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4081. Does root cause analysis improve patient safety? A systematic review at the Department of Veterans Affairs. | PSNet
      psnet.ahrq.gov/issue/does-root-cause-analysis-improve-patient-safety-systematic-review-department-veterans-affairs
      March 24, 2021 - Review Does root cause analysis improve patient safety? A systematic review at the Department of Veterans Affairs. Citation Text: Shah F, Falconer EA, Cimiotti JP. Does root cause analysis improve patient safety? A systematic review at the Department of Veterans Affairs. Qual Manag Healt…

4082. Our current approach to root cause analysis: is it contributing to our failure to improve patient safety? | PSNet
      psnet.ahrq.gov/issue/our-current-approach-root-cause-analysis-it-contributing-our-failure-improve-patient-safety
      October 23, 2013 - Study Classic Our current approach to root cause analysis: is it contributing to our failure to improve patient safety? Citation Text: Kellogg KM, Hettinger Z, Shah M, et al. Our current approach to root cause analysis: is it contributing to our failure to impro…

4083. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. | PSNet
      psnet.ahrq.gov/issue/incidence-and-preventability-adverse-drug-events-among-older-persons-ambulatory-setting
      March 11, 2011 - Study Classic Incidence and preventability of adverse drug events among older persons in the ambulatory setting. Citation Text: Gurwitz JH, Field T, Harrold LR, et al. Incidence and Preventability of Adverse Drug Events Among Older Persons in the Ambulatory Se…

4084. 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…

4085. Effect of a quality improvement intervention with daily round checklists, goal setting, and clinician prompting on mortality of critically ill patients. | PSNet
      psnet.ahrq.gov/issue/effect-quality-improvement-intervention-daily-round-checklists-goal-setting-and-clinician
      June 25, 2014 - Study Classic Effect of a quality improvement intervention with daily round checklists, goal setting, and clinician prompting on mortality of critically ill patients. Citation Text: Network WG for the CHECKLIST-ICUI and the BR in IC, Cavalcanti AB, Bozza FA, et …

4086. Testimonial injustice: linguistic bias in the medical records of black patients and women. | PSNet
      psnet.ahrq.gov/issue/testimonial-injustice-linguistic-bias-medical-records-black-patients-and-women
      July 28, 2021 - Study Testimonial injustice: linguistic bias in the medical records of black patients and women. Citation Text: Beach MC, Saha S, Park J, et al. Testimonial injustice: linguistic bias in the medical records of black patients and women. J Gen Intern Med. 2021;36(6):1708-1714. doi:10.1007/…

4087. 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 …

4088. Exploring safety culture within inpatient mental health units: the results from participant observation across three mental health services. | PSNet
      psnet.ahrq.gov/issue/exploring-safety-culture-within-inpatient-mental-health-units-results-participant-observation
      September 23, 2020 - Study Exploring safety culture within inpatient mental health units: the results from participant observation across three mental health services. Citation Text: Molloy L, Wilson V, O'Connor MF, et al. Exploring safety culture within inpatient mental health units: the results from partic…

4089. Design and reliability of a specific instrument to evaluate patient safety for patients with acute myocardial infarction treated in a predefined care track: a retrospective patient record review study in a single tertiary hospital in the Netherlands. | PSNet
      psnet.ahrq.gov/issue/design-and-reliability-specific-instrument-evaluate-patient-safety-patients-acute-myocardial
      October 18, 2023 - Study Design and reliability of a specific instrument to evaluate patient safety for patients with acute myocardial infarction treated in a predefined care track: a retrospective patient record review study in a single tertiary hospital in the Netherlands. Citation Text: Eindhoven DC, Bo…

4090. How safe is primary care? A systematic review. | PSNet
      psnet.ahrq.gov/issue/how-safe-primary-care-systematic-review
      December 18, 2013 - Review Classic How safe is primary care? A systematic review. Citation Text: Panesar SS, deSilva D, Carson-Stevens A, et al. How safe is primary care? A systematic review. BMJ Qual Saf. 2016;25(7):544-53. doi:10.1136/bmjqs-2015-004178. Copy Citation Format…

4091. Influencing a culture of quality and safety through huddles. | PSNet
      psnet.ahrq.gov/issue/influencing-culture-quality-and-safety-through-huddles
      April 05, 2023 - Study Influencing a culture of quality and safety through huddles. Citation Text: McCain N, Ferguson T, Barry Hultquist T, et al. Influencing a culture of quality and safety through huddles. J Nurs Care Qual. 2023;38(1):26-32. doi:10.1097/ncq.0000000000000642. Copy Citation Format:…

4092. Spreading a strategy to prevent suicide after psychiatric hospitalization: results of a quality improvement spread initiative. | PSNet
      psnet.ahrq.gov/issue/spreading-strategy-prevent-suicide-after-psychiatric-hospitalization-results-quality
      May 04, 2022 - Study Spreading a strategy to prevent suicide after psychiatric hospitalization: results of a quality improvement spread initiative. Citation Text: Riblet NB, Varela M, Ashby W, et al. Spreading a strategy to prevent suicide after psychiatric hospitalization: results of a quality improve…

4093. 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 …

4094. 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.…

4095. 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…

4096. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/844785/psn-pdf
      September 11, 2019 - Information flow during pediatric trauma care transitions: things falling through the cracks. September 11, 2019 Hoonakker PLT, Wooldridge AR, Hose B-Z, et al. Information flow during pediatric trauma care transitions: things falling through the cracks. Intern Emerg Med. 2019;14(5):797-805. doi:10.1007/s11739-019-0…

4097. 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…

4098. 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…

4099. 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…

4100. 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…