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  1. psnet.ahrq.gov/issue/defining-and-studying-errors-surgical-care-systematic-review
    July 20, 2022 - Review Defining and studying errors in surgical care: a systematic review. Citation Text: Marsh KM, Turrentine FE, Knight K, et al. Defining and studying errors in surgical care: a systematic review. Ann Surg. 2022;275(6):1067-1073. doi:10.1097/sla.0000000000005351. Copy Citation F…
  2. psnet.ahrq.gov/issue/effect-hospital-acquired-clostridium-difficile-infection-hospital-mortality
    April 22, 2011 - Study The effect of hospital-acquired Clostridium difficile infection on in-hospital mortality. Citation Text: Oake N, Taljaard M, van Walraven C, et al. The effect of hospital-acquired Clostridium difficile infection on in-hospital mortality. Arch Intern Med. 2010;170(20):1804-10. doi:1…
  3. psnet.ahrq.gov/issue/multitasking-clinician-decision-making-and-cognitive-demand-during-and-after-team-handoffs
    September 15, 2011 - Study The multitasking clinician: decision-making and cognitive demand during and after team handoffs in emergency care. Citation Text: Laxmisan A, Hakimzada F, Sayan OR, et al. The multitasking clinician: decision-making and cognitive demand during and after team handoffs in emergency c…
  4. psnet.ahrq.gov/issue/failure-rescue-deteriorating-patients-systematic-review-root-causes-and-improvement
    January 18, 2013 - Review Emerging Classic Failure to rescue deteriorating patients: a systematic review of root causes and improvement strategies. Citation Text: Burke JR, Downey C, Almoudaris AM. Failure to rescue deteriorating patients: a systematic review of root causes and im…
  5. psnet.ahrq.gov/issue/drug-related-problems-among-older-people-dementia-systematic-review
    January 12, 2022 - Review Drug-related problems among older people with dementia: a systematic review. Citation Text: Xue Qin QN, Ming LC, Abd Wahab MS, et al. Drug-related problems among older people with dementia: a systematic review. Res Social Adm Pharm. 2023;19(6):873-881. doi:10.1016/j.sapharm.2023.0…
  6. psnet.ahrq.gov/issue/designing-distractions-human-factors-approach-decreasing-interruptions-centralised-medication
    July 27, 2018 - Study Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication station. Citation Text: Colligan L, Guerlain S, Steck SE, et al. Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33660/psn-pdf
    December 01, 2007 - Number one, because there's a notion that this is not something that falls within our accountability
  8. psnet.ahrq.gov/perspective/lesson-vas-team-training-program
    November 01, 2011 - Reducing falls and fall-related injuries in the VA system. J Healthc Saf Q. 2003;1:25-33. 8. … Related Resources From the Same Author(s) Root cause analysis of reported patient falls
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852700/psn-pdf
    August 30, 2023 - since experienced higher rates of preventable infections, as well as increases in pressure ulcers and falls … performance measures are associated with measuring and reporting specific harms, such as an infection, falls
  10. psnet.ahrq.gov/perspective/preparing-health-reform-federal-government-and-nursing-workforce
    September 01, 2012 - Patients are at risk of falls. … The "solution" is an assessment form and an action plan related to the risk of falls.
  11. psnet.ahrq.gov/perspective/conversation-jack-needleman-phd
    September 01, 2012 - Patients are at risk of falls. … The "solution" is an assessment form and an action plan related to the risk of falls.
  12. psnet.ahrq.gov/issue/identifying-hospital-wide-harm-set-icd-9-cm-coded-conditions-associated-increased-cost-length
    September 07, 2016 - Study Identifying hospital-wide harm: a set of ICD-9–CM-coded conditions associated with increased cost, length of stay, and risk of mortality. Citation Text: Bankowitz RA, Doyle B, Duan M, et al. Identifying hospital-wide harm: a set of ICD-9-CM-coded conditions associated with increase…
  13. psnet.ahrq.gov/issue/medication-errors-during-treatment-new-oral-anticancer-agents-consequences-clinical-practice
    April 21, 2021 - Study Medication errors during treatment with new oral anticancer agents: consequences for clinical practice based on the AMBORA Study. Citation Text: Schlichtig K, Dürr P, Dörje F, et al. Medication errors during treatment with new oral anticancer agents: consequences for clinical pract…
  14. psnet.ahrq.gov/issue/enhancing-patient-safety-and-quality-care-improving-usability-electronic-health-record
    March 04, 2011 - Commentary Enhancing patient safety and quality of care by improving the usability of electronic health record systems: recommendations from AMIA. Citation Text: Middleton B, Bloomrosen M, Dente MA, et al. Enhancing patient safety and quality of care by improving the usability of electro…
  15. psnet.ahrq.gov/issue/monitoring-harm-associated-use-anticoagulants-pediatric-populations-through-trigger-based
    November 11, 2015 - Study Monitoring the harm associated with use of anticoagulants in pediatric populations through trigger-based automated adverse-event detection. Citation Text: Patregnani JT, Spaeder MC, Lemon V, et al. Monitoring the harm associated with use of anticoagulants in pediatric populations t…
  16. psnet.ahrq.gov/issue/meaningful-use-health-information-technology-and-declines-hospital-adverse-drug-events
    November 28, 2012 - Study Meaningful use of health information technology and declines in in-hospital adverse drug events. Citation Text: Furukawa MF, Spector WD, Limcangco R, et al. Meaningful use of health information technology and declines in in-hospital adverse drug events. J Am Med Inform Assoc. 2017;…
  17. psnet.ahrq.gov/issue/epistemology-patient-safety-research-framework-study-design-and-interpretation
    February 23, 2011 - Study Classic An epistemology of patient safety research: a framework for study design and interpretation. Citation Text: Brown C, Hofer T, Johal A, et al. An epistemology of patient safety research: a framework for study design and interpretation. Part 4. One s…
  18. psnet.ahrq.gov/issue/medically-necessary-time-sensitive-procedures-scoring-system-ethically-and-efficiently-manage
    October 11, 2017 - Commentary Emerging Classic Medically-necessary, time-sensitive procedures: a scoring system to ethically and efficiently manage resource scarcity and provider risk during the COVID-19 pandemic. Citation Text: Prachand VN, Milner R, Angelos P, et al. Medically-n…
  19. psnet.ahrq.gov/issue/communicating-patient-safety-information-through-video-and-oral-formats-comparison
    November 16, 2022 - Study Communicating patient safety information through video and oral formats-a comparison. Citation Text: Bånnsgård M, Nouri A, Finizia C, et al. Communicating patient safety information through video and oral formats-a comparison. J Patient Saf. 2023;19(2):137-142. doi:10.1097/pts.0000…
  20. psnet.ahrq.gov/issue/patient-safety-emergency-departments-problem-health-care-systems-international-survey
    February 26, 2020 - Study Patient safety in emergency departments: a problem for health care systems? An international survey. Citation Text: Petrino R, Tuunainen E, Bruzzone G, et al. Patient safety in emergency departments: a problem for health care systems? An international survey. Eur J Emerg Med. 2023;…

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