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  1. psnet.ahrq.gov/issue/medicares-policy-not-pay-treating-hospital-acquired-conditions-impact
    December 04, 2024 - Centers for Medicare and Medicaid Services (CMS) eliminated reimbursement for some preventable errors, including … The authors suggest several methods for strengthening the policy, including denying payments for readmissions
  2. psnet.ahrq.gov/issue/understanding-causes-medication-errors-and-adverse-drug-events-patients-mental-illness
    July 17, 2024 - Medication errors and adverse drug events (ADE) are common in community settings including primary care … patient populations (e.g., workforce shortages) but some were also unique to this patient group, including
  3. psnet.ahrq.gov/issue/safe-practice-environment-chapter-proposed-usp
    May 02, 2018 - This article discusses work space factors that can affect safe medication delivery, including lighting … June 10, 2018 Benefits and risks of including patients on RCA teams.
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43519/psn-pdf
    June 13, 2015 - A multiobserver study of the effects of including point-of- care patient photographs with portable radiography … A multiobserver study of the effects of including point- of-care patient photographs with portable radiography … https://psnet.ahrq.gov/issue/multiobserver-study-effects-including-point-care-patient-photographs-portable … https://psnet.ahrq.gov/issue/multiobserver-study-effects-including-point-care-patient-photographs-portable-radiography … https://psnet.ahrq.gov/issue/multiobserver-study-effects-including-point-care-patient-photographs-portable-radiography
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42922/psn-pdf
    April 12, 2014 - Successful implementation of standardized multidisciplinary bedside rounds, including daily goals, in … Successful implementation of standardized multidisciplinary bedside rounds, including daily goals, in … https://psnet.ahrq.gov/issue/successful-implementation-standardized-multidisciplinary-bedside-rounds- including-daily-goals … https://psnet.ahrq.gov/issue/successful-implementation-standardized-multidisciplinary-bedside-rounds-including-daily-goals … https://psnet.ahrq.gov/issue/successful-implementation-standardized-multidisciplinary-bedside-rounds-including-daily-goals
  6. psnet.ahrq.gov/issue/operational-failures-general-practice-consensus-building-study-priorities-improvement
    February 07, 2024 - This study, including general practitioners and patients in the UK National Health Service (NHS), used … Participants identified several areas for improvement, including missing test results and inaccuracies
  7. psnet.ahrq.gov/issue/adverse-outcomes-polypharmacy-older-people-systematic-review-reviews
    May 29, 2019 - The authors describe conflicting evidence on associating polypharmacy with adverse outcomes, including … Quality standards for safe medication in nursing homes: development through a multistep approach including
  8. psnet.ahrq.gov/issue/exploring-nurses-attitudes-skills-and-beliefs-medication-safety-practices
    October 21, 2020 - Nurses are responsible for several steps in the medication-use process, including preparation, administration … October 19, 2022 Bundle interventions including nontechnical skills for surgeons can
  9. psnet.ahrq.gov/issue/changes-early-high-risk-opioid-prescribing-practices-after-policy-interventions-washington
    November 03, 2021 - explore associations between opioid prescribing policy interventions implemented at different times (including … September 24, 2016 Prescribers' perspectives on including reason for use information
  10. psnet.ahrq.gov/issue/safety-health-care-ethnic-minority-patients-systematic-review
    May 25, 2022 - The authors identified several factors contributing to the increased risk, including language proficiency … November 17, 2021 Bundle interventions including nontechnical skills for surgeons can
  11. psnet.ahrq.gov/issue/rapid-response-systems-antibiotic-stewardship-and-medication-reconciliation-scoping-review
    March 18, 2020 - In this systematic review including 159 studies, the authors explored factors influencing successful … The researchers identified several common factors supporting effective implementation, including clinical
  12. psnet.ahrq.gov/issue/healthcare-professionals-experience-psychological-safety-voice-and-silence
    March 18, 2020 - influencing psychological safety and individual- and team-level inhibiting and motivating dynamics, including … Several intervention components to encourage psychological safety are reviewed, including inclusive behaviors
  13. psnet.ahrq.gov/issue/incident-and-long-term-opioid-therapy-among-patients-psychiatric-conditions-and-medications
    November 16, 2022 - Opioid medications are associated with an increased risk of adverse drug events , including overdose … Researchers found that those with underlying psychiatric and behavioral conditions (including opioid
  14. psnet.ahrq.gov/issue/healthcare-fragmentation-multimorbidity-potentially-inappropriate-medication-and-mortality
    April 12, 2019 - This population-based cohort study including 4.7 million Danish adults who interacted with primary or … The researchers found that higher levels of care fragmentation were associated with adverse outcomes, including
  15. psnet.ahrq.gov/issue/postdischarge-adverse-events-among-neonates-admitted-neonatal-intensive-care-unit
    October 05, 2022 - This prospective cohort, including infants discharged from one level 4 NICU between February 2017 and … July 2019, identified a high risk for post-discharge adverse events, (including procedural complications
  16. psnet.ahrq.gov/issue/exploring-impact-employee-engagement-and-patient-safety
    July 27, 2022 - This literature review including 15 studies found a positive correlation between engagement and perceptions … November 16, 2022 Bundle interventions including nontechnical skills for surgeons can
  17. psnet.ahrq.gov/issue/effect-clinical-experience-error-rate-emergency-physicians
    November 16, 2022 - Physician performance , including evaluation of diagnostic errors , is often examined by conducting … The authors argue for better methods for evaluating ongoing physician performance, including continuing
  18. psnet.ahrq.gov/issue/clinicians-use-health-information-exchange-technologies-medication-reconciliation-us
    August 04, 2021 - The 63 participating clinicians shared facilitators encouraging HIE use, including familiarity with the … They also identified several barriers to HIE use, including information overload and lack of integration
  19. psnet.ahrq.gov/issue/effects-night-surgery-postoperative-mortality-and-morbidity-multicentre-cohort-study
    July 19, 2019 - This retrospective cohort study including over 350,000 adult patients undergoing non-cardiac surgery … The effect was mediated by potentially preventable factors, including higher blood transfusion rates
  20. psnet.ahrq.gov/issue/potentially-inappropriate-prescribing-long-term-care-and-its-relationship-probable-delirium
    September 23, 2020 - Potentially inappropriate prescribing (PIP) is common and can contribute to patient harm, including … This population-based study including over 171,000 long-term care residents in Ontario, Canada, examined

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