AHRQ Search | Home Page

The problem with root cause analysis. | PSNet

psnet.ahrq.gov/issue/problem-root-cause-analysis

August 28, 2024 - Commentary The problem with root cause analysis. Citation Text: Peerally MF, Carr S, Waring J, et al. The problem with root cause analysis. BMJ Qual Saf. 2017;26(5):417-422. doi:10.1136/bmjqs-2016-005511. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML…

Hospital safety climate and safety outcomes: is there a relationship in the VA? | PSNet

psnet.ahrq.gov/issue/hospital-safety-climate-and-safety-outcomes-there-relationship-va

October 14, 2009 - Study Hospital safety climate and safety outcomes: is there a relationship in the VA? Citation Text: Rosen AK, Singer SJ, Zhao S, et al. Hospital safety climate and safety outcomes: is there a relationship in the VA? Med Care Res Rev. 2010;67(5):590-608. doi:10.1177/1077558709356703. …

Excess dosing of antiplatelet and antithrombin agents in the treatment of non–ST-segment elevation acute coronary syndromes. | PSNet

psnet.ahrq.gov/issue/excess-dosing-antiplatelet-and-antithrombin-agents-treatment-non-st-segment-elevation-acute

November 10, 2015 - Study Excess dosing of antiplatelet and antithrombin agents in the treatment of non–ST-segment elevation acute coronary syndromes. Citation Text: Alexander KP, Chen AY, Roe MT, et al. Excess dosing of antiplatelet and antithrombin agents in the treatment of non-ST-segment elevation acu…

Medical malpractice litigation and daylight saving time. | PSNet

psnet.ahrq.gov/issue/medical-malpractice-litigation-and-daylight-saving-time

March 24, 2019 - Study Medical malpractice litigation and daylight saving time. Citation Text: Gao C, Lage C, Scullin MK. Medical malpractice litigation and daylight saving time. J Clin Sleep Med. 2024;20(6):933-940. doi:10.5664/jcsm.11038. Copy Citation Format: DOI Google Scholar BibTeX En…

Using simulation to augment root cause analysis for patient safety incidents at a tertiary care women's and children's hospital: a qualitative feasibility study. | PSNet

psnet.ahrq.gov/issue/using-simulation-augment-root-cause-analysis-patient-safety-incidents-tertiary-care-womens

January 22, 2025 - Study Using simulation to augment root cause analysis for patient safety incidents at a tertiary care women's and children's hospital: a qualitative feasibility study. Citation Text: Burchell D, MacPhee S, Sinclair D, et al. Using simulation to augment root cause analysis for patient saf…

Pharmacists reducing medication risk in medical outpatient clinics: a retrospective study of 18 clinics. | PSNet

psnet.ahrq.gov/issue/pharmacists-reducing-medication-risk-medical-outpatient-clinics-retrospective-study-18

June 16, 2021 - Study Pharmacists reducing medication risk in medical outpatient clinics: a retrospective study of 18 clinics. Citation Text: Snoswell CL, De Guzman KR, Barras M. Pharmacists reducing medication risk in medical outpatient clinics: a retrospective study of 18 clinics. Intern Med J. 2023;5…

Prevalence of potentially inappropriate medication prescribing in US nursing homes, 2013-2017. | PSNet

psnet.ahrq.gov/issue/prevalence-potentially-inappropriate-medication-prescribing-us-nursing-homes-2013-2017

March 27, 2024 - Study Prevalence of potentially inappropriate medication prescribing in US nursing homes, 2013-2017. Citation Text: Riester MR, Goyal P, Steinman MA, et al. Prevalence of potentially inappropriate medication prescribing in US nursing homes, 2013-2017. J Gen Intern Med. 2023;38(6):1563-15…

The potential for improved teamwork to reduce medical errors in the emergency department. | PSNet

psnet.ahrq.gov/issue/potential-improved-teamwork-reduce-medical-errors-emergency-department

July 07, 2021 - Review Classic The potential for improved teamwork to reduce medical errors in the emergency department. Citation Text: Risser DT, Rice MM, Salisbury ML, et al. The potential for improved teamwork to reduce medical errors in the emergency department. Ann Emerg M…

An unintended consequence of electronic prescriptions: prevalence and impact of internal discrepancies. | PSNet

psnet.ahrq.gov/issue/unintended-consequence-electronic-prescriptions-prevalence-and-impact-internal-discrepancies

May 04, 2011 - Study An unintended consequence of electronic prescriptions: prevalence and impact of internal discrepancies. Citation Text: Palchuk MB, Fang EA, Cygielnik JM, et al. An unintended consequence of electronic prescriptions: prevalence and impact of internal discrepancies. J Am Med Inform…

High-reliability health care: getting there from here. | PSNet

psnet.ahrq.gov/issue/high-reliability-health-care-getting-there-here

January 23, 2012 - Study Classic High-reliability health care: getting there from here. Citation Text: Chassin MR, Loeb JM. High-reliability health care: getting there from here. Milbank Q. 2013;91(3):459-490. doi:10.1111/1468-0009.12023. Copy Citation Format: DOI Go…

Must we bust the trust?: Understanding how the clinician–patient relationship influences patient engagement in safety. | PSNet

psnet.ahrq.gov/issue/must-we-bust-trust-understanding-how-clinician-patient-relationship-influences-patient

January 11, 2023 - Study Must we bust the trust?: Understanding how the clinician–patient relationship influences patient engagement in safety. Citation Text: Mishra SR, Haldar S, Khelifi M, et al. Must we bust the trust?: Understanding how the clinician–patient relationship influences patient engagement i…

Risk of unintentional overdose with non-prescription acetaminophen products. | PSNet

psnet.ahrq.gov/issue/risk-unintentional-overdose-non-prescription-acetaminophen-products

January 22, 2014 - Study Risk of unintentional overdose with non-prescription acetaminophen products. Citation Text: Wolf MS, King J, Jacobson K, et al. Risk of unintentional overdose with non-prescription acetaminophen products. J Gen Intern Med. 2012;27(12):1587-93. doi:10.1007/s11606-012-2096-3. Copy …

Implementing high-reliability organization principles into practice: a rapid evidence review. | PSNet

psnet.ahrq.gov/issue/implementing-high-reliability-organization-principles-practice-rapid-evidence-review

October 21, 2020 - Review Implementing high-reliability organization principles into practice: a rapid evidence review. Citation Text: Veazie S, Peterson K, Bourne D, et al. Implementing high-reliability organization principles into practice: a rapid evidence review. J Patient Saf. 2022;18(1):e320-e328. do…

Caregiver and clinician perspectives on discharge medication counseling: a qualitative study. | PSNet

psnet.ahrq.gov/issue/caregiver-and-clinician-perspectives-discharge-medication-counseling-qualitative-study

January 31, 2024 - Study Caregiver and clinician perspectives on discharge medication counseling: a qualitative study. Citation Text: Carroll AR, Schlundt D, Bonnet K, et al. Caregiver and clinician perspectives on discharge medication counseling: a qualitative study. Hosp Pediatr. 2023;13(4):325-342. doi:…

Minor flow disruptions, traffic-related factors and their effect on major flow disruptions in the operating room. | PSNet

psnet.ahrq.gov/issue/minor-flow-disruptions-traffic-related-factors-and-their-effect-major-flow-disruptions

August 19, 2020 - Study Minor flow disruptions, traffic-related factors and their effect on major flow disruptions in the operating room. Citation Text: Joseph A, Khoshkenar A, Taaffe KM, et al. Minor flow disruptions, traffic-related factors and their effect on major flow disruptions in the operating roo…

Serious hazards of transfusion: evaluating the dangers of a wrong patient autologous salvaged blood in cardiac surgery. | PSNet

psnet.ahrq.gov/issue/serious-hazards-transfusion-evaluating-dangers-wrong-patient-autologous-salvaged-blood

May 11, 2022 - Commentary Serious hazards of transfusion: evaluating the dangers of a wrong patient autologous salvaged blood in cardiac surgery. Citation Text: Uramatsu M, Maeda H, Mishima S, et al. Serious hazards of transfusion: evaluating the dangers of a wrong patient autologous salvaged blood in …

Improving safety by evaluating the impact of the supply chain and drug shortages on health-systems. | PSNet

psnet.ahrq.gov/issue/improving-safety-evaluating-impact-supply-chain-and-drug-shortages-health-systems

November 04, 2020 - Commentary Improving safety by evaluating the impact of the supply chain and drug shortages on health-systems. Citation Text: Patel V, Cieslak K, Hertig JB. Improving safety by evaluating the impact of the supply chain and drug shortages on health-systems. Hosp Pharm. 2023;58(2):120-124.…

Nurse staffing and inpatient hospital mortality. | PSNet

psnet.ahrq.gov/issue/nurse-staffing-and-inpatient-hospital-mortality

June 22, 2022 - Study Classic Nurse staffing and inpatient hospital mortality. Citation Text: Needleman J, Buerhaus P, Pankratz S, et al. Nurse staffing and inpatient hospital mortality. New Engl J Med. 2011;364(11):1037-1045. doi:10.1056/NEJMsa1001025. Copy Citation Fo…

Can medical record reviewers reliably identify errors and adverse events in the ED? | PSNet

psnet.ahrq.gov/issue/can-medical-record-reviewers-reliably-identify-errors-and-adverse-events-ed

October 11, 2023 - Study Can medical record reviewers reliably identify errors and adverse events in the ED? Citation Text: Klasco RS, Wolfe RE, Lee T, et al. Can medical record reviewers reliably identify errors and adverse events in the ED? Am J Emerg Med. 2016;34(6):1043-8. doi:10.1016/j.ajem.2016.03.00…

Pending studies at hospital discharge: a pre-post analysis of an electronic medical record tool to improve communication at hospital discharge. | PSNet

psnet.ahrq.gov/issue/pending-studies-hospital-discharge-pre-post-analysis-electronic-medical-record-tool-improve

September 16, 2020 - Study Pending studies at hospital discharge: a pre-post analysis of an electronic medical record tool to improve communication at hospital discharge. Citation Text: Kantor MA, Evans KH, Shieh L. Pending studies at hospital discharge: a pre-post analysis of an electronic medical record to…

Search AHRQ

Results