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4001. Electronic Prescribing and Decision Support to Improve Rural Primary Care Quality | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/electronic-prescribing-and-decision-support-improve-rural-primary-care-quality
      January 01, 2023 - Electronic Prescribing and Decision Support to Improve Rural Primary Care Quality Project Final Report ( PDF , 275.07 KB) Disclaimer Disclaimer The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily …

4002. The effects of crew resource management on teamwork and safety climate at Veterans Health Administration facilities. | PSNet
      psnet.ahrq.gov/issue/effects-crew-resource-management-teamwork-and-safety-climate-veterans-health-administration
      December 11, 2024 - Study The effects of crew resource management on teamwork and safety climate at Veterans Health Administration facilities. Citation Text: Schwartz ME, Welsh DE, Paull DE, et al. The effects of crew resource management on teamwork and safety climate at Veterans Health Administration facil…

4003. Healing our own: a randomized trial to assess benefits of peer support. | PSNet
      psnet.ahrq.gov/issue/healing-our-own-randomized-trial-assess-benefits-peer-support
      May 19, 2021 - Study Healing our own: a randomized trial to assess benefits of peer support. Citation Text: 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.…

4004. Patient safety in inpatient mental health settings: a systematic review. | PSNet
      psnet.ahrq.gov/issue/patient-safety-inpatient-mental-health-settings-systematic-review
      November 13, 2019 - Review Emerging Classic Patient safety in inpatient mental health settings: a systematic review. Citation Text: Thibaut BI, Dewa LH, Ramtale SC, et al. Patient safety in inpatient mental health settings: a systematic review. BMJ Open. 2019;9(12):e030230. doi:10.…

4005. Regret among primary care physicians: a survey of diagnostic decisions. | PSNet
      psnet.ahrq.gov/issue/regret-among-primary-care-physicians-survey-diagnostic-decisions
      November 13, 2019 - Study Regret among primary care physicians: a survey of diagnostic decisions. Citation Text: Müller BS, Donner-Banzhoff N, Beyer M, et al. Regret among primary care physicians: a survey of diagnostic decisions. BMC Fam Pract. 2020;21(1). doi:10.1186/s12875-020-01125-w. Copy Citation …

4006. Correlation between the number of patient-reported adverse events, adverse drug events, and quality of life in older patients: an observational study. | PSNet
      psnet.ahrq.gov/issue/correlation-between-number-patient-reported-adverse-events-adverse-drug-events-and-quality
      August 10, 2022 - Study Correlation between the number of patient-reported adverse events, adverse drug events, and quality of life in older patients: an observational study. Citation Text: Beerlage-Davids CJ, Ponjee GHM, Vanhommerig JW, et al. Correlation between the number of patient-reported adverse ev…

4007. Adding automation and independent dual verification to reduce wrong blood in tube (WBIT) events. | PSNet
      psnet.ahrq.gov/issue/adding-automation-and-independent-dual-verification-reduce-wrong-blood-tube-wbit-events
      October 21, 2020 - Study Adding automation and independent dual verification to reduce wrong blood in tube (WBIT) events. Citation Text: Passwater M, Huggins YM, Delvo Favre ED, et al. Adding automation and independent dual verification to reduce wrong blood in tube (WBIT) events. Am J Clin Pathol. 2022;15…

4008. Healthcare-associated adverse events in alternate level of care patients awaiting long-term care in hospital. | PSNet
      psnet.ahrq.gov/issue/healthcare-associated-adverse-events-alternate-level-care-patients-awaiting-long-term-care
      March 17, 2021 - Study Healthcare-associated adverse events in alternate level of care patients awaiting long-term care in hospital. Citation Text: Lim Fat GJ, Gopaul A, Pananos AD, et al. Healthcare-associated adverse events in alternate level of care patients awaiting long-term care in hospital. Geriat…

4009. Unsafe care in residential settings for older adults. A content analysis of accreditation reports. | PSNet
      psnet.ahrq.gov/issue/unsafe-care-residential-settings-older-adults-content-analysis-accreditation-reports
      August 16, 2023 - Study Unsafe care in residential settings for older adults. A content analysis of accreditation reports. Citation Text: Hibbert PD, Ash R, Molloy CJ, et al. Unsafe care in residential settings for older adults: a content analysis of accreditation reports. Int J Qual Health Care. 2023;35(…

4010. Adverse events in long-term care residents transitioning from hospital back to nursing home. | PSNet
      psnet.ahrq.gov/issue/adverse-events-long-term-care-residents-transitioning-hospital-back-nursing-home
      April 28, 2021 - Study Adverse events in long-term care residents transitioning from hospital back to nursing home. Citation Text: Kapoor A, Field T, Handler S, et al. Adverse Events in Long-term Care Residents Transitioning From Hospital Back to Nursing Home. JAMA Intern Med. 2019;179(9):1254-1261. doi:…

4011. Death by suicide within 1 week of hospital discharge: a retrospective study of root cause analysis reports. | PSNet
      psnet.ahrq.gov/issue/death-suicide-within-1-week-hospital-discharge-retrospective-study-root-cause-analysis
      May 04, 2022 - Study Death by suicide within 1 week of hospital discharge: a retrospective study of root cause analysis reports. Citation Text: Riblet N, Shiner B, Watts B, et al. Death by Suicide Within 1 Week of Hospital Discharge: A Retrospective Study of Root Cause Analysis Reports. J Nerv Ment Dis…

4012. Miyasaka K et al. 1997 "Interactive communication in high-technology home care: videophones for pediatric ventilatory care." | Digital Healthcare Research
      digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/miyasaka-k-et-al-1997
      January 01, 1997 - Miyasaka K et al. 1997 "Interactive communication in high-technology home care: videophones for pediatric ventilatory care." Reference Miyasaka K, Suzuki Y, Sakai H, et al. Interactive communication in high-technology home care: videophones for pediatric ventilatory care. Pediatrics 1997;99(1):E11-E16…

4013. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73363/psn-pdf
      June 09, 2021 - Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure injuries and medication administration errors: an integrative review. June 9, 2021 Hada A, Coyer F. Shift?to?shift nursing handover interventions associated with improved inpatient outcomes—falls, pressure …

4014. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37792/psn-pdf
      February 15, 2011 - Exploring organizational context and structure as predictors of medication errors and patient falls. February 15, 2011 Mark BA, Hughes LC, Belyea M, et al. Exploring Organizational Context and Structure as Predictors of Medication Errors and Patient Falls. J Patient Saf. 2008;4(2). doi:10.1097/pts.0b013e3181695671.…

4015. Falling through the cracks: the invisible hospital cleaning workforce. | PSNet
      psnet.ahrq.gov/issue/falling-through-cracks-invisible-hospital-cleaning-workforce
      June 19, 2013 - Commentary Falling through the cracks: the invisible hospital cleaning workforce. Citation Text: Hacker CE, Debono D, Travaglia J, et al. Falling through the cracks: the invisible hospital cleaning workforce. J Health Organ Manag. 2022;36(8):981-986. doi:10.1108/jhom-02-2022-0035. Copy…

4016. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37518/psn-pdf
      March 13, 2008 - Innovation in patient safety: a new task design in reducing patient falls. March 13, 2008 Tzeng H-M, Yin C-Y. Innovation in patient safety: a new task design in reducing patient falls. J Nurs Care Qual. 2008;23(1):34-42. doi:10.1097/01.NCQ.0000303803.07457.e5. https://psnet.ahrq.gov/issue/innovation-patient-safety…

4017. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40454/psn-pdf
      June 01, 2012 - Influence of unit-level staffing on medication errors and falls in military hospitals. June 1, 2012 Breckenridge-Sproat S, Johantgen M, Patrician PA. Influence of unit-level staffing on medication errors and falls in military hospitals. West J Nurs Res. 2012;34(4):455-74. doi:10.1177/0193945911407090. https://psne…

4018. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39255/psn-pdf
      February 02, 2011 - The patient who falls: "It's always a trade-off." February 2, 2011 Tinetti ME, Kumar C. The patient who falls: "It's always a trade-off". JAMA. 2010;303(3):258-66. doi:10.1001/jama.2009.2024. https://psnet.ahrq.gov/issue/patient-who-falls-its-always-trade Through a case study, this article reviews evidence on risk…

4019. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47508/psn-pdf
      October 24, 2018 - Root cause analysis of reported patient falls in ORs in the Veterans Health Administration. October 24, 2018 Soncrant CM, Warner LJ, Neily J, et al. Root Cause Analysis of Reported Patient Falls in ORs in the Veterans Health Administration. AORN J. 2018;108(4):386-397. doi:10.1002/aorn.12372. https://psnet.ahrq.go…

4020. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41554/psn-pdf
      January 03, 2017 - Using root cause analysis to reduce falls with injury in community settings. January 3, 2017 Lee A, Mills PD, Neily J. Using root cause analysis to reduce falls with injury in community settings. Jt Comm J Qual Patient Saf. 2012;38(8):366-374. https://psnet.ahrq.gov/issue/using-root-cause-analysis-reduce-falls-inj…