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psnet.ahrq.gov/node/48163/psn-pdf
July 31, 2019 - The MedSafer Study: a controlled trial of an electronic
decision support tool for deprescribing in acute care.
July 31, 2019
McDonald EG, Wu PE, Rashidi B, et al. The MedSafer Study: A Controlled Trial of an Electronic Decision
Support Tool for Deprescribing in Acute Care. J Am Geriatr Soc. 2019;67(9):1843-1850.
d…
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psnet.ahrq.gov/node/35907/psn-pdf
October 03, 2017 - Transparent and open discussion of errors does not
increase malpractice risk in trauma patients.
October 3, 2017
Stewart RM, Corneille MG, Johnston J, et al. Transparent and open discussion of errors does not increase
malpractice risk in trauma patients. Ann Surg. 2006;243(5):645-9; discussion 649-51.
https://psne…
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psnet.ahrq.gov/node/47882/psn-pdf
May 01, 2019 - Impact of oncology drug shortages on chemotherapy
treatment.
May 1, 2019
Alpert A, Jacobson M. Impact of Oncology Drug Shortages on Chemotherapy Treatment. Clin Pharmacol
Ther. 2019;106(2):415-421. doi:10.1002/cpt.1390.
https://psnet.ahrq.gov/issue/impact-oncology-drug-shortages-chemotherapy-treatment
Drug shorta…
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psnet.ahrq.gov/node/836772/psn-pdf
March 23, 2022 - Error reduction in trauma care: lessons from an
anonymized, national, multicenter mortality reporting
system.
March 23, 2022
Hamad DM, Mandell SP, Stewart RM, et al. Error reduction in trauma care: Lessons from an anonymized,
national, multicenter mortality reporting system. J Trauma Acute Care Surg. 2022;92(3):47…
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psnet.ahrq.gov/node/36634/psn-pdf
March 03, 2011 - Surgeon information transfer and communication: factors
affecting quality and efficiency of inpatient care.
March 3, 2011
Williams RG, Silverman R, Schwind C, et al. Surgeon information transfer and communication: factors
affecting quality and efficiency of inpatient care. Ann Surg. 2007;245(2):159-69.
https://psn…
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psnet.ahrq.gov/node/36596/psn-pdf
May 20, 2015 - Disclosure of medical injury to patients: an improbable
risk management strategy.
May 20, 2015
Studdert DM, Mello MM, Gawande AA, et al. Disclosure of medical injury to patients: an improbable risk
management strategy. Health Aff (Millwood). 2007;26(1):215-226.
https://psnet.ahrq.gov/issue/disclosure-medical-injur…
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psnet.ahrq.gov/node/46823/psn-pdf
August 20, 2018 - Systems thinking and incivility in nursing practice: an
integrative review.
August 20, 2018
Phillips JM, Stalter AM, Winegardner S, et al. Systems thinking and incivility in nursing practice: An
integrative review. Nurs Forum. 2018;2018(3):286-298. doi:10.1111/nuf.12250.
https://psnet.ahrq.gov/issue/systems-thinki…
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psnet.ahrq.gov/node/40291/psn-pdf
September 09, 2011 - Outcomes of emergency department patients presenting
with adverse drug events.
September 9, 2011
Hohl CM, Nosyk B, Kuramoto L, et al. Outcomes of emergency department patients presenting with
adverse drug events. Ann Emerg Med. 2011;58(3):270-279.e4. doi:10.1016/j.annemergmed.2011.01.003.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/864373/psn-pdf
March 13, 2024 - Harnessing in situ simulation to identify human errors
and latent safety threats in adult tracheostomy care.
March 13, 2024
Hassan B, Tawfik M-M, Schiff E, et al. Harnessing in situ simulation to identify human errors and latent
safety threats in adult tracheostomy care. Jt Comm J Qual Patient Saf. 2024;50(4):279-2…
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psnet.ahrq.gov/node/72706/psn-pdf
February 03, 2021 - Impact of alarm fatigue on the work of nurses in an
intensive care environment--a systematic review.
February 3, 2021
Lewandowska K, Weisbrot M, Cieloszyk A, et al. Impact of alarm fatigue on the work of nurses in an
intensive care environment--a systematic review. Int J Environ Res Public Health. 2020;17(22):8409.…
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psnet.ahrq.gov/node/862988/psn-pdf
February 21, 2024 - Identifying and classifying diagnostic errors in acute care
across hospitals: early lessons from the Utility of
Predictive Systems in Diagnostic Errors (UPSIDE) study.
February 21, 2024
Dalal AK, Schnipper JL, Raffel K, et al. Identifying and classifying diagnostic errors in acute care across
hospitals: early less…
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psnet.ahrq.gov/node/47127/psn-pdf
June 05, 2018 - Incorporating medication indications into the prescribing
process.
June 5, 2018
Kron K, Myers S, Volk LA, et al. Incorporating medication indications into the prescribing process. Am J
Health-syst Pharm. 2018;75(11):774-783. doi:10.2146/ajhp170346.
https://psnet.ahrq.gov/issue/incorporating-medication-indications-…
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psnet.ahrq.gov/node/74154/psn-pdf
December 08, 2021 - Assessment of requests for medication-related follow-up
after hospital discharge, and the relation to unplanned
hospital revisits, in older patients: a multicentre
retrospective chart review.
December 8, 2021
Cam H, Kempen TGH, Eriksson H, et al. Assessment of requests for medication-related follow-up after
hospi…
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psnet.ahrq.gov/node/837137/psn-pdf
May 18, 2022 - Exploring system features of primary care practices that
promote better providers' clinical work satisfaction: a
qualitative comparative analysis.
May 18, 2022
Liu L, Chien AT, Singer SJ. Exploring system features of primary care practices that promote better
providers’ clinical work satisfaction. Health Care Mana…
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psnet.ahrq.gov/node/41725/psn-pdf
January 01, 2013 - Improving patient handovers from hospital to primary
care: a systematic review.
October 3, 2012
Hesselink G, Schoonhoven L, Barach P, et al. Improving patient handovers from hospital to primary care: a
systematic review. Ann Intern Med. 2013;157(6):417. doi:10.7326/0003-4819-157-6-201209180-00006.
https://psnet.ah…
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psnet.ahrq.gov/node/853968/psn-pdf
January 01, 2024 - When work harms: how better understanding of avoidable
employee harm can improve employee safety, patient
safety and healthcare quality.
September 27, 2023
Jones A, Neal A, Bailey S, et al. When work harms: how better understanding of avoidable employee harm
can improve employee safety, patient safety and healthca…
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psnet.ahrq.gov/node/45428/psn-pdf
January 25, 2017 - Too many, too few, or too unsafe? Impact of inappropriate
prescribing on mortality, and hospitalization in a cohort of
community-dwelling oldest old.
January 25, 2017
Wauters M, Elseviers M, Vaes B, et al. Too many, too few, or too unsafe? Impact of inappropriate
prescribing on mortality, and hospitalization in a …
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psnet.ahrq.gov/node/856635/psn-pdf
January 01, 2024 - System planning for modern-day Just Culture to mitigate
worker distress and second victim response.
November 29, 2023
Sells JR, Cole I, Dharmasukrit C, et al. System planning for modern-day Just Culture to mitigate worker
distress and second victim response. BMJ Lead. 2024;8(2):149-152. doi:10.1136/leader-2023-0008…
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psnet.ahrq.gov/node/866312/psn-pdf
July 17, 2024 - Development of patient safety measures to identify
inappropriate diagnosis of common infections.
July 17, 2024
White AT, Vaughn VM, Petty LA, et al. Development of patient safety measures to identify inappropriate
diagnosis of common infections. Clin Infect Dis. 2024;78(6):1403-1411. doi:10.1093/cid/ciae044.
https…
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psnet.ahrq.gov/node/45313/psn-pdf
September 27, 2016 - An acetaminophen icon helps reduce medication decision
errors in an experimental setting.
September 27, 2016
Shiffman S, Cotton H, Jessurun C, et al. An acetaminophen icon helps reduce medication decision errors in
an experimental setting. J Am Pharm Assoc (2003). 2016;56(5):495-503.e4.
doi:10.1016/j.japh.2016.04.…