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Improving the approach to defining, classifying, reporting and monitoring adverse events in seriously ill older adults: recommendations from a multi-stakeholder convening. | PSNet

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July 29, 2020 - Commentary Improving the approach to defining, classifying, reporting and monitoring adverse events in seriously ill older adults: recommendations from a multi-stakeholder convening. Citation Text: Baim-Lance A, Ferreira KB, Cohen HJ, et al. Improving the approach to defining, classifyin…

Multiple meanings of resilience: health professionals' experiences of a dual element training intervention designed to help them prepare for coping with error. | PSNet

psnet.ahrq.gov/issue/multiple-meanings-resilience-health-professionals-experiences-dual-element-training

August 10, 2022 - Study Multiple meanings of resilience: health professionals' experiences of a dual element training intervention designed to help them prepare for coping with error. Citation Text: Janes G, Harrison R, Johnson J, et al. Multiple meanings of resilience: health professionals' experiences o…

An intervention to decrease narcotic-related adverse drug events in children's hospitals. | PSNet

psnet.ahrq.gov/issue/intervention-decrease-narcotic-related-adverse-drug-events-childrens-hospitals

April 11, 2011 - Study An intervention to decrease narcotic-related adverse drug events in children's hospitals. Citation Text: Sharek PJ, McClead RE, Taketomo C, et al. An intervention to decrease narcotic-related adverse drug events in children's hospitals. Pediatrics. 2008;122(4):e861-e866. doi:10.1…

Association of hospital participation in a quality reporting program with surgical outcomes and expenditures for Medicare beneficiaries. | PSNet

psnet.ahrq.gov/issue/association-hospital-participation-quality-reporting-program-surgical-outcomes-and

January 13, 2016 - Study Classic Association of hospital participation in a quality reporting program with surgical outcomes and expenditures for Medicare beneficiaries. Citation Text: Osborne NH, Nicholas LH, Ryan AM, et al. Association of hospital participation in a quality repo…

Are adverse events related to the completeness of clinical records? Results from a retrospective records review using the Global Trigger Tool. | PSNet

psnet.ahrq.gov/issue/are-adverse-events-related-completeness-clinical-records-results-retrospective-records-review

July 01, 2009 - Study Are adverse events related to the completeness of clinical records? Results from a retrospective records review using the Global Trigger Tool. Citation Text: Scarpis E, Cautero P, Tullio A, et al. Are adverse events related to the completeness of clinical records? Results from a re…

Six major steps to make investigations of suicide valuable for learning and prevention. | PSNet

psnet.ahrq.gov/issue/six-major-steps-make-investigations-suicide-valuable-learning-and-prevention

December 07, 2022 - Review Six major steps to make investigations of suicide valuable for learning and prevention. Citation Text: Fröding E, Vincent C, Andersson-Gäre B, et al. Six major steps to make investigations of suicide valuable for learning and prevention. Arch Suicide Res. 2024;28(1):1-19. doi:10.1…

Escalation of care in surgery: a systematic risk assessment to prevent avoidable harm in hospitalized patients. | PSNet

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December 17, 2014 - Study Escalation of care in surgery: a systematic risk assessment to prevent avoidable harm in hospitalized patients. Citation Text: Johnston MJ, Arora S, Anderson O, et al. Escalation of care in surgery: a systematic risk assessment to prevent avoidable harm in hospitalized patients. An…

Implementation of the trigger review method in Scottish general practices: patient safety outcomes and potential for quality improvement. | PSNet

psnet.ahrq.gov/issue/implementation-trigger-review-method-scottish-general-practices-patient-safety-outcomes-and

November 07, 2011 - Study Implementation of the trigger review method in Scottish general practices: patient safety outcomes and potential for quality improvement. Citation Text: de Wet C, Black C, Luty S, et al. Implementation of the trigger review method in Scottish general practices: patient safety outco…

The e-Autopsy/e-Biopsy: a systematic chart review to increase safety and diagnostic accuracy. | PSNet

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May 12, 2021 - Commentary The e-Autopsy/e-Biopsy: a systematic chart review to increase safety and diagnostic accuracy. Citation Text: Kanter MH, Ghobadi A, Lurvey LD, et al. The e-Autopsy/e-Biopsy: a systematic chart review to increase safety and diagnostic accuracy. Diagnosis (Berl). 2022;9(4):430-43…

Lessons learned from a national hospital antibiotic stewardship implementation project. | PSNet

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July 20, 2022 - Study Lessons learned from a national hospital antibiotic stewardship implementation project. Citation Text: Cosgrove SE, Ahn R, Dullabh P, et al. Lessons learned from a national hospital antibiotic stewardship implementation project. Jt Comm J Qual Patient Saf. 2024;50(6):435-441. doi:1…

Innovative patient safety curriculum using iPad game (PASSED) improved patient safety concepts in undergraduate medical students. | PSNet

psnet.ahrq.gov/issue/innovative-patient-safety-curriculum-using-ipad-game-passed-improved-patient-safety-concepts

November 16, 2022 - Study Innovative patient safety curriculum using iPad game (PASSED) improved patient safety concepts in undergraduate medical students. Citation Text: Kow AWC, Ang BLS, Chong CS, et al. Innovative Patient Safety Curriculum Using iPAD Game (PASSED) Improved Patient Safety Concepts in Unde…

Effect of systematic physician cross-checking on reducing adverse events in the emergency department: the CHARMED cluster randomized trial. | PSNet

psnet.ahrq.gov/issue/effect-systematic-physician-cross-checking-reducing-adverse-events-emergency-department

November 29, 2023 - Study Emerging Classic Effect of systematic physician cross-checking on reducing adverse events in the emergency department: the CHARMED cluster randomized trial. Citation Text: Freund Y, Goulet H, Leblanc J, et al. Effect of Systematic Physician Cross-checking …

Using AHRQ Patient Safety Indicators to detect postdischarge adverse events in the Veterans Health Administration. | PSNet

psnet.ahrq.gov/issue/using-ahrq-patient-safety-indicators-detect-postdischarge-adverse-events-veterans-health

June 04, 2014 - Study Using AHRQ Patient Safety Indicators to detect postdischarge adverse events in the Veterans Health Administration. Citation Text: Mull HJ, Borzecki A, Chen Q, et al. Using AHRQ patient safety indicators to detect postdischarge adverse events in the Veterans Health Administration. A…

Identifying and prioritizing educational content from a malpractice claims database for clinical reasoning education in the vocational training of general practitioners. | PSNet

psnet.ahrq.gov/issue/identifying-and-prioritizing-educational-content-malpractice-claims-database-clinical

September 20, 2023 - Study Identifying and prioritizing educational content from a malpractice claims database for clinical reasoning education in the vocational training of general practitioners. Citation Text: van Sassen CGM, van den Berg PJ, Mamede S, et al. Identifying and prioritizing educational conten…

Using four-phased unit-based patient safety walkrounds to uncover correctable system flaws. | PSNet

psnet.ahrq.gov/issue/using-four-phased-unit-based-patient-safety-walkrounds-uncover-correctable-system-flaws

October 05, 2022 - Study Using four-phased unit-based patient safety walkrounds to uncover correctable system flaws. Citation Text: Taylor AM, Chuo J, Figueroa-Altmann A, et al. Using four-phased unit-based patient safety walkrounds to uncover correctable system flaws. Jt Comm J Qual Patient Saf. 2013;39…

Developing and evaluating an automated all-cause harm trigger system. | PSNet

psnet.ahrq.gov/issue/developing-and-evaluating-automated-all-cause-harm-trigger-system

July 31, 2013 - Study Developing and evaluating an automated all-cause harm trigger system. Citation Text: Sammer C, Miller S, Jones C, et al. Developing and Evaluating an Automated All-Cause Harm Trigger System. Jt Comm J Qual Patient Saf. 2017;43(4):155-165. doi:10.1016/j.jcjq.2017.01.004. Copy Cita…

Impact of errors in paper-based and computerized diabetes management with decision support for hospitalized patients with type 2 diabetes. A post-hoc analysis of a before and after study. | PSNet

psnet.ahrq.gov/issue/impact-errors-paper-based-and-computerized-diabetes-management-decision-support-hospitalized

April 03, 2024 - Study Impact of errors in paper-based and computerized diabetes management with decision support for hospitalized patients with type 2 diabetes. A post-hoc analysis of a before and after study. Citation Text: Donsa K, Beck P, Höll B, et al. Impact of errors in paper-based and computerize…

Physician perspectives on responding to clinician-perpetuated interpersonal racism against Black patients with serious illness. | PSNet

psnet.ahrq.gov/issue/physician-perspectives-responding-clinician-perpetuated-interpersonal-racism-against-black

July 26, 2023 - Study Physician perspectives on responding to clinician-perpetuated interpersonal racism against Black patients with serious illness. Citation Text: Brown CE, Snyder CR, Marshall AR, et al. Physician perspectives on responding to clinician-perpetuated interpersonal racism against Black p…

Encouraging resident adverse event reporting: a qualitative study of suggestions from the front lines. | PSNet

psnet.ahrq.gov/issue/encouraging-resident-adverse-event-reporting-qualitative-study-suggestions-front-lines

July 19, 2023 - Study Encouraging resident adverse event reporting: a qualitative study of suggestions from the front lines. Citation Text: Szymusiak J, Walk TJ, Benson M, et al. Encouraging Resident Adverse Event Reporting: A Qualitative Study of Suggestions from the Front Lines. Ped Qual Saf. 2019;4(3…

Successful implementation of a unit-based quality nurse to reduce central line-associated bloodstream infections. | PSNet

psnet.ahrq.gov/issue/successful-implementation-unit-based-quality-nurse-reduce-central-line-associated-bloodstream

September 23, 2020 - Study Successful implementation of a unit-based quality nurse to reduce central line-associated bloodstream infections. Citation Text: Thom KA, Li S, Custer M, et al. Successful implementation of a unit-based quality nurse to reduce central line-associated bloodstream infections. Am J …

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