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psnet.ahrq.gov/issue/organizational-learning-morbidity-and-mortality-conference
June 09, 2015 - Study
Organizational learning in the morbidity and mortality conference.
Citation Text:
Batthish M, Kuper A, Fine C, et al. Organizational learning in the morbidity and mortality conference. J Healthc Qual. 2024;46(2):100-108. doi:10.1097/jhq.0000000000000416.
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psnet.ahrq.gov/issue/completeness-serious-adverse-drug-event-reports-received-us-food-and-drug-administration-2014
September 25, 2008 - Study
Completeness of serious adverse drug event reports received by the US Food and Drug Administration in 2014.
Citation Text:
Moore TJ, Furberg CD, Mattison DR, et al. Completeness of serious adverse drug event reports received by the US Food and Drug Administration in 2014. Pharmacoe…
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psnet.ahrq.gov/issue/use-patient-digital-facial-images-confirm-patient-identity-childrens-hospitals-anesthesia
May 06, 2009 - Study
The use of patient digital facial images to confirm patient identity in a children's hospital's anesthesia information management system.
Citation Text:
Thomas JJ, Yaster M, Guffey P. The Use of Patient Digital Facial Images to Confirm Patient Identity in a Children's Hospital's An…
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psnet.ahrq.gov/issue/dynamic-risk-management-approach-reducing-harm-invasive-bedside-procedures-performed-during
April 13, 2022 - Commentary
A dynamic risk management approach for reducing harm from invasive bedside procedures performed during residency.
Citation Text:
Warm E, Ahmad Y, Kinnear B, et al. A dynamic risk management approach for reducing harm from invasive bedside procedures performed during residency.…
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psnet.ahrq.gov/issue/drug-error-anaesthetic-practice-review-896-reports-australian-incident-monitoring-study
June 13, 2011 - Study
Drug error in anaesthetic practice: a review of 896 reports from the Australian Incident Monitoring Study database.
Citation Text:
Abeysekera A, Bergman IJ, Kluger MT, et al. Drug error in anaesthetic practice: a review of 896 reports from the Australian Incident Monitoring Study…
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psnet.ahrq.gov/issue/retained-guidewires-veterans-health-administration-getting-root-problem
March 13, 2013 - Study
Retained guidewires in the Veterans Health Administration: getting to the root of the problem.
Citation Text:
Cherara L, Sculli GL, Paull DE, et al. Retained Guidewires in the Veterans Health Administration: Getting to the Root of the Problem. J Patient Saf. 2021;17(8):e991-e928. d…
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psnet.ahrq.gov/issue/effect-bar-code-assisted-medication-administration-medication-error-rates-adult-medical
July 23, 2010 - Study
Effect of bar-code–assisted medication administration on medication error rates in an adult medical intensive care unit.
Citation Text:
DeYoung JL, Vanderkooi ME, Barletta JF. Effect of bar-code-assisted medication administration on medication error rates in an adult medical inte…
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psnet.ahrq.gov/issue/unanticipated-death-after-discharge-home-emergency-department
November 16, 2022 - Study
Unanticipated death after discharge home from the emergency department.
Citation Text:
Sklar DP, Crandall CS, Loeliger E, et al. Unanticipated Death After Discharge Home From the Emergency Department. Ann Emerg Med. 2007;49(6). doi:10.1016/j.annemergmed.2006.11.018.
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psnet.ahrq.gov/issue/weekend-and-night-outcomes-statewide-trauma-system
November 16, 2022 - Study
Weekend and night outcomes in a statewide trauma system.
Citation Text:
Carr BG, Reilly PM, Schwab W, et al. Weekend and night outcomes in a statewide trauma system. Arch Surg. 2011;146(7):810-7. doi:10.1001/archsurg.2011.60.
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psnet.ahrq.gov/issue/association-overlapping-surgery-patient-outcomes-large-series-neurosurgical-cases
November 16, 2022 - Study
Association of overlapping surgery with patient outcomes in a large series of neurosurgical cases.
Citation Text:
Howard BM, Holland CM, Mehta C, et al. Association of Overlapping Surgery With Patient Outcomes in a Large Series of Neurosurgical Cases. JAMA Surg. 2018;153(4):313-321…
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psnet.ahrq.gov/issue/err-human-disclosure-must-be-taught-simulation-based-assessment-study
August 04, 2021 - Study
"To err is human" but disclosure must be taught: a simulation-based assessment study.
Citation Text:
Crimmins AC, Wong AH, Bonz JW, et al. "To Err Is Human" but Disclosure Must be Taught: A Simulation-Based Assessment Study. Simul Healthc. 2018;13(2):107-116. doi:10.1097/SIH.000000…
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psnet.ahrq.gov/issue/impact-out-hours-admission-patient-mortality-longitudinal-analysis-tertiary-acute-hospital
July 21, 2017 - Study
Impact of out-of-hours admission on patient mortality: longitudinal analysis in a tertiary acute hospital.
Citation Text:
Han L, Sutton M, Clough S, et al. Impact of out-of-hours admission on patient mortality: longitudinal analysis in a tertiary acute hospital. BMJ Qual Saf. 2018;…
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psnet.ahrq.gov/issue/second-victim-unanticipated-adverse-events
February 12, 2020 - Commentary
The second victim of unanticipated adverse events.
Citation Text:
Chen S, Skidmore S, Ferrigno BN, et al. The second victim of unanticipated adverse events. J Thorac Cardiovasc Surg. 2023;166(3):890-894. doi:10.1016/j.jtcvs.2022.09.010.
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psnet.ahrq.gov/issue/defining-minimum-necessary-anticoagulation-related-communication-discharge-consensus-care
March 04, 2020 - Study
Defining minimum necessary anticoagulation-related communication at discharge: Consensus of the Care Transitions Task Force of the New York State Anticoagulation Coalition.
Citation Text:
Triller D, Myrka A, Gassler J, et al. Defining Minimum Necessary Anticoagulation-Related Commu…
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psnet.ahrq.gov/issue/parental-preferences-error-disclosure-reporting-and-legal-action-after-medical-error-care
May 24, 2010 - Study
Parental preferences for error disclosure, reporting, and legal action after medical error in the care of their children.
Citation Text:
Hobgood C, Tamayo-Sarver JH, Elms A, et al. Parental preferences for error disclosure, reporting, and legal action after medical error in the c…
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psnet.ahrq.gov/issue/impact-rapid-response-team-outcome-patients-transferred-ward-icu-single-center-study
May 27, 2011 - Study
The impact of rapid response team on outcome of patients transferred from the ward to the ICU: a single-center study.
Citation Text:
Karpman C, Keegan MT, Jensen J, et al. The impact of rapid response team on outcome of patients transferred from the ward to the ICU: a single-cent…
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psnet.ahrq.gov/issue/residents-numeric-inputting-error-computerized-physician-order-entry-prescription
March 24, 2019 - Study
Residents' numeric inputting error in computerized physician order entry prescription.
Citation Text:
Wu X, Wu C, Zhang K, et al. Residents' numeric inputting error in computerized physician order entry prescription. Int J Med Inform. 2016;88:25-33. doi:10.1016/j.ijmedinf.2016.01.0…
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www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/implementation-guides/implementation-guide1/impguide1ref.html
March 01, 2019 - Endnotes
Implementation Guide Number 1
This Implementation Guide includes suggested steps and tips for implementing initiatives for improving child health care quality from the CMS-funded national evaluation of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) Quality Demonstration …
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psnet.ahrq.gov/issue/organizational-factors-associated-high-performance-quality-and-safety-academic-medical
January 03, 2017 - Study
Classic
Organizational factors associated with high performance in quality and safety in academic medical centers.
Citation Text:
Keroack MA, Youngberg BJ, Cerese JL, et al. Organizational factors associated with high performance in quality and safety in…
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digital.ahrq.gov/track-3-improving-health-communities-through-regional-health-information-exchange-hie
January 01, 2023 - This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: https://digital.ahrq.gov/contact-us . Let us know th…