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4021. Inadequate hand-off communication. | PSNet
      psnet.ahrq.gov/issue/inadequate-hand-communication
      April 02, 2015 - Sentinel Event Alerts Inadequate hand-off communication. Citation Text: Inadequate hand-off communication. Sentinel event alert. 2017;58(58):1-6. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download C…

4022. Filling a gap in safety metrics: development of a patient-centred framework to identify and categorise patient-reported breakdowns related to the diagnostic process in ambulatory care. | PSNet
      psnet.ahrq.gov/issue/filling-gap-safety-metrics-development-patient-centred-framework-identify-and-categorise
      February 15, 2023 - Study Filling a gap in safety metrics: development of a patient-centred framework to identify and categorise patient-reported breakdowns related to the diagnostic process in ambulatory care. Citation Text: Bell SK, Bourgeois FC, DesRoches CM, et al. Filling a gap in safety metrics: devel…

4023. Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients. | PSNet
      psnet.ahrq.gov/issue/root-cause-analysis-reports-help-identify-common-factors-delayed-diagnosis-and-treatment
      October 24, 2018 - Study Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients. Citation Text: Giardina TD, King BJ, Ignaczak AP, et al. Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients. Health A…

4024. Self-reported gaps in care coordination and preventable adverse outcomes among older adults receiving home health care. | PSNet
      psnet.ahrq.gov/issue/self-reported-gaps-care-coordination-and-preventable-adverse-outcomes-among-older-adults
      July 06, 2022 - Study Self-reported gaps in care coordination and preventable adverse outcomes among older adults receiving home health care. Citation Text: Sterling MR, Lau J, Rajan M, et al. Self‐reported gaps in care coordination and preventable adverse outcomes among older adults receiving home heal…

4025. Stakeholder perspectives on contributors to delayed and inaccurate diagnosis of cardiovascular disease and their implications for digital health technologies: a UK-based qualitative study. | PSNet
      psnet.ahrq.gov/issue/stakeholder-perspectives-contributors-delayed-and-inaccurate-diagnosis-cardiovascular-disease
      August 18, 2021 - Study Stakeholder perspectives on contributors to delayed and inaccurate diagnosis of cardiovascular disease and their implications for digital health technologies: a UK-based qualitative study. Citation Text: Abdullayev K, Gorvett O, Sochiera A, et al. Stakeholder perspectives on contri…

4026. Effectiveness of pharmacist intervention to reduce medication errors and health-care resources utilization after transitions of care: a meta-analysis of randomized controlled trials. | PSNet
      psnet.ahrq.gov/issue/effectiveness-pharmacist-intervention-reduce-medication-errors-and-health-care-resources
      August 04, 2021 - Review Effectiveness of pharmacist intervention to reduce medication errors and health-care resources utilization after transitions of care: a meta-analysis of randomized controlled trials. Citation Text: De Oliveira GS, Castro-Alves LJ, Kendall MC, et al. Effectiveness of Pharmacist Int…

4027. A taxonomy for advancing systematic error analysis in multi-site electronic health record-based clinical concept extraction. | PSNet
      psnet.ahrq.gov/issue/taxonomy-advancing-systematic-error-analysis-multi-site-electronic-health-record-based
      March 24, 2019 - Study A taxonomy for advancing systematic error analysis in multi-site electronic health record-based clinical concept extraction. Citation Text: Fu S, Wang L, He H, et al. A taxonomy for advancing systematic error analysis in multi-site electronic health record-based clinical concept ex…

4028. Speaking up about safety concerns: multi-setting qualitative study of patients' views and experiences. | PSNet
      psnet.ahrq.gov/issue/speaking-about-safety-concerns-multi-setting-qualitative-study-patients-views-and-experiences
      May 18, 2016 - Study Speaking up about safety concerns: multi-setting qualitative study of patients' views and experiences. Citation Text: Entwistle VA, McCaughan D, Watt I, et al. Speaking up about safety concerns: multi-setting qualitative study of patients' views and experiences. Qual Saf Health C…

4029. Association of current opioid use with serious adverse events among older adult survivors of breast cancer. | PSNet
      psnet.ahrq.gov/issue/association-current-opioid-use-serious-adverse-events-among-older-adult-survivors-breast
      February 15, 2023 - Study Association of current opioid use with serious adverse events among older adult survivors of breast cancer. Citation Text: Winn AN, Check DK, Farkas A, et al. Association of current opioid use with serious adverse events among older adult survivors of breast cancer. JAMA Netw Open.…

4030. Promoting medication safety for older adults upon hospital discharge: guiding principles for a medication discharge plan. | PSNet
      psnet.ahrq.gov/issue/promoting-medication-safety-older-adults-upon-hospital-discharge-guiding-principles
      July 31, 2019 - Study Promoting medication safety for older adults upon hospital discharge: guiding principles for a medication discharge plan. Citation Text: Zhang FH, Lauzon J, Payette J, et al. Promoting medication safety for older adults upon hospital discharge: guiding principles for a medication d…

4031. Potentially inappropriate prescribing among older persons: a meta-analysis of observational studies. | PSNet
      psnet.ahrq.gov/issue/potentially-inappropriate-prescribing-among-older-persons-meta-analysis-observational-studies
      May 27, 2020 - Review Emerging Classic Potentially inappropriate prescribing among older persons: a meta-analysis of observational studies. Citation Text: Liew TM, Lee CS, Shawn KLG, et al. Potentially Inappropriate Prescribing Among Older Persons: A Meta-Analysis of Observati…

4032. Using community detection techniques to identify themes in COVID-19-related patient safety event reports. | PSNet
      psnet.ahrq.gov/issue/using-community-detection-techniques-identify-themes-covid-19-related-patient-safety-event
      July 29, 2020 - Study Using community detection techniques to identify themes in COVID-19-related patient safety event reports. Citation Text: Boxley C, Krevat SA, Sengupta S, et al. Using community detection techniques to identify themes in COVID-19-related patient safety event reports. J Patient Saf. …

4033. Primary care teams' reported actions to improve medication safety: a qualitative study with insights in high reliability organising. | PSNet
      psnet.ahrq.gov/issue/primary-care-teams-reported-actions-improve-medication-safety-qualitative-study-insights-high
      July 06, 2022 - Study Primary care teams' reported actions to improve medication safety: a qualitative study with insights in high reliability organising. Citation Text: Young RA, Gurses AP, Fulda KG, et al. Primary care teams’ reported actions to improve medication safety: a qualitative study with insi…

4034. 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 …

4035. 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.…

4036. 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…

4037. 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…

4038. 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…

4039. 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…

4040. 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…