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psnet.ahrq.gov/node/40392/psn-pdf
February 10, 2015 - 'Global Trigger Tool' shows that adverse events in
hospitals may be ten times greater than previously
measured.
February 10, 2015
Classen D, Resar RK, Griffin F, et al. 'Global trigger tool' shows that adverse events in hospitals may be ten
times greater than previously measured. Health Aff (Millwood). 2011;30(4):…
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psnet.ahrq.gov/node/840259/psn-pdf
November 16, 2022 - Clinician collaboration to improve clinical decision
support: the Clickbusters initiative.
November 16, 2022
Mc Coy AB, Russo EM, Johnson KB, et al. Clinician collaboration to improve clinical decision support: the
Clickbusters initiative. J Am Med Inform Assoc. Epub 2022 Mar 4
https://psnet.ahrq.gov/innovation/cl…
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psnet.ahrq.gov/node/845356/psn-pdf
March 29, 2023 - A novel approach for engagement in team training in
high-technology surgery: the robotic-assisted surgery
olympics.
March 29, 2023
Cohen TN, Anger JT, Kanji FF, et al. A novel approach for engagement in team training in high-technology
surgery: the robotic-assisted surgery olympics. J Patient Saf. 2022;18(6):570-5…
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psnet.ahrq.gov/node/46411/psn-pdf
April 12, 2019 - Effect of health information exchange on recognition of
medication discrepancies is interrupted when data
charges are introduced: results of a cluster-randomized
controlled trial.
April 12, 2019
Boockvar K, Ho W, Pruskowski J, et al. Effect of health information exchange on recognition of medication
discrepancies…
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psnet.ahrq.gov/node/45293/psn-pdf
February 01, 2017 - Patient safety incidents involving sick children in primary
care in England and Wales: a mixed methods analysis.
February 1, 2017
Rees P, Edwards A, Powell C, et al. Patient Safety Incidents Involving Sick Children in Primary Care in
England and Wales: A Mixed Methods Analysis. PLoS Med. 2017;14(1):e1002217.
doi:1…
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psnet.ahrq.gov/node/42099/psn-pdf
March 13, 2013 - Inpatient fall prevention programs as a patient safety
strategy: a systematic review.
March 13, 2013
Miake-Lye IM, Hempel S, Ganz DA, et al. Inpatient fall prevention programs as a patient safety strategy: a
systematic review. Ann Intern Med. 2013;158(5 Pt 2):390-396. doi:10.7326/0003-4819-158-5-201303051-
00005.
…
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psnet.ahrq.gov/node/845358/psn-pdf
March 29, 2023 - Implementation of a medication reconciliation risk
stratification tool integrated within an electronic health
record: a case series of three academic medical centers.
March 29, 2023
Chu ES, El-Kareh R, Biondo A, et al. Implementation of a medication reconciliation risk stratification tool
integrated within an elec…
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psnet.ahrq.gov/node/44434/psn-pdf
June 21, 2016 - Hospital board and management practices are strongly
related to hospital performance on clinical quality
metrics.
June 21, 2016
Tsai TC, Jha AK, Gawande AA, et al. Hospital board and management practices are strongly related to
hospital performance on clinical quality metrics. Health Aff (Millwood). 2015;34(8):130…
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psnet.ahrq.gov/node/39617/psn-pdf
February 18, 2011 - Potential unintended consequences due to Medicare's
"No Pay for Errors Rule"? A randomized controlled trial of
an educational intervention with internal medicine
residents.
February 18, 2011
Mookherjee S, Vidyarthi AR, Ranji SR, et al. Potential Unintended Consequences Due to Medicare’s “No
Pay for Errors Rule”? …
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psnet.ahrq.gov/node/47117/psn-pdf
November 16, 2018 - Using a pediatric trigger tool to estimate total harm
burden hospital-acquired conditions represent.
November 16, 2018
Stockwell DC, Landrigan CP, Schuster MA, et al. Using a Pediatric Trigger Tool to Estimate Total Harm
Burden Hospital-acquired Conditions Represent. Pediatr Qual Saf. 2018;3(3):e081.
doi:10.1097/p…
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psnet.ahrq.gov/node/47928/psn-pdf
January 01, 2021 - Perceptions of pediatric hospital safety culture in the
United States: an analysis of the 2016 Hospital Survey on
Patient Safety Culture.
April 24, 2019
Gampetro PJ, Segvich JP, Jordan N, et al. Perceptions of Pediatric Hospital Safety Culture in the United
States: An Analysis of the 2016 Hospital Survey on Patien…
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psnet.ahrq.gov/node/39501/psn-pdf
January 03, 2017 - Harmful medication errors involving unfractionated and
low-molecular-weight heparin in three patient safety
reporting programs.
January 3, 2017
Grissinger MC, Hicks RW, Keroack MA, et al. Harmful medication errors involving unfractionated and low-
molecular-weight heparin in three patient safety reporting programs…
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psnet.ahrq.gov/innovation/battle-buddies-rapid-deployment-psychological-resilience-intervention-health-care
September 09, 2020 - EMERGING INNOVATIONS
Battle Buddies: rapid deployment of a psychological resilience intervention for health care workers during the COVID-19 pandemic
Citation Text:
Albott CS, Wozniak JR, McGlinch BP, et al. Battle Buddies: rapid deployment of a psychological resilience intervention for health car…
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psnet.ahrq.gov/perspective/conversation-mark-l-graber-md
January 01, 2016 - errors, these areas include clarifying responsibilities for follow-up of abnormal clinical findings, identifying … with further refinement, a single clinician could use the recently developed Safer Dx instrument for identifying
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psnet.ahrq.gov/web-mm/delayed-diagnosis-mesenteric-ischemia
March 31, 2021 - Identifying Risks to Patient Safety
The PCP, gastroenterologist, and endocrinologist did not fully
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psnet.ahrq.gov/web-mm/duplicate-therapies-retail-pharmacy
August 05, 2022 - mitigated through best practices in medication reconciliation , which is defined as the process of identifying
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psnet.ahrq.gov/web-mm/all-history
February 28, 2011 - These "ring downs" are necessarily brief, do not include identifying information (beyond patient age
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psnet.ahrq.gov/node/49431/psn-pdf
January 01, 2004 - Keys to detecting acute aortic dissection are a complete history (identifying the quality, severity,
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psnet.ahrq.gov/node/841469/psn-pdf
December 14, 2022 - care, critical care, rheumatology, pulmonology, and
oncology, should be aware of the importance of identifying
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psnet.ahrq.gov/node/49497/psn-pdf
December 01, 2005 - Once identified, these instructors need to develop skills in identifying learning objectives for various