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  1. Hospitalisation for medication misadventures among older adults with and without dementia: a 5-year retrospective study. | PSNet

    psnet.ahrq.gov/issue/hospitalisation-medication-misadventures-among-older-adults-and-without-dementia-5-year
    August 18, 2021 - Study Hospitalisation for medication misadventures among older adults with and without dementia: a 5-year retrospective study. Citation Text: Mullan J, Burns P, Mohanan L, et al. Hospitalisation for medication misadventures among older adults with and without dementia: A 5-year retrospec…

  2. Intravenous smart pumps at the point of care: a descriptive, observational study. | PSNet

    psnet.ahrq.gov/issue/intravenous-smart-pumps-point-care-descriptive-observational-study
    February 24, 2021 - Study Intravenous smart pumps at the point of care: a descriptive, observational study. Citation Text: Giuliano KK, Blake JWC, Bittner NP, et al. Intravenous smart pumps at the point of care: a descriptive, observational study. J Patient Saf. 2022;18(6):553-558. doi:10.1097/pts.000000000…

  3. Improving infusion pump safety through usability testing. | PSNet

    psnet.ahrq.gov/issue/improving-infusion-pump-safety-through-usability-testing
    July 15, 2020 - Commentary Improving infusion pump safety through usability testing. Citation Text: Miller K, Arnold R, Capan M, et al. Improving infusion pump safety through usability testing. J Nurs Care Qual. 2017;32(2):141-149. doi:10.1097/NCQ.0000000000000208. Copy Citation Format: DO…

  4. Using smart IV infusion pumps outside of patient rooms. | PSNet

    psnet.ahrq.gov/issue/using-smart-iv-infusion-pumps-outside-patient-rooms
    September 23, 2020 - Commentary Using smart IV infusion pumps outside of patient rooms. Citation Text: Messing EG, Abraham RS, Quinn NJ, et al. Using smart IV infusion pumps outside of patient rooms. Am J Nurs. 2022;122(2). doi:10.1097/01.naj.0000819772.45006.5d. Copy Citation Format: DOI Googl…

  5. Lost opportunities: how physicians communicate about medical errors. | PSNet

    psnet.ahrq.gov/issue/lost-opportunities-how-physicians-communicate-about-medical-errors
    July 10, 2008 - Study Lost opportunities: how physicians communicate about medical errors. Citation Text: Garbutt J, Waterman AD, Kapp JM, et al. Lost Opportunities: How Physicians Communicate About Medical Errors. Health Aff (Millwood). 2008;27(1):246-255. doi:10.1377/hlthaff.27.1.246. Copy Citati…

  6. Patients' experiences with communication-and-resolution programs after medical injury. | PSNet

    psnet.ahrq.gov/issue/patients-experiences-communication-and-resolution-programs-after-medical-injury
    May 05, 2021 - Study Patients' experiences with communication-and-resolution programs after medical injury. Citation Text: Moore J, Bismark M, Mello MM. Patients' Experiences With Communication-and-Resolution Programs After Medical Injury. JAMA Intern Med. 2017;177(11):1595-1603. doi:10.1001/jamaintern…

  7. Developing standardized "receiver-driven" handoffs between referring providers and the emergency department: results of a multidisciplinary needs assessment. | PSNet

    psnet.ahrq.gov/issue/developing-standardized-receiver-driven-handoffs-between-referring-providers-and-emergency
    June 03, 2020 - Study Developing standardized "receiver-driven" handoffs between referring providers and the emergency department: results of a multidisciplinary needs assessment. Citation Text: Huth K, Stack AM, Chi G, et al. Developing Standardized "Receiver-Driven" Handoffs Between Referring Provider…

  8. Employee / Staff Pre-Go-Live Expectations / Perceptions Clinical Information Systems Survey DR ONLY (pdf file)

    digital.ahrq.gov/sites/default/files/docs/survey/cis-survey-pre-go-live.pdf
    June 16, 2021 - Employee / Staff Pre-Go-Live Expectations / Perceptions Clinical Information Systems Survey DR ONLY Employee and Staff Pre-Go-Live Expectations and Perceptions Clinical Information Systems Survey University of Iowa, Iowa City IA This is a questionnaire designed to be completed by clinical staff across a health ca…

  9. The role of the medical emergency team in end-of-life care: a multicenter, prospective, observational study. | PSNet

    psnet.ahrq.gov/issue/role-medical-emergency-team-end-life-care-multicenter-prospective-observational-study
    July 13, 2010 - Study The role of the medical emergency team in end-of-life care: a multicenter, prospective, observational study. Citation Text: Jones D, Bagshaw SM, Barrett J, et al. The role of the medical emergency team in end-of-life care: a multicenter, prospective, observational study. Crit Car…

  10. Understanding the knowledge gaps in whistleblowing and speaking up in health care: narrative reviews of the research literature and formal inquiries, a legal analysis and stakeholder interviews. | PSNet

    psnet.ahrq.gov/issue/understanding-knowledge-gaps-whistleblowing-and-speaking-health-care-narrative-reviews
    September 11, 2018 - Book/Report Understanding the knowledge gaps in whistleblowing and speaking up in health care: narrative reviews of the research literature and formal inquiries, a legal analysis and stakeholder interviews. Citation Text: Understanding the knowledge gaps in whistleblowing and speaking up…

  11. Supporting error management and safety climate in ambulatory care practices: the CIRSforte study. | PSNet

    psnet.ahrq.gov/issue/supporting-error-management-and-safety-climate-ambulatory-care-practices-cirsforte-study
    September 07, 2022 - Study Supporting error management and safety climate in ambulatory care practices: the CIRSforte study. Citation Text: Müller BS, Lüttel D, Schütze D, et al. Supporting error management and safety climate in ambulatory care practices: the CIRSforte study. J Patient Saf. 2024;20(5):314-32…

  12. Parents' perspective on safety in neonatal intensive care: a mixed-methods study. | PSNet

    psnet.ahrq.gov/issue/parents-perspective-safety-neonatal-intensive-care-mixed-methods-study
    November 08, 2017 - Study Parents' perspective on safety in neonatal intensive care: a mixed-methods study. Citation Text: Lyndon A, Jacobson CH, Fagan KM, et al. Parents' perspectives on safety in neonatal intensive care: a mixed-methods study. BMJ Qual Saf. 2014;23(11):902-9. doi:10.1136/bmjqs-2014-003009…

  13. Why an open disclosure procedure is and is not followed after an avoidable adverse event. | PSNet

    psnet.ahrq.gov/issue/why-open-disclosure-procedure-and-not-followed-after-avoidable-adverse-event
    August 11, 2021 - Study Why an open disclosure procedure is and is not followed after an avoidable adverse event. Citation Text: Carrillo I, Mira JJ, Guilabert M, et al. Why an open disclosure procedure is and is not followed after an avoidable adverse event. J Patient Saf. 2021;17(6):e529-e533. doi:10.10…

  14. Interpersonal and organizational dynamics are key drivers of failure to rescue. | PSNet

    psnet.ahrq.gov/issue/interpersonal-and-organizational-dynamics-are-key-drivers-failure-rescue
    June 18, 2019 - Study Interpersonal and organizational dynamics are key drivers of failure to rescue. Citation Text: Smith ME, Wells EE, Friese CR, et al. Interpersonal And Organizational Dynamics Are Key Drivers Of Failure To Rescue. Health Aff (Millwood). 2018;37(11):1870-1876. doi:10.1377/hlthaff.201…

  15. Balancing safety, comfort, and fall risk: an intervention to limit opioid and benzodiazepine prescriptions for geriatric patients. | PSNet

    psnet.ahrq.gov/issue/balancing-safety-comfort-and-fall-risk-intervention-limit-opioid-and-benzodiazepine
    November 09, 2022 - Study Balancing safety, comfort, and fall risk: an intervention to limit opioid and benzodiazepine prescriptions for geriatric patients. Citation Text: Bloomer A, Wally M, Bailey G, et al. Balancing safety, comfort, and fall risk: an intervention to limit opioid and benzodiazepine prescr…

  16. Wrong administration route of medications in the domestic setting: a review of an underestimated public health topic. | PSNet

    psnet.ahrq.gov/issue/wrong-administration-route-medications-domestic-setting-review-underestimated-public-health
    December 15, 2021 - Review Wrong administration route of medications in the domestic setting: a review of an underestimated public health topic. Citation Text: Gualano MR, Lo Moro G, Voglino G, et al. Wrong administration route of medications in the domestic setting: a review of an underestimated public hea…

  17. Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. | PSNet

    psnet.ahrq.gov/issue/medication-reconciliation-during-transitions-care-patient-safety-strategy-systematic-review
    January 12, 2022 - Review Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Citation Text: Kwan JL, Lo L, Sampson M, et al. Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158…

  18. Lessons learnt from incidents reported by postgraduate trainees in Dutch general practice. A prospective cohort study. | PSNet

    psnet.ahrq.gov/issue/lessons-learnt-incidents-reported-postgraduate-trainees-dutch-general-practice-prospective
    February 23, 2011 - Study Lessons learnt from incidents reported by postgraduate trainees in Dutch general practice. A prospective cohort study. Citation Text: Zwart DLM, Heddema WS, Vermeulen MI, et al. Lessons learnt from incidents reported by postgraduate trainees in Dutch general practice. A prospecti…

  19. Characteristics of critical incident reporting systems in primary care: an international survey. | PSNet

    psnet.ahrq.gov/issue/characteristics-critical-incident-reporting-systems-primary-care-international-survey
    September 07, 2022 - Study Characteristics of critical incident reporting systems in primary care: an international survey. Citation Text: Höcherl A, Lüttel D, Schütze D, et al. Characteristics of critical incident reporting systems in primary care: an international survey. J Patient Saf. 2022;18(1):e85-e91.…

  20. Socio-technical issues and challenges in implementing safe patient handovers: insights from ethnographic case studies. | PSNet

    psnet.ahrq.gov/issue/socio-technical-issues-and-challenges-implementing-safe-patient-handovers-insights
    July 19, 2023 - Study Socio-technical issues and challenges in implementing safe patient handovers: insights from ethnographic case studies. Citation Text: Balka E, Tolar M, Coates S, et al. Socio-technical issues and challenges in implementing safe patient handovers: insights from ethnographic case st…
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