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"Never events" and the quest to reduce preventable harm. | PSNet

psnet.ahrq.gov/issue/never-events-and-quest-reduce-preventable-harm

June 01, 2016 - Commentary "Never events" and the quest to reduce preventable harm. Citation Text: Austin M, Pronovost P. "Never events" and the quest to reduce preventable harm. Jt Comm J Qual Patient Saf. 2015;41(6):279-288. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 X…

Pediatric ADHD medication exposures reported to US poison control centers. | PSNet

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November 28, 2018 - Study Pediatric ADHD medication exposures reported to US poison control centers. Citation Text: King SA, Casavant MJ, Spiller HA, et al. Pediatric ADHD Medication Exposures Reported to US Poison Control Centers. Pediatrics. 2018;141(6). doi:10.1542/peds.2017-3872. Copy Citation For…

Opioid prescribing and adverse events in opioid-naive patients treated by emergency physicians versus family physicians: a population-based cohort study. | PSNet

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July 18, 2018 - Study Opioid prescribing and adverse events in opioid-naive patients treated by emergency physicians versus family physicians: a population-based cohort study. Citation Text: Borgundvaag B, McLeod S, Khuu W, et al. Opioid prescribing and adverse events in opioid-naive patients treated by…

Delayed recognition of deterioration of patients in general wards is mostly caused by human related monitoring failures: a root cause analysis of unplanned ICU admissions. | PSNet

psnet.ahrq.gov/issue/delayed-recognition-deterioration-patients-general-wards-mostly-caused-human-related

December 21, 2017 - Study Delayed recognition of deterioration of patients in general wards is mostly caused by human related monitoring failures: a root cause analysis of unplanned ICU admissions. Citation Text: van Galen LS, Struik PW, Driesen BEJM, et al. Delayed Recognition of Deterioration of Patients …

Good Practice Guides on Medication Errors: Part 1 and Part 2. | PSNet

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August 03, 2016 - Book/Report Good Practice Guides on Medication Errors: Part 1 and Part 2. Citation Text: Goedecke T, Ord K, Newbould V, et al. Medication Errors: New Eu Good Practice Guide On Risk Minimisation And Error Prevention. Springer Science and Business Media LLC; 2016. doi:10.1007/s40264-016-04…

Physician burnout, well-being, and work unit safety grades in relationship to reported medical errors. | PSNet

psnet.ahrq.gov/issue/physician-burnout-well-being-and-work-unit-safety-grades-relationship-reported-medical-errors

June 01, 2022 - Study Classic Physician burnout, well-being, and work unit safety grades in relationship to reported medical errors. Citation Text: Tawfik DS, Profit J, Morgenthaler TI, et al. Physician Burnout, Well-being, and Work Unit Safety Grades in Relationship to Reporte…

Provider-patient communication and hospital ratings: perceived gaps and forward thinking about the effects of COVID-19. | PSNet

psnet.ahrq.gov/issue/provider-patient-communication-and-hospital-ratings-perceived-gaps-and-forward-thinking-about

December 16, 2020 - Study Provider-patient communication and hospital ratings: perceived gaps and forward thinking about the effects of COVID-19. Citation Text: Belasen AT, Hertelendy AJ, Belasen AR, et al. Provider–patient communication and hospital ratings: perceived gaps and forward thinking about the ef…

Intervention to reduce transmission of resistant bacteria in intensive care. | PSNet

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February 29, 2012 - Study Classic Intervention to reduce transmission of resistant bacteria in intensive care. Citation Text: Huskins C, Huckabee CM, O'Grady NP, et al. Intervention to reduce transmission of resistant bacteria in intensive care. N Engl J Med. 2011;364(15):1407-18…

Association between mobile telephone interruptions and medication administration errors in a pediatric intensive care unit. | PSNet

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June 29, 2009 - Study Association between mobile telephone interruptions and medication administration errors in a pediatric intensive care unit. Citation Text: Bonafide CP, Miller JM, Localio AR, et al. Association between mobile telephone interruptions and medication administration errors in a pediatr…

Characterization of adverse events detected in a large health care delivery system using an enhanced Global Trigger Tool over a five-year interval. | PSNet

psnet.ahrq.gov/issue/characterization-adverse-events-detected-large-health-care-delivery-system-using-enhanced

May 25, 2013 - Study Characterization of adverse events detected in a large health care delivery system using an enhanced Global Trigger Tool over a five-year interval. Citation Text: Kennerly DA, Kudyakov R, da Graca B, et al. Characterization of adverse events detected in a large health care delivery…

The $17.1 billion problem: the annual cost of measurable medical errors. | PSNet

psnet.ahrq.gov/issue/171-billion-problem-annual-cost-measurable-medical-errors

May 26, 2021 - Study Classic The $17.1 billion problem: the annual cost of measurable medical errors. Citation Text: Van Den Bos J, Rustagi K, Gray T, et al. The $17.1 Billion Problem: The Annual Cost Of Measurable Medical Errors. Health Aff. 2011;30(4):596-603. doi:10.1377/hl…

Vital signs: trends in emergency department visits for suspected opioid overdoses- United States, July 2016- September 2017. | PSNet

psnet.ahrq.gov/issue/vital-signs-trends-emergency-department-visits-suspected-opioid-overdoses-united-states-july

January 23, 2019 - Study Vital signs: trends in emergency department visits for suspected opioid overdoses- United States, July 2016- September 2017. Citation Text: Vivolo-Kantor AM, Seth P, Gladden M, et al. Vital Signs: Trends in Emergency Department Visits for Suspected Opioid Overdoses - United States,…

Opioid-prescribing patterns of emergency physicians and risk of long-term use. | PSNet

psnet.ahrq.gov/issue/opioid-prescribing-patterns-emergency-physicians-and-risk-long-term-use

August 15, 2018 - Study Opioid-prescribing patterns of emergency physicians and risk of long-term use. Citation Text: Barnett ML, Olenski AR, Jena AB. Opioid-Prescribing Patterns of Emergency Physicians and Risk of Long-Term Use. N Engl J Med. 2017;376(7):663-673. doi:10.1056/NEJMsa1610524. Copy Citatio…

Addressing veteran health-related social needs: how Joint Commission standards accelerated integration and expansion of tools and services in the Veterans Health Administration. | PSNet

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November 24, 2021 - Commentary Addressing veteran health-related social needs: how Joint Commission standards accelerated integration and expansion of tools and services in the Veterans Health Administration. Citation Text: List JM, Russell LE, Hausmann LRM, et al. Addressing veteran health-related social n…

Impact of hospital-acquired pneumonia on the Medicare program. | PSNet

psnet.ahrq.gov/issue/impact-hospital-acquired-pneumonia-medicare-program

August 07, 2013 - Study Impact of hospital-acquired pneumonia on the Medicare program. Citation Text: Baker DL, Giuliano KK, Desmarais M, et al. Impact of hospital-acquired pneumonia on the Medicare program. Infect Control Hosp Epidemiol. 2024;45(3):316-321. doi:10.1017/ice.2023.221. Copy Citation F…

Two-state collaborative study of a multifaceted intervention to decrease ventilator-associated events. | PSNet

psnet.ahrq.gov/issue/two-state-collaborative-study-multifaceted-intervention-decrease-ventilator-associated-events

January 15, 2014 - Study Two-state collaborative study of a multifaceted intervention to decrease ventilator-associated events. Citation Text: Rawat N, Yang T, Ali KJ, et al. Two-State Collaborative Study of a Multifaceted Intervention to Decrease Ventilator-Associated Events. Crit Care Med. 2017;45(7):120…

Optimizing measurement of misdiagnosis-related harms using symptom-disease pair analysis of diagnostic error (SPADE): comparison groups to maximize SPADE validity. | PSNet

psnet.ahrq.gov/issue/optimizing-measurement-misdiagnosis-related-harms-using-symptom-disease-pair-analysis

July 21, 2021 - Commentary Optimizing measurement of misdiagnosis-related harms using symptom-disease pair analysis of diagnostic error (SPADE): comparison groups to maximize SPADE validity. Citation Text: Liberman AL, Wang Z, Zhu Y, et al. Optimizing measurement of misdiagnosis-related harms using symp…

Guidelines for opioid prescribing in children and adolescents after surgery: an expert panel opinion. | PSNet

psnet.ahrq.gov/issue/guidelines-opioid-prescribing-children-and-adolescents-after-surgery-expert-panel-opinion

June 23, 2021 - Review Guidelines for opioid prescribing in children and adolescents after surgery: an expert panel opinion. Citation Text: Kelley-Quon LI, Kirkpatrick MG, Ricca RL, et al. Guidelines for opioid prescribing in children and adolescents after surgery: an expert panel opinion. JAMA Surg. 20…

Targeted versus universal decolonization to prevent ICU infection. | PSNet

psnet.ahrq.gov/issue/targeted-versus-universal-decolonization-prevent-icu-infection

November 16, 2022 - Study Classic Targeted versus universal decolonization to prevent ICU infection. Citation Text: Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368(24):2255-2265. doi:10.1056/nejmoa12…

Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-based sample. | PSNet

psnet.ahrq.gov/issue/missed-diagnosis-stroke-emergency-department-cross-sectional-analysis-large-population-based

April 08, 2018 - Study Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-based sample. Citation Text: Newman-Toker DE, Moy E, Valente E, et al. Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-b…

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