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Paying the piper: investing in infrastructure for patient safety. | PSNet

psnet.ahrq.gov/issue/paying-piper-investing-infrastructure-patient-safety

July 01, 2017 - Commentary Classic Paying the piper: investing in infrastructure for patient safety. Citation Text: Pronovost P, Rosenstein BJ, Paine LA, et al. Paying the piper: investing in infrastructure for patient safety. Jt Comm J Qual Patient Saf. 2008;34(6):342-8. Co…

The dichotomy of the application of a systems approach in UK healthcare the challenges and priorities for implementation. | PSNet

psnet.ahrq.gov/issue/dichotomy-application-systems-approach-uk-healthcare-challenges-and-priorities-implementation

January 09, 2018 - Commentary The dichotomy of the application of a systems approach in UK healthcare the challenges and priorities for implementation. Citation Text: Pickup L, Lang A, Atkinson S, et al. The dichotomy of the application of a systems approach in UK healthcare the challenges and priorities f…

Adverse diagnostic events in hospitalised patients: a single-centre, retrospective cohort study. | PSNet

psnet.ahrq.gov/issue/adverse-diagnostic-events-hospitalised-patients-single-centre-retrospective-cohort-study

December 07, 2022 - Study Adverse diagnostic events in hospitalised patients: a single-centre, retrospective cohort study. Citation Text: Dalal AK, Plombon S, Konieczny K, et al. Adverse diagnostic events in hospitalised patients: a single-centre, retrospective cohort study. BMJ Qual Saf. 2024;Epub Oct 1. d…

How to prevent or reduce prescribing errors: an evidence brief for policy authors. | PSNet

psnet.ahrq.gov/issue/how-prevent-or-reduce-prescribing-errors-evidence-brief-policy-authors

July 27, 2022 - Review How to prevent or reduce prescribing errors: an evidence brief for policy authors. Citation Text: de Araújo BC, de Melo RC, de Bortoli MC, et al. How to prevent or reduce prescribing errors: an evidence brief for policy authors. Front Pharmacol. 2019;10:439. doi:10.3389/fphar.2019…

The impact of improving teamwork on patient outcomes in surgery: a systematic review. | PSNet

psnet.ahrq.gov/issue/impact-improving-teamwork-patient-outcomes-surgery-systematic-review

May 13, 2020 - Review The impact of improving teamwork on patient outcomes in surgery: a systematic review. Citation Text: Sun R, Marshall DC, Sykes MC, et al. The impact of improving teamwork on patient outcomes in surgery: A systematic review. Int J Surg. 2018;53:171-177. doi:10.1016/j.ijsu.2018.03.0…

Look-alike medications in the perioperative setting: scoping review of medication incidents and risk reduction interventions. | PSNet

psnet.ahrq.gov/issue/look-alike-medications-perioperative-setting-scoping-review-medication-incidents-and-risk

October 04, 2023 - Review Look-alike medications in the perioperative setting: scoping review of medication incidents and risk reduction interventions. Citation Text: Ryan AN, Robertson KL, Glass BD. Look-alike medications in the perioperative setting: scoping review of medication incidents and risk reduct…

Reflecting on diagnostic errors: taking a second look is not enough. | PSNet

psnet.ahrq.gov/issue/reflecting-diagnostic-errors-taking-second-look-not-enough

September 26, 2016 - Study Reflecting on diagnostic errors: taking a second look is not enough. Citation Text: Monteiro SD, Sherbino J, Patel A, et al. Reflecting on Diagnostic Errors: Taking a Second Look is Not Enough. J Gen Intern Med. 2015;30(9):1270-4. doi:10.1007/s11606-015-3369-4. Copy Citation …

Statewide perinatal quality improvement, teamwork, and communication activities in Oklahoma and Texas. | PSNet

psnet.ahrq.gov/issue/statewide-perinatal-quality-improvement-teamwork-and-communication-activities-oklahoma-and

October 19, 2022 - Study Statewide perinatal quality improvement, teamwork, and communication activities in Oklahoma and Texas. Citation Text: Stierman EK, O'Brien BT, Stagg J, et al. Statewide perinatal quality improvement, teamwork, and communication activities in Oklahoma and Texas. Qual Manag Health Ca…

Less is more: a project to reduce the number of PIMs (potentially inappropriate medications) on an elderly care ward. | PSNet

psnet.ahrq.gov/issue/less-more-project-reduce-number-pims-potentially-inappropriate-medications-elderly-care-ward

September 27, 2017 - Commentary Less is more: a project to reduce the number of PIMs (potentially inappropriate medications) on an elderly care ward. Citation Text: Aung TH, Beck AJ, Siese T, et al. Less is more: a project to reduce the number of PIMs (potentially inappropriate medications) on an elderly car…

Five system barriers to achieving ultrasafe health care. | PSNet

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September 29, 2017 - Commentary Classic Five system barriers to achieving ultrasafe health care. Citation Text: Amalberti R, Auroy Y, Berwick D, et al. Five system barriers to achieving ultrasafe health care. Ann Intern Med. 2005;142(9):756-64. Copy Citation Format: …

System factors affecting intraoperative risk and resilience: applying a novel integrated approach to study surgical performance and patient safety. | PSNet

psnet.ahrq.gov/issue/system-factors-affecting-intraoperative-risk-and-resilience-applying-novel-integrated

August 25, 2021 - Study Emerging Classic System factors affecting intraoperative risk and resilience: applying a novel integrated approach to study surgical performance and patient safety. Citation Text: Kolodzey L, Trbovich PL, Kashfi A, et al. System Factors Affecting Intraope…

Pharmacist linkage in care transitions: from academic medical center to community. | PSNet

psnet.ahrq.gov/issue/pharmacist-linkage-care-transitions-academic-medical-center-community

November 16, 2022 - Study Pharmacist linkage in care transitions: from academic medical center to community. Citation Text: Bloodworth LS, Malinowski SS, Lirette ST, et al. Pharmacist linkage in care transitions: from academic medical center to community. J Am Pharm Assoc . 2019;59(6):896-904. doi:10.1016/j…

Despite federal legislation, shortages of drugs used in acute care settings remain persistent and prolonged. | PSNet

psnet.ahrq.gov/issue/despite-federal-legislation-shortages-drugs-used-acute-care-settings-remain-persistent-and

August 15, 2018 - Study Despite federal legislation, shortages of drugs used in acute care settings remain persistent and prolonged. Citation Text: Chen SI, Fox ER, Hall K, et al. Despite Federal Legislation, Shortages Of Drugs Used In Acute Care Settings Remain Persistent And Prolonged. Health Aff (Millw…

Exploring system features of primary care practices that promote better providers' clinical work satisfaction: a qualitative comparative analysis. | PSNet

psnet.ahrq.gov/issue/exploring-system-features-primary-care-practices-promote-better-providers-clinical-work

May 25, 2022 - Study Exploring system features of primary care practices that promote better providers' clinical work satisfaction: a qualitative comparative analysis. Citation Text: Liu L, Chien AT, Singer SJ. Exploring system features of primary care practices that promote better providers’ clinical …

Cybersecurity in health is an urgent patient safety concern: we can learn from existing patient safety improvement strategies to address it. | PSNet

psnet.ahrq.gov/issue/cybersecurity-health-urgent-patient-safety-concern-we-can-learn-existing-patient-safety

October 28, 2020 - Commentary Cybersecurity in health is an urgent patient safety concern: we can learn from existing patient safety improvement strategies to address it. Citation Text: O’Brien N, Ghafur S, Durkin M. Cybersecurity in health is an urgent patient safety concern: we can learn from existing pa…

Implementation, evaluation, and recommendations for extension of AHRQ Common Formats to capture patient- and carepartner-generated safety data. | PSNet

psnet.ahrq.gov/issue/implementation-evaluation-and-recommendations-extension-ahrq-common-formats-capture-patient

June 13, 2018 - Study Implementation, evaluation, and recommendations for extension of AHRQ Common Formats to capture patient- and carepartner-generated safety data. Citation Text: Collins S, Couture B, Dykes PC, et al. Implementation, evaluation, and recommendations for extension of AHRQ Common Formats…

The use of a CPOE log for the analysis of physicians' behavior when responding to drug-duplication reminders. | PSNet

psnet.ahrq.gov/issue/use-cpoe-log-analysis-physicians-behavior-when-responding-drug-duplication-reminders

October 27, 2016 - Study The use of a CPOE log for the analysis of physicians' behavior when responding to drug-duplication reminders. Citation Text: Long A-J, Chang P, Li Y-C, et al. The use of a CPOE log for the analysis of physicians’ behavior when responding to drug-duplication reminders. Int J Med I…

Society for Maternal-Fetal Medicine Special Statement: curriculum outline on patient safety and quality for maternal-fetal medicine fellows. | PSNet

psnet.ahrq.gov/issue/society-maternal-fetal-medicine-special-statement-curriculum-outline-patient-safety-and

September 22, 2021 - Organizational Policy/Guidelines Society for Maternal-Fetal Medicine Special Statement: curriculum outline on patient safety and quality for maternal-fetal medicine fellows. Citation Text: Society for Maternal-Fetal Medicine Special Statement: curriculum outline on patient safety and qua…

Cross-Check QA: a quality assurance workflow to prevent missed diagnoses by alerting inadvertent discordance between the radiologist and AI in the interpretation of high acuity CT scans. | PSNet

psnet.ahrq.gov/issue/cross-check-qa-quality-assurance-workflow-prevent-missed-diagnoses-alerting-inadvertent

March 04, 2015 - Study Cross-Check QA: a quality assurance workflow to prevent missed diagnoses by alerting inadvertent discordance between the radiologist and AI in the interpretation of high acuity CT scans. Citation Text: Chekmeyan M, Baccei SJ, Garwood ER. Cross-Check QA: a quality assurance workflow…

Improving employee voice about transgressive or disruptive behavior: a case study. | PSNet

psnet.ahrq.gov/issue/improving-employee-voice-about-transgressive-or-disruptive-behavior-case-study

June 16, 2021 - Study Improving employee voice about transgressive or disruptive behavior: a case study. Citation Text: Dixon-Woods M, Campbell A, Martin G, et al. Improving Employee Voice About Transgressive or Disruptive Behavior: A Case Study. Acad Med. 2019;94(4):579-585. doi:10.1097/ACM.00000000000…

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