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psnet.ahrq.gov/issue/relationship-between-medication-event-rates-and-leapfrog-computerized-physician-order-entry
November 26, 2014 - Study
Relationship between medication event rates and the Leapfrog computerized physician order entry evaluation tool.
Citation Text:
Leung AA, Keohane C, Lipsitz S, et al. Relationship between medication event rates and the Leapfrog computerized physician order entry evaluation tool. J …
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psnet.ahrq.gov/issue/failure-debrief-after-critical-events-anesthesia-associated-failures-communication-during
September 24, 2018 - Study
Emerging Classic
Failure to debrief after critical events in anesthesia is associated with failures in communication during the event.
Citation Text:
Arriaga AF, Sweeney RE, Clapp JT, et al. Failure to Debrief after Critical Events in Anesthesia Is Associa…
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psnet.ahrq.gov/issue/factors-affect-opioid-quality-improvement-initiatives-primary-care-insights-ten-health
November 03, 2021 - Study
Factors that affect opioid quality improvement initiatives in primary care: insights from ten health systems.
Citation Text:
Childs E, Tano CA, Mikosz CA, et al. Factors that affect opioid quality improvement initiatives in primary care: insights from ten health systems. Jt Comm J …
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psnet.ahrq.gov/issue/preventable-proportion-healthcare-associated-infections-2005-2016-systematic-review-and-meta
April 26, 2017 - Review
The preventable proportion of healthcare-associated infections 2005-2016: systematic review and meta-analysis.
Citation Text:
Schreiber PW, Sax H, Wolfensberger A, et al. The preventable proportion of healthcare-associated infections 2005-2016: Systematic review and meta-analysis.…
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psnet.ahrq.gov/issue/risk-factors-associated-medication-ordering-errors
December 02, 2020 - Study
Risk factors associated with medication ordering errors.
Citation Text:
Abraham J, Galanter WL, Touchette DR, et al. Risk factors associated with medication ordering errors. J Am Med Inform Assoc. 2021;18(1):86-94. doi:10.1093/jamia/ocaa264.
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DOI …
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psnet.ahrq.gov/issue/resident-and-rn-perceptions-impact-medical-emergency-team-education-and-patient-safety
September 24, 2010 - Study
Resident and RN perceptions of the impact of a medical emergency team on education and patient safety in an academic medical center.
Citation Text:
Sarani B, Sonnad SS, Bergey MR, et al. Resident and RN perceptions of the impact of a medical emergency team on education and patien…
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psnet.ahrq.gov/issue/association-surgeon-patient-sex-concordance-postoperative-outcomes
September 09, 2020 - Study
Association of surgeon-patient sex concordance with postoperative outcomes.
Citation Text:
Wallis CJD, Jerath A, Coburn N, et al. Association of surgeon-patient sex concordance with postoperative outcomes. JAMA Surg. 2022;157(2):146-156. doi:10.1001/jamasurg.2021.6339.
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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;…
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psnet.ahrq.gov/issue/introduction-rapid-response-system-united-states-veterans-affairs-hospital-reduced-cardiac
January 02, 2017 - Study
Introduction of a rapid response system at a United States Veterans Affairs hospital reduced cardiac arrests.
Citation Text:
Lighthall GK, Parast L, Rapoport L, et al. Introduction of a rapid response system at a United States veterans affairs hospital reduced cardiac arrests. Anes…
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psnet.ahrq.gov/issue/implementing-and-evaluating-patient-focused-safety-technology-adult-acute-mental-health-wards
April 06, 2022 - Study
Implementing and evaluating patient-focused safety technology on adult acute mental health wards.
Citation Text:
Kendal S, Louch G, Walker L, et al. Implementing and evaluating patient‐focused safety technology on adult acute mental health wards. J Psychiatr Ment Health Nurs. 2024;…
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psnet.ahrq.gov/issue/increasing-compliance-world-health-organization-surgical-safety-checklist-regional-health
September 12, 2018 - Study
Increasing compliance with the World Health Organization surgical safety checklist—a regional health system's experience.
Citation Text:
Gitelis ME, Kaczynski A, Shear T, et al. Increasing compliance with the World Health Organization Surgical Safety Checklist-A regional health sys…
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psnet.ahrq.gov/issue/computerized-surveillance-adverse-drug-events-hospital-patients
March 27, 2005 - Study
Classic
Computerized surveillance of adverse drug events in hospital patients.
Citation Text:
Classen DC, Pestotnik SL, Evans RS, et al. Computerized surveillance of adverse drug events in hospital patients. JAMA. 1991;266(20):2847-51.
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psnet.ahrq.gov/issue/iatrogenic-illness-general-medical-service-university-hospital
August 17, 2017 - Study
Classic
Iatrogenic illness on a general medical service at a university hospital.
Citation Text:
Steel K, Gertman PM, Crescenzi C, et al. Iatrogenic illness on a general medical service at a university hospital. N Engl J Med. 1981;304(11):638-42.
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psnet.ahrq.gov/issue/secondary-analysis-hand-offs-internal-medicine-using-i-pass-mnemonic
April 22, 2013 - Study
Secondary analysis of hand-offs in internal medicine using the I-PASS mnemonic.
Citation Text:
Huber A, Moyano B, Blondon K. Secondary analysis of hand-offs in internal medicine using the I-PASS mnemonic. BMC Med Educ. 2024;24(1):1046. doi:10.1186/s12909-024-05880-7.
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psnet.ahrq.gov/issue/color-coded-prefilled-medication-syringes-decrease-time-delivery-and-dosing-errors-simulated
September 09, 2015 - Study
Color-coded prefilled medication syringes decrease time to delivery and dosing errors in simulated prehospital pediatric resuscitations: a randomized crossover trial.
Citation Text:
Stevens AD, Hernandez C, Jones S, et al. Color-coded prefilled medication syringes decrease time to …
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psnet.ahrq.gov/issue/effects-reducing-or-eliminating-resident-work-shifts-over-16-hours-systematic-review
November 12, 2014 - Review
Effects of reducing or eliminating resident work shifts over 16 hours: a systematic review.
Citation Text:
Levine AC, Adusumilli J, Landrigan CP. Effects of reducing or eliminating resident work shifts over 16 hours: a systematic review. Sleep. 2010;33(8):1043-53. doi:10.1093/sl…
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psnet.ahrq.gov/node/60864/psn-pdf
August 31, 2020 - Safety Across The Board
August 31, 2020
Fitall E, Hall KK, Gale B. Safety Across The Board . PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/safety-across-board
Defining Safety Across the Board
Safety Across The Board (SAB) is a concept originating from the Centers for Medicare & Medicaid Services
(CMS…
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psnet.ahrq.gov/issue/development-testing-and-findings-pediatric-focused-trigger-tool-identify-medication-related
April 11, 2011 - Study
Development, testing, and findings of a pediatric-focused trigger tool to identify medication-related harm in US children's hospitals.
Citation Text:
Takata GS, Mason W, Taketomo C, et al. Development, testing, and findings of a pediatric-focused trigger tool to identify medicati…
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psnet.ahrq.gov/issue/beating-weekend-trend-increased-mortality-older-adult-traumatic-brain-injury-tbi-patients
December 21, 2014 - Slideset
Beating the weekend trend: increased mortality in older adult traumatic brain injury (TBI) patients admitted on weekends.
Citation Text:
Schneider EB, Hirani SA, Hambridge HL, et al. Beating the weekend trend: increased mortality in older adult traumatic brain injury (TBI) pat…
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psnet.ahrq.gov/issue/self-reported-patient-safety-competence-among-canadian-medical-students-and-postgraduate
December 04, 2015 - Study
Self-reported patient safety competence among Canadian medical students and postgraduate trainees: a cross-sectional survey.
Citation Text:
Doyle P, VanDenKerkhof E, Edge DS, et al. Self-reported patient safety competence among Canadian medical students and postgraduate trainees: a…