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4041. Does root cause analysis improve patient safety? A systematic review at the Department of Veterans Affairs. | PSNet
      psnet.ahrq.gov/issue/does-root-cause-analysis-improve-patient-safety-systematic-review-department-veterans-affairs
      March 24, 2021 - Review Does root cause analysis improve patient safety? A systematic review at the Department of Veterans Affairs. Citation Text: Shah F, Falconer EA, Cimiotti JP. Does root cause analysis improve patient safety? A systematic review at the Department of Veterans Affairs. Qual Manag Healt…

4042. A review of adverse event reports from emergency departments in the Veterans Health Administration. | PSNet
      psnet.ahrq.gov/issue/review-adverse-event-reports-emergency-departments-veterans-health-administration
      November 17, 2021 - Study A review of adverse event reports from emergency departments in the Veterans Health Administration. Citation Text: Gill S, Mills PD, Watts BV, et al. A Review of Adverse Event Reports From Emergency Departments in the Veterans Health Administration. J Patient Saf. 2021;17(8):e898-…

4043. Patient safety risks associated with telecare: a systematic review and narrative synthesis of the literature. | PSNet
      psnet.ahrq.gov/issue/patient-safety-risks-associated-telecare-systematic-review-and-narrative-synthesis-literature
      October 09, 2024 - Review Patient safety risks associated with telecare: a systematic review and narrative synthesis of the literature. Citation Text: Guise V, Anderson JE, Wiig S. Patient safety risks associated with telecare: a systematic review and narrative synthesis of the literature. BMC Health Serv …

4044. When disasters strike the emergency department: a case series and narrative review. | PSNet
      psnet.ahrq.gov/issue/when-disasters-strike-emergency-department-case-series-and-narrative-review
      September 30, 2020 - Commentary When disasters strike the emergency department: a case series and narrative review. Citation Text: Barten DG, Klokman VW, Cleef S, et al. When disasters strike the emergency department: a case series and narrative review. Int J Emerg Med. 2021;14(1):49. doi:10.1186/s12245-021-…

4045. Incident reporting system does not detect adverse drug events: a problem for quality improvement. | PSNet
      psnet.ahrq.gov/issue/incident-reporting-system-does-not-detect-adverse-drug-events-problem-quality-improvement
      February 10, 2011 - Study Classic Incident reporting system does not detect adverse drug events: a problem for quality improvement. Citation Text: Cullen DJ, Bates DW, Small SD, et al. The incident reporting system does not detect adverse drug events: a problem for quality improvem…

4046. Reducing medication errors for adults in hospital settings. | PSNet
      psnet.ahrq.gov/issue/reducing-medication-errors-adults-hospital-settings
      March 09, 2022 - Review Reducing medication errors for adults in hospital settings. Citation Text: Ciapponi A, Fernandez Nievas SE, Seijo M, et al. Reducing medication errors for adults in hospital settings. Cochrane Database Syst Rev. 2021;11(11):CD009985. doi:10.1002/14651858.cd009985.pub2. Copy Cita…

4047. The effect of providing staff training and enhanced support to care homes on care processes, safety climate and avoidable harms: evaluation of a care home quality improvement programme in England. | PSNet
      psnet.ahrq.gov/issue/effect-providing-staff-training-and-enhanced-support-care-homes-care-processes-safety-climate
      September 15, 2021 - Study The effect of providing staff training and enhanced support to care homes on care processes, safety climate and avoidable harms: evaluation of a care home quality improvement programme in England. Citation Text: Damery S, Flanagan S, Jones J, et al. The effect of providing staff tr…

4048. Electronic patient identification for sample labeling reduces wrong blood in tube errors. | PSNet
      psnet.ahrq.gov/issue/electronic-patient-identification-sample-labeling-reduces-wrong-blood-tube-errors
      September 20, 2012 - Study Emerging Classic Electronic patient identification for sample labeling reduces wrong blood in tube errors. Citation Text: Kaufman RM, Dinh A, Cohn CS, et al. Electronic patient identification for sample labeling reduces wrong blood in tube errors. Transfus…

4049. Not sick enough to worry? "Influenza-like" symptoms and work-related behavior among healthcare workers and other professionals: results of a global survey. | PSNet
      psnet.ahrq.gov/issue/not-sick-enough-worry-influenza-symptoms-and-work-related-behavior-among-healthcare-workers
      August 03, 2022 - Study Not sick enough to worry? "Influenza-like" symptoms and work-related behavior among healthcare workers and other professionals: results of a global survey. Citation Text: Tartari E, Saris K, Kenters N, et al. Not sick enough to worry? "Influenza-like" symptoms and work-related beha…

4050. Analysis of clinical decision support system malfunctions: a case series and survey. | PSNet
      psnet.ahrq.gov/issue/analysis-clinical-decision-support-system-malfunctions-case-series-and-survey
      April 29, 2018 - Study Analysis of clinical decision support system malfunctions: a case series and survey. Citation Text: Wright A, Hickman T-TT, McEvoy D, et al. Analysis of clinical decision support system malfunctions: a case series and survey. J Am Med Inform Assoc. 2016;23(6):1068-1076. doi:10.1093…

4051. Promising practices for improving hospital patient safety culture. | PSNet
      psnet.ahrq.gov/issue/promising-practices-improving-hospital-patient-safety-culture
      December 09, 2020 - Study Classic Promising practices for improving hospital patient safety culture. Citation Text: Campione J, Famolaro T. Promising Practices for Improving Hospital Patient Safety Culture. Jt Comm J Qual Patient Saf. 2018;44(1):23-32. doi:10.1016/j.jcjq.2017.09.00…

4052. A qualitative study of patient involvement in medicines management after hospital discharge: an under-recognised source of systems resilience. | PSNet
      psnet.ahrq.gov/issue/qualitative-study-patient-involvement-medicines-management-after-hospital-discharge-under
      August 03, 2011 - Study A qualitative study of patient involvement in medicines management after hospital discharge: an under-recognised source of systems resilience. Citation Text: Fylan B, Armitage G, Naylor D, et al. A qualitative study of patient involvement in medicines management after hospital disc…

4053. Why test results are still getting "lost" to follow-up: a qualitative study of implementation gaps. | PSNet
      psnet.ahrq.gov/issue/why-test-results-are-still-getting-lost-follow-qualitative-study-implementation-gaps
      June 22, 2022 - Study Why test results are still getting "lost" to follow-up: a qualitative study of implementation gaps. Citation Text: Zimolzak AJ, Shahid U, Giardina TD, et al. Why test results are still getting "lost" to follow-up: a qualitative study of implementation gaps. J Gen Intern Med. 2022;3…

4054. Readiness of US general surgery residents for independent practice. | PSNet
      psnet.ahrq.gov/issue/readiness-us-general-surgery-residents-independent-practice
      April 24, 2018 - Study Classic Readiness of US general surgery residents for independent practice. Citation Text: George BC, Bohnen JD, Williams RG, et al. Readiness of US General Surgery Residents for Independent Practice. Ann Surg. 2017;266(4):582-594. doi:10.1097/SLA.00000000…

4055. Influence of a general practice pharmacist on medication management for patients at risk of medicine-related harm: a qualitative evaluation. | PSNet
      psnet.ahrq.gov/issue/influence-general-practice-pharmacist-medication-management-patients-risk-medicine-related
      May 19, 2021 - Study Influence of a general practice pharmacist on medication management for patients at risk of medicine-related harm: a qualitative evaluation. Citation Text: Jordan M, Young-Whitford M, Mullan J, et al. Influence of a general practice pharmacist on medication management for patients …

4056. Clinical decision support alert malfunctions: analysis and empirically derived taxonomy. | PSNet
      psnet.ahrq.gov/issue/clinical-decision-support-alert-malfunctions-analysis-and-empirically-derived-taxonomy
      December 04, 2016 - Study Clinical decision support alert malfunctions: analysis and empirically derived taxonomy. Citation Text: Wright A, Ai A, Ash JS, et al. Clinical decision support alert malfunctions: analysis and empirically derived taxonomy. J Am Med Inform Assoc. 2018;25(5):496-506. doi:10.1093/jam…

4057. Perceptions of hospital electronic health record (EHR) training, support, and patient safety by staff position and tenure. | PSNet
      psnet.ahrq.gov/issue/perceptions-hospital-electronic-health-record-ehr-training-support-and-patient-safety-staff
      October 03, 2018 - Study Perceptions of hospital electronic health record (EHR) training, support, and patient safety by staff position and tenure. Citation Text: Campione JR, Liu H. Perceptions of hospital electronic health record (EHR) training, support, and patient safety by staff position and tenure. B…

4058. Declines in hospitalizations for acute cardiovascular conditions during the COVID-19 pandemic: a multicenter tertiary care experience. | PSNet
      psnet.ahrq.gov/issue/declines-hospitalizations-acute-cardiovascular-conditions-during-covid-19-pandemic
      April 24, 2018 - Study Declines in hospitalizations for acute cardiovascular conditions during the COVID-19 pandemic: a multicenter tertiary care experience. Citation Text: Bhatt AS, Moscone A, McElrath EE, et al. Declines in Hospitalizations for Acute Cardiovascular Conditions During the COVID-19 Pandem…

4059. Self-reported gaps in care coordination and preventable adverse outcomes among older adults receiving home health care. | PSNet
      psnet.ahrq.gov/issue/self-reported-gaps-care-coordination-and-preventable-adverse-outcomes-among-older-adults
      July 06, 2022 - Study Self-reported gaps in care coordination and preventable adverse outcomes among older adults receiving home health care. Citation Text: Sterling MR, Lau J, Rajan M, et al. Self‐reported gaps in care coordination and preventable adverse outcomes among older adults receiving home heal…

4060. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60864/psn-pdf
      August 31, 2020 - Safety Across The Board August 31, 2020 Fitall E, Hall KK, Gale B. Safety Across The Board . PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/safety-across-board Defining Safety Across the Board Safety Across The Board (SAB) is a concept originating from the Centers for Medicare & Medicaid Services (CMS…