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  1. psnet.ahrq.gov/issue/facilitating-safe-transition-pediatric-emergency-department-home-post-discharge-phone-call
    March 13, 2015 - Study Facilitating a safe transition from the pediatric emergency department to home with a post-discharge phone call: a quality-improvement initiative to improve patient safety. Citation Text: Bucaro PJ, Black E. Facilitating a safe transition from the pediatric emergency department to …
  2. psnet.ahrq.gov/issue/patient-factors-associated-new-prescribing-potentially-inappropriate-medications-multimorbid
    August 18, 2021 - Study Patient factors associated with new prescribing of potentially inappropriate medications in multimorbid US older adults using multiple medications. Citation Text: Jungo KT, Streit S, Lauffenburger JC. Patient factors associated with new prescribing of potentially inappropriate medi…
  3. psnet.ahrq.gov/issue/ten-years-online-incident-reporting-and-learning-using-cpirls-implications-improved-patient
    December 23, 2020 - Study Ten years of online incident reporting and learning using CPiRLS: implications for improved patient safety. Citation Text: Thomas M, Swait G, Finch R. Ten years of online incident reporting and learning using CPiRLS: implications for improved patient safety. Chiropr Man Therap. 202…
  4. psnet.ahrq.gov/issue/unpacking-complexity-covid-19-fatalities-adverse-events-contributing-factors-single-center
    January 25, 2023 - Study Unpacking the complexity of COVID-19 fatalities: adverse events as contributing factors--a single-center, retrospective analysis of the first two years of the pandemic. Citation Text: Zińczuk A, Rorat M, Simon K, et al. Unpacking the complexity of COVID-19 fatalities: adverse event…
  5. psnet.ahrq.gov/issue/prevalence-medical-error-related-end-life-communication-canadian-hospitals-results
    November 23, 2016 - Study Classic The prevalence of medical error related to end-of-life communication in Canadian hospitals: results of a multicentre observational study. Citation Text: Heyland DK, Ilan R, Jiang X, et al. The prevalence of medical error related to end-of-life comm…
  6. psnet.ahrq.gov/issue/application-human-factors-methods-ensure-appropriate-infant-identification-and-abduction
    April 27, 2022 - Commentary Application of human factors methods to ensure appropriate infant identification and abduction prevention within the hospital setting. Citation Text: Webster KLW, Stikes R, Bunnell L, et al. Application of human factors methods to ensure appropriate infant identification and a…
  7. psnet.ahrq.gov/issue/antimicrobial-residual-drug-error-intensive-care-unit-single-blinded-prospective
    November 21, 2021 - Study Antimicrobial residual drug error in the intensive care unit; a single blinded prospective observational study. Citation Text: Jarrett P, Keogh S, Roberts JA, et al. Antimicrobial residual drug error in the intensive care unit; a single blinded prospective observational study. Inte…
  8. psnet.ahrq.gov/issue/what-known-about-adverse-events-older-medical-hospital-inpatients-systematic-review
    January 12, 2012 - Review What is known about adverse events in older medical hospital inpatients? A systematic review of the literature. Citation Text: Long SJ, Brown KF, Ames D, et al. What is known about adverse events in older medical hospital inpatients? A systematic review of the literature. Int J He…
  9. psnet.ahrq.gov/issue/what-can-we-learn-about-patient-safety-information-sources-within-acute-hospital-step-ladder
    October 09, 2024 - Study What can we learn about patient safety from information sources within an acute hospital: a step on the ladder of integrated risk management? Citation Text: Hogan H, Olsen S, Scobie S, et al. What can we learn about patient safety from information sources within an acute hospital…
  10. psnet.ahrq.gov/issue/trust-temporality-and-systems-how-do-patients-understand-patient-safety-primary-care
    February 09, 2016 - Study Trust, temporality and systems: how do patients understand patient safety in primary care? A qualitative study. Citation Text: Rhodes P, Campbell S, Sanders C. Trust, temporality and systems: how do patients understand patient safety in primary care? A qualitative study. Health Exp…
  11. psnet.ahrq.gov/issue/changes-hospital-adverse-events-and-patient-outcomes-associated-private-equity-acquisition
    July 12, 2023 - Study Changes in hospital adverse events and patient outcomes associated with private equity acquisition. Citation Text: Kannan S, Bruch JD, Song Z. Changes in hospital adverse events and patient outcomes associated with private equity acquisition. JAMA. 2023;330(24):2365-2375. doi:10.10…
  12. psnet.ahrq.gov/issue/association-between-night-time-surgery-and-occurrence-intraoperative-adverse-events-and
    October 13, 2021 - Study Association between night-time surgery and occurrence of intraoperative adverse events and postoperative pulmonary complications. Citation Text: Association between night-time surgery and occurrence of intraoperative adverse events and postoperative pulmonary complications. Cortegi…
  13. psnet.ahrq.gov/issue/causes-their-death-appear-unto-our-shame-perpetual-why-root-cause-analysis-not-best-model
    September 27, 2016 - Study The causes of their death appear (unto our shame perpetual): why root cause analysis is not the best model for error investigation in mental health services. Citation Text: Vrklevski LP, McKechnie L, OʼConnor N. The Causes of Their Death Appear (Unto Our Shame Perpetual): Why Root …
  14. psnet.ahrq.gov/issue/polypharmacy-and-potentially-inappropriate-medication-people-dementia-nationwide-study
    March 06, 2012 - Study Emerging Classic Polypharmacy and potentially inappropriate medication in people with dementia: a nationwide study. Citation Text: Kristensen RU, Nørgaard A, Jensen-Dahm C, et al. Polypharmacy and Potentially Inappropriate Medication in People with Dementi…
  15. 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…
  16. 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…
  17. 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…
  18. 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…
  19. 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…
  20. 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…