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Interdisciplinary Quality Improvement Conference: using a revised morbidity and mortality format to focus on systems-based patient safety issues in a VA hospital: design and outcomes. | PSNet

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July 22, 2020 - Study Interdisciplinary Quality Improvement Conference: using a revised morbidity and mortality format to focus on systems-based patient safety issues in a VA hospital: design and outcomes. Citation Text: Gerstein WH, Ledford J, Cooper J, et al. Interdisciplinary Quality Improvement Conf…

Patient identification of diagnostic safety blindspots and participation in "good catches" through shared visit notes. | PSNet

psnet.ahrq.gov/issue/patient-identification-diagnostic-safety-blindspots-and-participation-good-catches-through

October 27, 2021 - Study Patient identification of diagnostic safety blindspots and participation in "good catches" through shared visit notes. Citation Text: Bell SK, Bourgeois FC, Dong J, et al. Patient identification of diagnostic safety blindspots and participation in "good catches" through shared visi…

"It is not the fault of the health care team - it is the way the system works": a mixed-methods quality improvement study of patients with advanced cancer and family members reveals challenges navigating a fragmented healthcare system and the administrative and financial burdens of care. | PSNet

psnet.ahrq.gov/issue/it-not-fault-health-care-team-it-way-system-works-mixed-methods-quality-improvement-study

March 24, 2019 - Study "It is not the fault of the health care team - it is the way the system works": a mixed-methods quality improvement study of patients with advanced cancer and family members reveals challenges navigating a fragmented healthcare system and the administrative and financial burdens of care. …

Medication errors in the outpatient setting: classification and root cause analysis. | PSNet

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December 16, 2020 - Study Medication errors in the outpatient setting: classification and root cause analysis. Citation Text: Friedman AL, Geoghegan SR, Sowers NM, et al. Medication errors in the outpatient setting: classification and root cause analysis. Arch Surg. 2007;142(3):278-83; discussion 284. Cop…

Pain management best practices from multispecialty organizations during the COVID-19 pandemic and public health crises. | PSNet

psnet.ahrq.gov/issue/pain-management-best-practices-multispecialty-organizations-during-covid-19-pandemic-and

November 16, 2022 - Commentary Pain management best practices from multispecialty organizations during the COVID-19 pandemic and public health crises. Citation Text: Cohen SP, Baber ZB, Buvanendran A, et al. Pain Management Best Practices from Multispecialty Organizations During the COVID-19 Pandemic and Pu…

Strategies to identify patient risks of prescription opioid addiction when initiating opioids for pain: a systematic review. | PSNet

psnet.ahrq.gov/issue/strategies-identify-patient-risks-prescription-opioid-addiction-when-initiating-opioids-pain

November 16, 2022 - Review Classic Strategies to identify patient risks of prescription opioid addiction when initiating opioids for pain: a systematic review. Citation Text: Klimas J, Gorfinkel L, Fairbairn N, et al. Strategies to Identify Patient Risks of Prescription Opioid Addi…

Role-modeling and medical error disclosure: a national survey of trainees. | PSNet

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December 21, 2017 - Study Role-modeling and medical error disclosure: a national survey of trainees. Citation Text: Martinez W, Hickson GB, Miller BM, et al. Role-modeling and medical error disclosure: a national survey of trainees. Acad Med. 2014;89(3):482-9. doi:10.1097/ACM.0000000000000156. Copy Citati…

Systematic review of safety checklists for use by medical care teams in acute hospital settings—limited evidence of effectiveness. | PSNet

psnet.ahrq.gov/issue/systematic-review-safety-checklists-use-medical-care-teams-acute-hospital-settings-limited

July 29, 2020 - Review Systematic review of safety checklists for use by medical care teams in acute hospital settings—limited evidence of effectiveness. Citation Text: Ko HCH, Turner TJ, Finnigan MA. Systematic review of safety checklists for use by medical care teams in acute hospital settings--limi…

Research designs for studies evaluating the effectiveness of change and improvement strategies. | PSNet

psnet.ahrq.gov/issue/research-designs-studies-evaluating-effectiveness-change-and-improvement-strategies

September 20, 2011 - Study Classic Research designs for studies evaluating the effectiveness of change and improvement strategies. Citation Text: Eccles M, Grimshaw J, Campbell M, et al. Research designs for studies evaluating the effectiveness of change and improvement strategies. …

Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental study. | PSNet

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December 21, 2014 - Study Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental study. Citation Text: Walker PC, Bernstein SJ, Jones JNT, et al. Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental study. Arch Intern Med. 2009;169(21):2003-10. d…

Use of medical emergency team responses to reduce hospital cardiopulmonary arrests. | PSNet

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April 06, 2011 - Study Classic Use of medical emergency team responses to reduce hospital cardiopulmonary arrests. Citation Text: Devita MA, Braithwaite RS, Mahidhara R, et al. Use of medical emergency team responses to reduce hospital cardiopulmonary arrests. Qual Saf Health …

Nonfatal opioid overdoses at an urban emergency department during the COVID-19 pandemic. | PSNet

psnet.ahrq.gov/issue/nonfatal-opioid-overdoses-urban-emergency-department-during-covid-19-pandemic

March 24, 2021 - Study Nonfatal opioid overdoses at an urban emergency department during the COVID-19 pandemic. Citation Text: Ochalek TA, Cumpston KL, Wills BK, et al. Nonfatal opioid overdoses at an urban emergency department during the COVID-19 pandemic. JAMA. 2020;324(16):1673-1674. doi:10.1001/jama.…

Changes in default alarm settings and standard in-service are insufficient to improve alarm fatigue in an intensive care unit: a pilot project. | PSNet

psnet.ahrq.gov/issue/changes-default-alarm-settings-and-standard-service-are-insufficient-improve-alarm-fatigue

May 29, 2019 - Study Changes in default alarm settings and standard in-service are insufficient to improve alarm fatigue in an intensive care unit: a pilot project. Citation Text: Sowan AK, Gomez TM, Tarriela AF, et al. Changes in Default Alarm Settings and Standard In-Service are Insufficient to Impro…

What do medical records tell us about potentially harmful co-prescribing? | PSNet

psnet.ahrq.gov/issue/what-do-medical-records-tell-us-about-potentially-harmful-co-prescribing

December 19, 2011 - Study Classic What do medical records tell us about potentially harmful co-prescribing? Citation Text: Lafata JE, Simpkins J, Kaatz S, et al. What do medical records tell us about potentially harmful co-prescribing? Jt Comm J Qual Patient Saf. 2007;33(7):395-4…

Incidence and severity of prescribing errors in parenteral nutrition for pediatric inpatients at a neonatal and pediatric intensive care unit. | PSNet

psnet.ahrq.gov/issue/incidence-and-severity-prescribing-errors-parenteral-nutrition-pediatric-inpatients-neonatal

June 23, 2021 - Study Incidence and severity of prescribing errors in parenteral nutrition for pediatric inpatients at a neonatal and pediatric intensive care unit. Citation Text: Hermanspann T, Schoberer M, Robel-Tillig E, et al. Incidence and Severity of Prescribing Errors in Parenteral Nutrition for …

Four states with robust prescription drug monitoring programs reduced opioid dosages. | PSNet

psnet.ahrq.gov/issue/four-states-robust-prescription-drug-monitoring-programs-reduced-opioid-dosages

June 21, 2016 - Study Classic Four states with robust prescription drug monitoring programs reduced opioid dosages. Citation Text: Haffajee RL, Mello MM, Zhang F, et al. Four States With Robust Prescription Drug Monitoring Programs Reduced Opioid Dosages. Health Aff (Millwood).…

Outpatient opioid prescriptions for children and opioid-related adverse events. | PSNet

psnet.ahrq.gov/issue/outpatient-opioid-prescriptions-children-and-opioid-related-adverse-events

July 31, 2017 - Study Emerging Classic Outpatient opioid prescriptions for children and opioid-related adverse events. Citation Text: Chung CP, Callahan T, Cooper WO, et al. Outpatient Opioid Prescriptions for Children and Opioid-Related Adverse Events. Pediatrics. 2018;142(2):…

Prevalence of undiagnosed diabetes identified by a novel electronic medical record diabetes screening program in an urban emergency department in the US. | PSNet

psnet.ahrq.gov/issue/prevalence-undiagnosed-diabetes-identified-novel-electronic-medical-record-diabetes-screening

January 04, 2021 - Study Prevalence of undiagnosed diabetes identified by a novel electronic medical record diabetes screening program in an urban emergency department in the US. Citation Text: Danielson KK, Rydzon B, Nicosia M, et al. Prevalence of undiagnosed diabetes identified by a novel electronic med…

A cross-sectional analysis investigating organizational factors that influence near-miss error reporting among hospital pharmacists. | PSNet

psnet.ahrq.gov/issue/cross-sectional-analysis-investigating-organizational-factors-influence-near-miss-error

September 25, 2013 - Study A cross-sectional analysis investigating organizational factors that influence near-miss error reporting among hospital pharmacists. Citation Text: Patterson ME, Pace HA. A Cross-sectional Analysis Investigating Organizational Factors That Influence Near-Miss Error Reporting Among …

Understanding the multidimensional effects of resident duty hours restrictions: a thematic analysis of published viewpoints in surgery. | PSNet

psnet.ahrq.gov/issue/understanding-multidimensional-effects-resident-duty-hours-restrictions-thematic-analysis

July 03, 2016 - Review Understanding the multidimensional effects of resident duty hours restrictions: a thematic analysis of published viewpoints in surgery. Citation Text: Devitt KS, Kim MJ, Conn LG, et al. Understanding the Multidimensional Effects of Resident Duty Hours Restrictions: A Thematic Anal…

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