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psnet.ahrq.gov/issue/clinical-characteristics-and-short-term-outcomes-acute-kidney-injury-missed-diagnosis-older
April 20, 2022 - with severe COVID-19 in intensive care unit. … In this cohort of 107 patients with severe or critical COVID-19 in Wuhan, China, 45% developed acute … However, nearly half of those patients (46%) were not diagnosed during their stay in the hospital. … Patients with undiagnosed AKI experienced greater hospital mortality than those without AKI or diagnosed … November 10, 2021
Inpatient telemedicine and new models of care during COVID-19: hospital
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psnet.ahrq.gov/issue/evaluation-policies-limiting-opioid-exposure-opioid-prescribing-and-patient-pain-opioid-naive
May 18, 2022 - opioid-naive patients undergoing elective surgery in a large American health system. … patients undergoing elective surgery in a large American health system. … patients undergoing elective surgery in a large American health system. … February 15, 2023
Miscarriage treatment-related morbidities and adverse events in hospitals … April 17, 2019
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Outpatient Surgery
Hospitals
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psnet.ahrq.gov/issue/effect-standardized-handoff-curriculum-improved-clinician-preparedness-intensive-care-unit
October 19, 2022 - communication in eight intensive care units (ICUs) across two hospital systems. … a multistate hospital network--13 academic medical centers, April-June 2020. … August 20, 2018
Changes in error patterns in unanticipated trauma deaths during 20 years … : in pursuit of zero preventable deaths. … November 12, 2014
Families as partners in hospital error and adverse event surveillance
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psnet.ahrq.gov/issue/understanding-differences-electronic-health-record-ehr-use-linking-individual-physicians
November 17, 2015 - physicians' perceptions of uncertainty and EHR use patterns in ambulatory care. … of uncertainty and EHR use patterns in ambulatory care. … both hospital and ambulatory settings. … patterns in the ambulatory setting. … of uncertainty and EHR use patterns in ambulatory care.
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psnet.ahrq.gov/issue/efficacy-tolerability-and-dose-dependent-effects-opioid-analgesics-low-back-pain-systematic
March 02, 2011 - a small and short-term decrease in pain, which is deemed clinically insignificant. … care in England: retrospective case note review. … of drugs in anaesthesia: prospective randomised clinical evaluation. … October 12, 2018
The burden of opioid-related mortality in the United States. … June 1, 2016
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Hospitals
Physicians
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psnet.ahrq.gov/issue/new-recommendations-duty-hours-acgme-task-force
July 14, 2021 - The recommendations are perhaps most notable for what they do not contain—a reduction in the 80-hour … to Engage in Patient Safety. … July 29, 2020
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Related Resources
Changes in hospital mortality … April 8, 2011
Impact of reduction in working hours for doctors in training on postgraduate … October 1, 2007
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Hospitals
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psnet.ahrq.gov/issue/implementing-medication-reconciliation-outpatient-pediatrics
September 23, 2020 - Implementing medication reconciliation in outpatient pediatrics. … 2009 and eventually eliminating it as a separate NPSG in 2011. … a multistate hospital network--13 academic medical centers, April-June 2020. … May 4, 2010
Changes in medication safety indicators in England throughout the covid-19 … Development of a tool within the electronic medical record to facilitate medication reconciliation after hospital
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psnet.ahrq.gov/issue/framework-evaluating-appropriateness-clinical-decision-support-alerts-and-responses
March 21, 2017 - May 20, 2019
Problem list completeness in electronic health records: a multi-site study … The incidence and severity of adverse events affecting patients after discharge from the hospital … February 17, 2021
Overrides of medication alerts in ambulatory care. … March 4, 2011
Defining the incidence of cardiorespiratory instability in patients in … November 17, 2010
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Hospitals
Health
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psnet.ahrq.gov/issue/patient-safety-emergency-departments-problem-health-care-systems-international-survey
February 26, 2020 - Patient safety in emergency departments: a problem for health care systems? … Patient safety in emergency departments: a problem for health care systems? … examination tool during the Covid-19 emergency: the experience of the onco-haematology center of Tor Vergata Hospital … in Rome. … April 26, 2023
Crisis in the Lakeshore Hospital ER.
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psnet.ahrq.gov/issue/how-would-final-year-medical-students-perform-if-their-skill-based-prescription-assessment
October 18, 2023 - This retrospective cohort study conducted at one medical center in the Netherlands identified a high … rate of errors in prescriptions written by medical students (40% of all prescriptions). … lists reported by patients in personal health records: a prospective cohort study in a hospital setting … July 29, 2020
Do professionalism lapses in medical school predict problems in residency … July 31, 2012
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Hospitals
Ambulatory
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psnet.ahrq.gov/issue/successful-implementation-unit-based-quality-nurse-reduce-central-line-associated-bloodstream
September 23, 2020 - CLABSI rates in other adult ICUs. … a multistate hospital network--13 academic medical centers, April-June 2020. … March 24, 2019
Families as partners in hospital error and adverse event surveillance. … March 1, 2023
Toolkit for Preventing CLABSI and CAUTI in ICUs. … February 29, 2012
Improving patient safety in intensive care units in Michigan.
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psnet.ahrq.gov/issue/clinical-diagnoses-vs-autopsy-findings-early-deceased-septic-patients-intensive-care
September 22, 2021 - Study
Clinical diagnoses vs. autopsy findings in early deceased septic patients in … Clinical diagnoses vs. autopsy findings in early deceased septic patients in the intensive care: a retrospective … Clinical diagnoses vs. autopsy findings in early deceased septic patients in the intensive care: a retrospective … lists reported by patients in personal health records: a prospective cohort study in a hospital setting … April 27, 2022
We are not there yet: a qualitative system probing study of a hospital
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psnet.ahrq.gov/issue/qualitative-perspectives-emergency-nurses-electronic-health-record-behavioral-flags-promote
January 25, 2023 - Based on semi-structured interviews with 25 registered nurses working in the emergency department (ED … with failures in communication during the event. … a multistate hospital network--13 academic medical centers, April-June 2020. … September 23, 2020
What's in a name? … April 3, 2019
Clinical practice guideline: safe medication use in the ICU.
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psnet.ahrq.gov/issue/learning-different-lenses-reports-medical-errors-primary-care-clinicians-staff-and-patients
June 11, 2008 - Study
Learning from different lenses: reports of medical errors in primary care by … August 9, 2011
Management of test results in family medicine offices. … Diagnostic Safety and Quality
April 26, 2023
From fable to reality at Parkland Hospital … June 17, 2009
Characteristics of medication errors and adverse drug events in hospitals … participating in the California Pediatric Patient Safety Initiative.
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psnet.ahrq.gov/issue/impact-crm-based-team-training-obstetric-outcomes-and-clinicians-patient-safety-attitudes
January 12, 2011 - The training program was associated with a decrease in frequency and severity of adverse events and in … While similar benefits of teamwork training are described in other clinical settings, this study’s … U.S. hospitals. … hospital procedural units. … July 8, 2009
Teamwork in obstetric critical care.
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psnet.ahrq.gov/issue/preventing-iatrogenic-overdose-review-emergency-department-opioid-related-adverse-drug-events
August 12, 2020 - Study
Preventing iatrogenic overdose: a review of in–emergency department opioid-related … This study was conducted using a trigger tool method in which all cases of naloxone administration in … August 12, 2020
Association of the Hospital Readmissions Reduction Program implementation … with readmission and mortality outcomes in heart failure. … August 20, 2018
Alert burden in pediatric hospitals: a cross-sectional analysis of six
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psnet.ahrq.gov/issue/learning-mistakes-factors-influence-how-students-and-residents-learn-medical-errors
November 15, 2011 - Effect of different interventions to help primary care clinicians avoid unsafe opioid prescribing in … June 13, 2011
Comparing patient-reported hospital adverse events with medical record … review: do patients know something that hospitals do not? … education: results from the 2012 clerkship directors in internal medicine survey. … January 2, 2017
Morbidity and mortality conference in emergency medicine residencies
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psnet.ahrq.gov/issue/changes-prescription-and-over-counter-medication-and-dietary-supplement-use-among-older
May 06, 2020 - Study
Changes in prescription and over-the-counter medication and dietary supplement … use among older adults in the United States, 2005 vs 2011. … Changes in Prescription and Over-the-Counter Medication and Dietary Supplement Use Among Older Adults … in the United States, 2005 vs 2011. … in the United States, 2005 vs 2011.
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psnet.ahrq.gov/issue/stakeholder-perceptions-and-attitudes-towards-problematic-polypharmacy-and-prescribing
July 10, 2019 - prescribing cascade occurs when a medication side effect is misinterpreted as a new symptom resulting in … caregivers, physicians, pharmacists, and other experts for their perspectives on prescribing cascades in … June 29, 2022
Prevalence of potentially inappropriate prescribing in older people in … primary care and its association with hospital admission: longitudinal study. … children (PIPc) in primary care using a modified Delphi technique.
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psnet.ahrq.gov/issue/fda-drug-prescribing-warnings-black-box-half-empty-or-half-full
December 19, 2011 - While the authors acknowledge significant variability in compliance with BBW medications, the warnings … themselves failed to prevent their use in many circumstances. … July 29, 2020
Incidence and trends of sepsis in US hospitals using clinical vs claims … August 20, 2018
Effect of nonpayment for preventable infections in U.S. hospitals. … March 29, 2010
Strategies for safe medication use in ambulatory care settings in the