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  1. What is known about adverse events in older medical hospital inpatients? A systematic review of the literature. | PSNet

    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…

  2. Empowerment failure: how shortcomings in physician communication unwittingly undermine patient autonomy. | PSNet

    psnet.ahrq.gov/issue/empowerment-failure-how-shortcomings-physician-communication-unwittingly-undermine-patient
    January 17, 2019 - Study Empowerment failure: how shortcomings in physician communication unwittingly undermine patient autonomy. Citation Text: Ubel PA, Scherr KA, Fagerlin A. Empowerment Failure: How Shortcomings in Physician Communication Unwittingly Undermine Patient Autonomy. Am J Bioeth. 2017;17(11):…

  3. Systematic review on the prevalence, frequency and comparative value of adverse events data in social media. | PSNet

    psnet.ahrq.gov/issue/systematic-review-prevalence-frequency-and-comparative-value-adverse-events-data-social-media
    October 06, 2021 - Review Systematic review on the prevalence, frequency and comparative value of adverse events data in social media. Citation Text: Golder S, Norman G, Loke YK. Systematic review on the prevalence, frequency and comparative value of adverse events data in social media. Br J Clin Pharmacol…

  4. Application of human factors methods to ensure appropriate infant identification and abduction prevention within the hospital setting. | PSNet

    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…

  5. 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. | PSNet

    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 …

  6. Good Practice Guides on Medication Errors: Part 1 and Part 2. | PSNet

    psnet.ahrq.gov/issue/good-practice-guides-medication-errors-part-1-and-part-2
    August 03, 2016 - Book/Report Good Practice Guides on Medication Errors: Part 1 and Part 2. Citation Text: Goedecke T, Ord K, Newbould V, et al. Medication Errors: New Eu Good Practice Guide On Risk Minimisation And Error Prevention. Springer Science and Business Media LLC; 2016. doi:10.1007/s40264-016-04…

  7. Trust, temporality and systems: how do patients understand patient safety in primary care? A qualitative study. | PSNet

    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…

  8. Failure to rescue and 30-day in-hospital mortality in hospitals with and without crew-resource-management safety training. | PSNet

    psnet.ahrq.gov/issue/failure-rescue-and-30-day-hospital-mortality-hospitals-and-without-crew-resource-management
    January 26, 2022 - Study Failure to rescue and 30-day in-hospital mortality in hospitals with and without crew-resource-management safety training. Citation Text: Bacon CT, McCoy TP, Henshaw DS. Failure to rescue and 30‐day in‐hospital mortality in hospitals with and without crew‐resource‐management safety…

  9. Interventions to reduce the incidence of medical error and its financial burden in health care systems: a systematic review of systematic reviews. | PSNet

    psnet.ahrq.gov/issue/interventions-reduce-incidence-medical-error-and-its-financial-burden-health-care-systems
    September 29, 2021 - Review Interventions to reduce the incidence of medical error and its financial burden in health care systems: a systematic review of systematic reviews. Citation Text: Ahsani-Estahbanati E, Sergeevich Gordeev V, Doshmangir L. Interventions to reduce the incidence of medical error and it…

  10. U.S. Preventive Services Task Force Highlights High-Priority Evidence Gaps in 2024 Report to Congress (pdf file)

    www.uspreventiveservicestaskforce.org/uspstf/sites/default/files/file/supporting_documents/2024-annual-report-to-congress-bulletin.pdf
    January 01, 2024 - U.S. Preventive Services Task Force Highlights High-Priority Evidence Gaps in 2024 Report to Congress 1 www.uspreventiveservicestaskforce.org U.S. Preventive Services Task Force Highlights High-Priority Evidence Gaps in 2024 Report to Congress Task Force calls for more research to improve the health of…

  11. The barriers and enhancers to trust in a just culture in hospital settings: a systematic review. | PSNet

    psnet.ahrq.gov/issue/barriers-and-enhancers-trust-just-culture-hospital-settings-systematic-review
    February 02, 2022 - Review The barriers and enhancers to trust in a just culture in hospital settings: a systematic review. Citation Text: van Marum S, Verhoeven D, de Rooy D. The barriers and enhancers to trust in a just culture in hospital settings: a systematic review. J Patient Saf. 2022;18(7):e1067-e10…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50647/psn-pdf
    November 06, 2019 - ‘Fear of falling’: how hospitals do even more harm by keeping patients in bed. November 6, 2019 Bailey M. Kaiser Health News. October 17, 2019. https://psnet.ahrq.gov/issue/fear-falling-how-hospitals-do-even-more-harm-keeping-patients-bed Patient falls with harm are a common sentinel event. This news story discuss…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837863/psn-pdf
    August 17, 2022 - The Nursing Home Expert Panel’s Falls Investigation Guide Toolkit: How-To Guide. August 17, 2022 Portland, OR: Oregon Patient Safety Commission; 2022.  https://psnet.ahrq.gov/issue/nursing-home-expert-panels-falls-investigation-guide-toolkit-how-guide Patient falls are common sentinel events. The latest revis…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50862/psn-pdf
    February 05, 2020 - Assessment of nursing home reporting of major injury falls for quality measurement on Nursing Home Compare. February 5, 2020 Sanghavi P, Pan S, Caudry D. Assessment of nursing home reporting of major injury falls for quality measurement on nursing home compare. Health Serv Res. 2020;55(2):201-210. doi:10.1111/1475-…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38715/psn-pdf
    February 17, 2011 - Medicare nonpayment, hospital falls, and unintended consequences. February 17, 2011 Inouye SK, Brown CJ, Tinetti ME. Medicare nonpayment, hospital falls, and unintended consequences. N Engl J Med. 2009;360(23):2390-3. doi:10.1056/NEJMp0900963. https://psnet.ahrq.gov/issue/medicare-nonpayment-hospital-falls-and-uni…

  16. 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.…

  17. 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…

  18. 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…

  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/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…
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