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National and institutional trends in adverse events over time: a systematic review and meta-analysis of longitudinal retrospective patient record review studies. | PSNet

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February 03, 2021 - Review National and institutional trends in adverse events over time: a systematic review and meta-analysis of longitudinal retrospective patient record review studies. Citation Text: Connolly W, Li B, Conroy RM, et al. National and institutional trends in adverse events over time: a sys…

Frequency and preventability of adverse drug events in the outpatient setting. | PSNet

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May 15, 2024 - Study Frequency and preventability of adverse drug events in the outpatient setting. Citation Text: Wasserman RL, Edrees HH, Amato MG, et al. Frequency and preventability of adverse drug events in the outpatient setting. BMJ Qual Saf. 2024;Epub Jul 9. doi:10.1136/bmjqs-2024-017098. Cop…

Did the organization of primary care practices during the COVID-19 pandemic influence quality and safety? - an international survey. | PSNet

psnet.ahrq.gov/issue/did-organization-primary-care-practices-during-covid-19-pandemic-influence-quality-and-safety

January 08, 2025 - Study Did the organization of primary care practices during the COVID-19 pandemic influence quality and safety? - an international survey. Citation Text: Eriksson M, Blomberg K, Arvidsson E, et al. Did the organization of primary care practices during the COVID-19 pandemic influence qual…

Quality improvement initiatives lead to reduction in nulliparous term singleton vertex cesarean delivery rate. | PSNet

psnet.ahrq.gov/issue/quality-improvement-initiatives-lead-reduction-nulliparous-term-singleton-vertex-cesarean

October 19, 2022 - Study Classic Quality improvement initiatives lead to reduction in nulliparous term singleton vertex cesarean delivery rate. Citation Text: Vadnais MA, Hacker MR, Shah NT, et al. Quality improvement initiatives lead to reduction in nulliparous term singleton ver…

Assessing the STOPS framework for coping with intraoperative errors: evidence of efficacy, hints of hubris, and a bridge to abridging burnout. | PSNet

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June 14, 2023 - Study Assessing the STOPS framework for coping with intraoperative errors: evidence of efficacy, hints of hubris, and a bridge to abridging burnout. Citation Text: D'Angelo JD, Rivera M, Rasmussen TE, et al. Assessing the stops framework for coping with intraoperative errors: evidence of…

Racial bias in pulse oximetry measurement. | PSNet

psnet.ahrq.gov/issue/racial-bias-pulse-oximetry-measurement

January 19, 2022 - Study Classic Racial bias in pulse oximetry measurement. Citation Text: Sjoding MW, Dickson RP, Iwashyna TJ, et al. Racial bias in pulse oximetry measurement. N Engl J Med. 2020;383(25):2477-2478. doi:10.1056/nejmc2029240. Copy Citation Format: DOI…

State policies for prescription drug monitoring programs and adverse opioid-related hospital events. | PSNet

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August 11, 2021 - Study State policies for prescription drug monitoring programs and adverse opioid-related hospital events. Citation Text: Wen K, Johnson P, Jeng PJ, et al. State policies for prescription drug monitoring programs and adverse opioid-related hospital events. Med Care. 2020;58(7):610-616. d…

Just what the doctor ordered. Review of the evidence of the impact of computerized physician order entry system on medication errors. | PSNet

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June 15, 2016 - Review Just what the doctor ordered. Review of the evidence of the impact of computerized physician order entry system on medication errors. Citation Text: Shamliyan TA, Duval S, Du J, et al. Just what the doctor ordered. Review of the evidence of the impact of computerized physician o…

Tall Man lettering and potential prescription errors: a time series analysis of 42 children's hospitals in the USA over 9 years. | PSNet

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January 12, 2012 - Study Tall Man lettering and potential prescription errors: a time series analysis of 42 children's hospitals in the USA over 9 years. Citation Text: Zhong W, Feinstein JA, Patel NS, et al. Tall Man lettering and potential prescription errors: a time series analysis of 42 children's hosp…

Evaluation of the extended-release/long-acting opioid prescribing Risk Evaluation and Mitigation Strategy Program by the US Food and Drug Administration: a review. | PSNet

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March 06, 2019 - Study Evaluation of the extended-release/long-acting opioid prescribing Risk Evaluation and Mitigation Strategy Program by the US Food and Drug Administration: a review. Citation Text: Heyward J, Olson L, Sharfstein JM, et al. Evaluation of the Extended-Release/Long-Acting Opioid Prescri…

Does the implementation of an electronic prescribing system create unintended medication errors? A study of the sociotechnical context through the analysis of reported medication incidents. | PSNet

psnet.ahrq.gov/issue/does-implementation-electronic-prescribing-system-create-unintended-medication-errors-study

August 24, 2016 - Study Does the implementation of an electronic prescribing system create unintended medication errors? A study of the sociotechnical context through the analysis of reported medication incidents. Citation Text: Redwood S, Rajakumar A, Hodson J, et al. Does the implementation of an elec…

The next organizational challenge: finding and addressing diagnostic error. | PSNet

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November 16, 2022 - Commentary The next organizational challenge: finding and addressing diagnostic error. Citation Text: Graber ML, Trowbridge RL, Myers JS, et al. The next organizational challenge: finding and addressing diagnostic error. Jt Comm J Qual Patient Saf. 2014;40(3):102-10. Copy Citation …

Effects of nursing rounds on patients' call light use, satisfaction, and safety. | PSNet

psnet.ahrq.gov/issue/effects-nursing-rounds-patients-call-light-use-satisfaction-and-safety

September 01, 2021 - Study Effects of nursing rounds on patients' call light use, satisfaction, and safety. Citation Text: Meade CM, Bursell AL, Ketelsen L. Effects of nursing rounds: on patients' call light use, satisfaction, and safety. Am J Nurs. 2006;106(9):58-71. Copy Citation Format: Go…

Incidence and predictors of opioid prescription at discharge after traumatic injury. | PSNet

psnet.ahrq.gov/issue/incidence-and-predictors-opioid-prescription-discharge-after-traumatic-injury

July 02, 2019 - Study Classic Incidence and predictors of opioid prescription at discharge after traumatic injury. Citation Text: Chaudhary MA, Schoenfeld AJ, Harlow AF, et al. Incidence and Predictors of Opioid Prescription at Discharge After Traumatic Injury. JAMA Surg. 2017;…

Impact of incorporating pharmacy claims data into electronic medication reconciliation. | PSNet

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September 01, 2016 - Study Impact of incorporating pharmacy claims data into electronic medication reconciliation. Citation Text: Phansalkar S, Her QL, Tucker AD, et al. Impact of incorporating pharmacy claims data into electronic medication reconciliation. Am J Health Syst Pharm. 2015;72(3):212-7. doi:10.21…

Exposures to structural racism and racial discrimination among pregnant and early post-partum Black women living in Oakland, California. | PSNet

psnet.ahrq.gov/issue/exposures-structural-racism-and-racial-discrimination-among-pregnant-and-early-post-partum

August 12, 2019 - Study Exposures to structural racism and racial discrimination among pregnant and early post-partum Black women living in Oakland, California. Citation Text: Chambers BD, Arabia SE, Arega HA, et al. Exposures to structural racism and racial discrimination among pregnant and early post‐pa…

National quality program achieves improvements in safety culture and reduction in preventable harms in community hospitals. | PSNet

psnet.ahrq.gov/issue/national-quality-program-achieves-improvements-safety-culture-and-reduction-preventable-harms

November 02, 2022 - Study National quality program achieves improvements in safety culture and reduction in preventable harms in community hospitals. Citation Text: Frush K, Chamness C, Olson B, et al. National Quality Program Achieves Improvements in Safety Culture and Reduction in Preventable Harms in Com…

The Diagnostic Error Index: a quality improvement initiative to identify and measure diagnostic errors. | PSNet

psnet.ahrq.gov/issue/diagnostic-error-index-quality-improvement-initiative-identify-and-measure-diagnostic-errors

July 14, 2021 - Study The Diagnostic Error Index: a quality improvement initiative to identify and measure diagnostic errors. Citation Text: Perry MF, Melvin JE, Kasick RT, et al. The Diagnostic Error Index: a quality improvement initiative to identify and measure diagnostic errors. J Pediatr. 2021;232:…

Evaluating the impact of a pharmacist-led prescribing feedback intervention on prescribing errors in a hospital setting. | PSNet

psnet.ahrq.gov/issue/evaluating-impact-pharmacist-led-prescribing-feedback-intervention-prescribing-errors

August 26, 2020 - Study Evaluating the impact of a pharmacist-led prescribing feedback intervention on prescribing errors in a hospital setting. Citation Text: Lloyd M, Watmough SD, O'Brien SV, et al. Evaluating the impact of a pharmacist-led prescribing feedback intervention on prescribing errors in a ho…

Protocolization of analgesia and sedation through smart technology in intensive care: improving patient safety. | PSNet

psnet.ahrq.gov/issue/protocolization-analgesia-and-sedation-through-smart-technology-intensive-care-improving

March 09, 2022 - Study Protocolization of analgesia and sedation through smart technology in intensive care: improving patient safety. Citation Text: Ojeda IM, Sánchez-Cuervo M, Candela-Toha Á, et al. Protocolization of Analgesia and Sedation Through Smart Technology in Intensive Care: Improving Patient …

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