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psnet.ahrq.gov/node/45434/psn-pdf
September 22, 2017 - Organisational strategies to implement hospital pressure
ulcer prevention programmes: findings from a national
survey.
September 22, 2017
Soban LM, Kim L, Yuan AH, et al. Organisational strategies to implement hospital pressure ulcer
prevention programmes: findings from a national survey. J Nurs Manag. 2017;25(6):…
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psnet.ahrq.gov/node/43798/psn-pdf
January 07, 2015 - Pharmacist-managed inpatient discharge medication
reconciliation: a combined onsite and telepharmacy
model.
January 7, 2015
Keeys C, Kalejaiye B, Skinner M, et al. Pharmacist-managed inpatient discharge medication reconciliation:
a combined onsite and telepharmacy model. Am J Health Syst Pharm. 2014;71(24):2159-66…
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psnet.ahrq.gov/node/41703/psn-pdf
November 08, 2012 - Anatomy of an incident disclosure: the importance of
dialogue.
November 8, 2012
Iedema R, Allen S. Anatomy of an incident disclosure: the importance of dialogue. Jt Comm J Qual Patient
Saf. 2012;38(10):435-42.
https://psnet.ahrq.gov/issue/anatomy-incident-disclosure-importance-dialogue
Physician organizations who…
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psnet.ahrq.gov/node/36457/psn-pdf
May 27, 2011 - Controversies surrounding use of order sets for clinical
decision support in computerized provider order entry.
May 27, 2011
Bobb AM, Payne TH, Gross PA. Viewpoint: controversies surrounding use of order sets for clinical decision
support in computerized provider order entry. J Am Med Inform Assoc. 2007;14(1):41-7.…
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psnet.ahrq.gov/node/838631/psn-pdf
October 19, 2022 - An asset-based quality improvement tool for health care
organizations: cultivating organization wide quality
improvement and health care professional engagement.
October 19, 2022
Loving VA, Nolan C, Bessel M. An asset-based quality improvement tool for health care organizations:
cultivating organization wide quali…
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psnet.ahrq.gov/node/60251/psn-pdf
April 22, 2020 - Exploring the association between organizational culture
and large-scale adverse events: evidence from the
Veterans Health Administration.
April 22, 2020
George J, Elwy AR, Charns MP, et al. Exploring the Association Between Organizational Culture and
Large-Scale Adverse Events: Evidence from the Veterans Health A…
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psnet.ahrq.gov/node/866276/psn-pdf
July 10, 2024 - Quality and patient safety metrics: developing a
structured program for improving patient care in the
Department of Medicine at The Ottawa Hospital.
July 10, 2024
Hasimja-Saraqini D, McNeill K, Kuk H, et al. Quality and patient safety metrics: developing a structured
program for improving patient care in the Depar…
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psnet.ahrq.gov/node/837799/psn-pdf
August 10, 2022 - Effect of a pharmacy-based centralized intravenous
admixture service on the prevalence of medication errors:
a before-and-after study.
August 10, 2022
Jessurun JG, Hunfeld NGM, Van Rosmalen J, et al. Effect of a pharmacy-based centralized intravenous
admixture service on the prevalence of medication errors: a befo…
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psnet.ahrq.gov/node/45861/psn-pdf
April 05, 2017 - Assessing content validity and user perspectives on the
Team Check-up Tool: expert survey and user focus
groups.
April 5, 2017
Marsteller JA, Hsu Y-J, Chan KS, et al. Assessing content validity and user perspectives on the Team
Check-up Tool: expert survey and user focus groups. BMJ Qual Saf. 2017;26(4):288-295.
…
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psnet.ahrq.gov/node/47069/psn-pdf
June 18, 2021 - Physical and verbal violence against health care workers.
June 18, 2021
Physical and verbal violence against health care workers. Sentinel Event Alert. 2018;59:1-9 (revised June
18, 2021).
https://psnet.ahrq.gov/issue/physical-and-verbal-violence-against-health-care-workers
The Joint Commission issues sentinel eve…
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psnet.ahrq.gov/node/50836/psn-pdf
January 29, 2020 - Developing a cancer-specific trigger tool to identify
treatment-related adverse events using administrative
data.
January 29, 2020
Weingart SN, Nelson J, Koethe B, et al. Developing a cancer?specific trigger tool to identify treatment?
related adverse events using administrative data. Cancer Med. 2020;9(4):1462-14…
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psnet.ahrq.gov/node/74692/psn-pdf
January 26, 2022 - Changes made to orders placed by overnight admitting
residents on teaching rounds the next day.
January 26, 2022
Chiel L, Freiman E, Yarahuan J, et al. Changes made to orders placed by overnight admitting residents on
teaching rounds the next day. Hosp Pediatr. 2021;12(1):e35-e38. doi:10.1542/hpeds.2021-005823.
ht…
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psnet.ahrq.gov/node/48017/psn-pdf
January 01, 2020 - The 2018 Gosport Independent Panel report into deaths at
the National Health Service's Gosport War Memorial
Hospital. Does the culture of the medical profession
influence health outcomes?
June 12, 2019
Bennett S. The 2018 Gosport Independent Panel report into deaths at the National Health Service’s
Gosport War Me…
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psnet.ahrq.gov/node/843415/psn-pdf
February 01, 2023 - Explaining the negative effects of patient participation in
patient safety: an exploratory qualitative study in an
academic tertiary healthcare centre in the Netherlands.
February 1, 2023
Van der Voorden M, Ahaus K, Franx A. Explaining the negative effects of patient participation in patient
safety: an exploratory…
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psnet.ahrq.gov/node/44331/psn-pdf
September 09, 2015 - Temporal trends in patient safety in the Netherlands:
reductions in preventable adverse events or the end of
adverse events as a useful metric?
September 9, 2015
Shojania KG, van de Mheen PJM-. Temporal trends in patient safety in the Netherlands: reductions in
preventable adverse events or the end of adverse even…
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psnet.ahrq.gov/node/851886/psn-pdf
August 02, 2023 - Hospitalization due to adverse drug events in older adults
with cancer: a retrospective analysis.
August 2, 2023
Walsh DJ, Sahm LJ, O'Driscoll M, et al. Hospitalization due to adverse drug events in older adults with
cancer: a retrospective analysis. J Geriatr Oncol. 2023;14(6):101540. doi:10.1016/j.jgo.2023.101540…
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psnet.ahrq.gov/node/866745/psn-pdf
September 18, 2024 - State of the Science and Future Directions to Improve
Diagnostic Safety in Older Adults.
September 18, 2024
Tran AK, Syed Q, Bierman AS, et al. State Of The Science And Future Directions To Improve Diagnostic
Safety In Older Adults. Rockville, MD: Agency for Healthcare Research and Quality; September 2024.
AHRQ Pu…
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psnet.ahrq.gov/node/854994/psn-pdf
January 01, 2024 - Contextual factors influencing the implementation of a
multifaceted intervention to improve teamwork and
quality for hospitalized patients: a multi-site qualitative
comparative case study.
November 1, 2023
Terwilliger IA, Johnson JK, Manojlovich M, et al. Contextual Factors Influencing the Implementation of a
Mul…
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psnet.ahrq.gov/node/37091/psn-pdf
March 02, 2016 - The tension between needing to improve care and
knowing how to do it.
March 2, 2016
Auerbach AD, Landefeld S, Shojania KG. The tension between needing to improve care and knowing how
to do it. N Engl J Med. 2007;357(6):608-13.
https://psnet.ahrq.gov/issue/tension-between-needing-improve-care-and-knowing-how-do-it
…
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psnet.ahrq.gov/node/36455/psn-pdf
December 22, 2010 - Changing the work environment in ICUs to achieve
patient-focused care: the time has come.
December 22, 2010
McCauley K, Irwin RS. Changing the work environment in ICUs to achieve patient-focused care: the time
has come. Chest. 2006;130(5):1571-8.
https://psnet.ahrq.gov/issue/changing-work-environment-icus-achieve-…