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4101. Wrong-patient blood transfusion error: leveraging technology to overcome human error in intraoperative blood component administration. | PSNet
      psnet.ahrq.gov/issue/wrong-patient-blood-transfusion-error-leveraging-technology-overcome-human-error
      December 09, 2020 - Study Wrong-patient blood transfusion error: leveraging technology to overcome human error in intraoperative blood component administration. Citation Text: Hensley NB, Koch CG, Pronovost P, et al. Wrong-Patient Blood Transfusion Error: Leveraging Technology to Overcome Human Error in Int…

4102. Improving patient safety culture in primary care: a systematic review. | PSNet
      psnet.ahrq.gov/issue/improving-patient-safety-culture-primary-care-systematic-review
      June 17, 2015 - Review Improving patient safety culture in primary care: a systematic review. Citation Text: Verbakel NJ, Langelaan M, Verheij TJM, et al. Improving Patient Safety Culture in Primary Care: A Systematic Review. J Patient Saf. 2016;12(3):152-8. doi:10.1097/PTS.0000000000000075. Copy Cita…

4103. Postdischarge adverse events among neonates admitted to the neonatal intensive care unit. | PSNet
      psnet.ahrq.gov/issue/postdischarge-adverse-events-among-neonates-admitted-neonatal-intensive-care-unit
      October 05, 2022 - Study Postdischarge adverse events among neonates admitted to the neonatal intensive care unit. Citation Text: Tsilimingras D, Natarajan G, Bajaj M, et al. Postdischarge adverse events among neonates admitted to the neonatal intensive care unit. J Patient Saf. 2022;18(5):462-469. doi:10.…

4104. I-PASS illness diversity identifies patients at risk for overnight clinical deterioration. | PSNet
      psnet.ahrq.gov/issue/i-pass-illness-diversity-identifies-patients-risk-overnight-clinical-deterioration
      November 16, 2022 - Study I-PASS illness diversity identifies patients at risk for overnight clinical deterioration. Citation Text: Shah C, Sanber K, Jacobson R, et al. I-PASS illness diversity identifies patients at risk for overnight clinical deterioration. J Grad Med Educ. 2020;12(5):578-582. doi:10.4300…

4105. Rates of adverse events in hospitalized patients after summer-time resident changeover in the United States: is there a July effect? | PSNet
      psnet.ahrq.gov/issue/rates-adverse-events-hospitalized-patients-after-summer-time-resident-changeover-united
      June 22, 2022 - Study Rates of adverse events in hospitalized patients after summer-time resident changeover in the United States: is there a July effect? Citation Text: Metersky ML, Eldridge N, Wang Y, et al. Rates of adverse events in hospitalized patients after summer-time resident changeover in the …

4106. Trends in healthcare incident reporting and relationship to safety and quality data in acute hospitals: results from the National Reporting and Learning System. | PSNet
      psnet.ahrq.gov/issue/trends-healthcare-incident-reporting-and-relationship-safety-and-quality-data-acute-hospitals
      March 28, 2011 - Study Trends in healthcare incident reporting and relationship to safety and quality data in acute hospitals: results from the National Reporting and Learning System. Citation Text: Hutchinson A, Young TA, Cooper KL, et al. Trends in healthcare incident reporting and relationship to sa…

4107. Correlates of missed or late versus timely diagnosis of dementia in healthcare settings. | PSNet
      psnet.ahrq.gov/issue/correlates-missed-or-late-versus-timely-diagnosis-dementia-healthcare-settings
      March 09, 2022 - Study Correlates of missed or late versus timely diagnosis of dementia in healthcare settings. Citation Text: Chen Y, Power MC, Grodstein F, et al. Correlates of missed or late versus timely diagnosis of dementia in healthcare settings. Alzheimers Dement. 2024;20(8):5551-5560. doi:10.100…

4108. DEVISE: Data Exchange of Vaccine Information between an Immunization Information System and Electronic Health Record | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/devise-data-exchange-vaccine-information-between-immunization-information
      January 01, 2023 - DEVISE: Data Exchange of Vaccine Information between an Immunization Information System and Electronic Health Record Project Final Report ( PDF , 237.23 KB) Disclaimer Disclaimer The findings and conclusions in this document are those of the author(s), who are responsible for i…

4109. Nurses' harm prevention practices during admission of an older person to the hospital: a multi-method qualitative study. | PSNet
      psnet.ahrq.gov/issue/nurses-harm-prevention-practices-during-admission-older-person-hospital-multi-method
      May 11, 2022 - Study Nurses' harm prevention practices during admission of an older person to the hospital: a multi-method qualitative study. Citation Text: Redley B, Douglas T, Hoon L, et al. Nurses' harm prevention practices during admission of an older person to the hospital: a multi‐method qualitat…

4110. Diagnostic discordance, health information exchange, and inter-hospital transfer outcomes: a population study. | PSNet
      psnet.ahrq.gov/issue/diagnostic-discordance-health-information-exchange-and-inter-hospital-transfer-outcomes
      May 19, 2021 - Study Diagnostic discordance, health information exchange, and inter-hospital transfer outcomes: a population study. Citation Text: Usher M, Sahni N, Herrigel D, et al. Diagnostic discordance, health information exchange, and inter-hospital transfer outcomes: a population study. J Gen In…

4111. Telemedicine as a medical examination tool during the Covid-19 emergency: the experience of the onco-haematology center of Tor Vergata Hospital in Rome. | PSNet
      psnet.ahrq.gov/issue/telemedicine-medical-examination-tool-during-covid-19-emergency-experience-onco-haematology
      September 15, 2021 - Study Telemedicine as a medical examination tool during the Covid-19 emergency: the experience of the onco-haematology center of Tor Vergata Hospital in Rome. Citation Text: Postorino M, Treglia M, Giammatteo J, et al. Telemedicine as a medical examination tool during the Covid-19 emerge…

4112. Training in safe opioid prescribing and treatment of opioid use disorder in internal medicine residencies: a national survey of program directors. | PSNet
      psnet.ahrq.gov/issue/training-safe-opioid-prescribing-and-treatment-opioid-use-disorder-internal-medicine
      March 17, 2021 - Study Training in safe opioid prescribing and treatment of opioid use disorder in internal medicine residencies: a national survey of program directors. Citation Text: Windish DM, Catalanotti JS, Zaas A, et al. Training in safe opioid prescribing and treatment of opioid use disorder in i…

4113. 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 …

4114. 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.…

4115. 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…

4116. 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…

4117. 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…

4118. 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…

4119. 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…

4120. 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…