polypharmacy and drug ad…

An initiative to reduce insulin-related adverse drug events in a children's hospital. | PSNet

psnet.ahrq.gov/issue/initiative-reduce-insulin-related-adverse-drug-events-childrens-hospital

March 24, 2021 - Study An initiative to reduce insulin-related adverse drug events in a children's hospital. Citation Text: Lawson SA, Hornung LN, Lawrence M, et al. An initiative to reduce insulin-related adverse drug events in a children's hospital. Pediatrics. 2022;149(1):e2020004937. doi:10.1542/peds…

National surveillance of emergency department visits for outpatient adverse drug events in children and adolescents. | PSNet

psnet.ahrq.gov/issue/national-surveillance-emergency-department-visits-outpatient-adverse-drug-events-children-and

March 24, 2021 - Study National surveillance of emergency department visits for outpatient adverse drug events in children and adolescents. Citation Text: Cohen AL, Budnitz DS, Weidenbach KN, et al. National surveillance of emergency department visits for outpatient adverse drug events in children and …

In the eye of the storm: the role of the pharmacist in medication safety during the COVID-19 pandemic at an urban teaching hospital. | PSNet

psnet.ahrq.gov/issue/eye-storm-role-pharmacist-medication-safety-during-covid-19-pandemic-urban-teaching-hospital

June 02, 2021 - Commentary In the eye of the storm: the role of the pharmacist in medication safety during the COVID-19 pandemic at an urban teaching hospital. Citation Text: Kanaan AO, Sullivan KM, Seed SM, et al. In the eye of the storm: the role of the pharmacist in medication safety during the COVID…

The impact of Rapid Response System on delayed emergency team activation patient characteristics and outcomes—a follow-up study. | PSNet

psnet.ahrq.gov/issue/impact-rapid-response-system-delayed-emergency-team-activation-patient-characteristics-and

November 03, 2008 - Study The impact of Rapid Response System on delayed emergency team activation patient characteristics and outcomes—a follow-up study. Citation Text: Calzavacca P, Licari E, Tee A, et al. The impact of Rapid Response System on delayed emergency team activation patient characteristics a…

Increased risk of burnout for physicians and nurses involved in a patient safety incident. | PSNet

psnet.ahrq.gov/issue/increased-risk-burnout-physicians-and-nurses-involved-patient-safety-incident

September 21, 2016 - Study Increased risk of burnout for physicians and nurses involved in a patient safety incident. Citation Text: Van Gerven E, Elst TV, Vandenbroeck S, et al. Increased Risk of Burnout for Physicians and Nurses Involved in a Patient Safety Incident. Med Care. 2016;54(10):937-943. doi:10.1…

Using Safety-II and resilient healthcare principles to learn from Never Events. | PSNet

psnet.ahrq.gov/issue/using-safety-ii-and-resilient-healthcare-principles-learn-never-events

February 20, 2019 - Study Using Safety-II and resilient healthcare principles to learn from Never Events. Citation Text: Anderson JE, Watt AJ. Using Safety-II and resilient healthcare principles to learn from Never Events. Int J Qual Health Care. 2020;32(3):196-203. doi:10.1093/intqhc/mzaa009. Copy Citati…

Insights into the problem of alarm fatigue with physiologic monitor devices: a comprehensive observational study of consecutive intensive care unit patients. | PSNet

psnet.ahrq.gov/issue/insights-problem-alarm-fatigue-physiologic-monitor-devices-comprehensive-observational-study

July 17, 2013 - Study Classic Insights into the problem of alarm fatigue with physiologic monitor devices: a comprehensive observational study of consecutive intensive care unit patients. Citation Text: Drew BJ, Harris P, Zègre-Hemsey JK, et al. Insights into the problem of ala…

Breast cancer treatment delays by socioeconomic and health care access latent classes in Black and White women. | PSNet

psnet.ahrq.gov/issue/breast-cancer-treatment-delays-socioeconomic-and-health-care-access-latent-classes-black-and

May 18, 2022 - Study Breast cancer treatment delays by socioeconomic and health care access latent classes in Black and White women. Citation Text: Emerson MA, Golightly YM, Aiello AE, et al. Breast cancer treatment delays by socioeconomic and health care access latent classes in Black and White women.…

Strategies to prevent missed nursing care: an international qualitative study based upon a positive deviance approach. | PSNet

psnet.ahrq.gov/issue/strategies-prevent-missed-nursing-care-international-qualitative-study-based-upon-positive

May 18, 2022 - Study Strategies to prevent missed nursing care: an international qualitative study based upon a positive deviance approach. Citation Text: Longhini J, Papastavrou E, Efstathiou G, et al. Strategies to prevent missed nursing care: an international qualitative study based upon a positive …

Association of nurse workload with missed nursing care in the neonatal intensive care unit. | PSNet

psnet.ahrq.gov/issue/association-nurse-workload-missed-nursing-care-neonatal-intensive-care-unit

September 27, 2017 - Study Emerging Classic Association of nurse workload with missed nursing care in the neonatal intensive care unit. Citation Text: Tubbs-Cooley HL, Mara CA, Carle AC, et al. Association of Nurse Workload With Missed Nursing Care in the Neonatal Intensive Care Uni…

A literature review of the training offered to qualified prescribers to use electronic prescribing systems: why is it so important? | PSNet

psnet.ahrq.gov/issue/literature-review-training-offered-qualified-prescribers-use-electronic-prescribing-systems

December 21, 2022 - Review A literature review of the training offered to qualified prescribers to use electronic prescribing systems: why is it so important? Citation Text: Brown CL, Reygate K, Slee A, et al. A literature review of the training offered to qualified prescribers to use electronic prescribing…

The impact of a nursing-led intervention bundle with a bedside checklist to reduce mortality during the initial COVID-19 pandemic and implications for future emergencies. | PSNet

psnet.ahrq.gov/issue/impact-nursing-led-intervention-bundle-bedside-checklist-reduce-mortality-during-initial

May 05, 2010 - Study The impact of a nursing-led intervention bundle with a bedside checklist to reduce mortality during the initial COVID-19 pandemic and implications for future emergencies. Citation Text: Pugh S, Chan F, Han S, et al. The impact of a nursing-led intervention bundle with a bedside che…

Effect on patient safety of a resident physician schedule without 24-hour shifts. | PSNet

psnet.ahrq.gov/issue/effect-patient-safety-resident-physician-schedule-without-24-hour-shifts

March 10, 2021 - Study Emerging Classic Effect on patient safety of a resident physician schedule without 24-hour shifts. Citation Text: Landrigan CP, Rahman SA, Sullivan JP, et al. Effect on patient safety of a resident physician schedule without 24-hour shifts. N Engl J Med. 2…

Association of pediatric resident physician depression and burnout with harmful medical errors on inpatient services. | PSNet

psnet.ahrq.gov/issue/association-pediatric-resident-physician-depression-and-burnout-harmful-medical-errors

April 24, 2018 - Study Emerging Classic Association of pediatric resident physician depression and burnout with harmful medical errors on inpatient services. Citation Text: Brunsberg KA, Landrigan CP, Garcia BM, et al. Association of Pediatric Resident Physician Depression and B…

The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving US adult populations. | PSNet

psnet.ahrq.gov/issue/frequency-diagnostic-errors-outpatient-care-estimations-three-large-observational-studies

April 09, 2013 - Study Classic The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving US adult populations. Citation Text: Singh H, Meyer AND, Thomas EJ. The frequency of diagnostic errors in outpatient care: estimatio…

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