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  1. Reducing falls in hospitalized children and adolescents with cancer and blood disorders: a quality improvement journey. | PSNet

    psnet.ahrq.gov/issue/reducing-falls-hospitalized-children-and-adolescents-cancer-and-blood-disorders-quality
    November 16, 2022 - Study Reducing falls in hospitalized children and adolescents with cancer and blood disorders: a quality improvement journey. Citation Text: Morrissey LK, Ho P, Ilowite M, et al. Reducing falls in hospitalized children and adolescents with cancer and blood disorders: a quality improvemen…

  2. Medication errors and processes to reduce them in care homes in the United Kingdom: a scoping review. | PSNet

    psnet.ahrq.gov/issue/medication-errors-and-processes-reduce-them-care-homes-united-kingdom-scoping-review
    October 28, 2020 - Review Medication errors and processes to reduce them in care homes in the United Kingdom: a scoping review. Citation Text: Irons MW, Auta A, Portlock JC, et al. Medication errors and processes to reduce them in care homes in the United Kingdom: a scoping review. Home Health Care Serv Q.…

  3. The TeamSTEPPS for Improving Diagnosis Team Assessment Tool: scale development and psychometric evaluation. | PSNet

    psnet.ahrq.gov/issue/teamstepps-improving-diagnosis-team-assessment-tool-scale-development-and-psychometric
    January 22, 2025 - Study The TeamSTEPPS for Improving Diagnosis Team Assessment Tool: scale development and psychometric evaluation. Citation Text: Ali KJ, Goeschel CA, Eckroade MM, et al. The TeamSTEPPS for Improving Diagnosis Team Assessment Tool: scale development and psychometric evaluation. Jt Comm J …

  4. Interpreting and coding causal relationships for quality and safety using ICD-11. | PSNet

    psnet.ahrq.gov/issue/interpreting-and-coding-causal-relationships-quality-and-safety-using-icd-11
    November 15, 2017 - Commentary Interpreting and coding causal relationships for quality and safety using ICD-11. Citation Text: Januel J-M, Southern DA, Ghali WA. Interpreting and coding causal relationships for quality and safety using ICD-11. BMC Med Inform Decis Mak. 2023;21(Suppl 6):385. doi:10.1186/s12…

  5. Systems engineering analysis of diagnostic referral closed-loop processes. | PSNet

    psnet.ahrq.gov/issue/systems-engineering-analysis-diagnostic-referral-closed-loop-processes
    December 07, 2022 - Study Systems engineering analysis of diagnostic referral closed-loop processes. Citation Text: Nehls N, Yap TS, Salant T, et al. Systems engineering analysis of diagnostic referral closed-loop processes. BMJ Open Qual. 2021;10(4):e001603. doi:10.1136/bmjoq-2021-001603. Copy Citation …

  6. Provider-to-provider communication during transitions of care from outpatient to acute care: a systematic review. | PSNet

    psnet.ahrq.gov/issue/provider-provider-communication-during-transitions-care-outpatient-acute-care-systematic
    October 29, 2017 - Review Provider-to-provider communication during transitions of care from outpatient to acute care: a systematic review. Citation Text: Luu N-P, Pitts S, Petty BG, et al. Provider-to-Provider Communication during Transitions of Care from Outpatient to Acute Care: A Systematic Review. J G…

  7. Contextual factors influencing the implementation of a multifaceted intervention to improve teamwork and quality for hospitalized patients: a multi-site qualitative comparative case study. | PSNet

    psnet.ahrq.gov/issue/contextual-factors-influencing-implementation-multifaceted-intervention-improve-teamwork-and
    November 15, 2023 - Study Contextual factors influencing the implementation of a multifaceted intervention to improve teamwork and quality for hospitalized patients: a multi-site qualitative comparative case study. Citation Text: Terwilliger IA, Johnson JK, Manojlovich M, et al. Contextual Factors Influenci…

  8. Measuring patient safety in real time: an essential method for effectively improving the safety of care. | PSNet

    psnet.ahrq.gov/issue/measuring-patient-safety-real-time-essential-method-effectively-improving-safety-care
    February 15, 2011 - Commentary Measuring patient safety in real time: an essential method for effectively improving the safety of care. Citation Text: Classen DC, Griffin FA, Berwick DM. Measuring Patient Safety in Real Time: An Essential Method for Effectively Improving the Safety of Care. Ann Intern Med. …

  9. A new patient safety smartphone application for prevention of "forgotten" ureteral stents: results from a clinical pilot study in 194 patients. | PSNet

    psnet.ahrq.gov/issue/new-patient-safety-smartphone-application-prevention-forgotten-ureteral-stents-results
    July 01, 2015 - Study A new patient safety smartphone application for prevention of "forgotten" ureteral stents: results from a clinical pilot study in 194 patients. Citation Text: Molina WR, Pessoa R, da Silva RD, et al. A new patient safety smartphone application for prevention of "forgotten" ureteral…

  10. Development of a professionalism committee approach to address unprofessional medical staff behavior at an academic medical center. | PSNet

    psnet.ahrq.gov/issue/development-professionalism-committee-approach-address-unprofessional-medical-staff-behavior
    October 19, 2022 - Commentary Development of a professionalism committee approach to address unprofessional medical staff behavior at an academic medical center. Citation Text: Speck RM, Foster JJ, Mulhern VA, et al. Development of a professionalism committee approach to address unprofessional medical staf…

  11. What methods are used to apply positive deviance within healthcare organisations? A systematic review. | PSNet

    psnet.ahrq.gov/issue/what-methods-are-used-apply-positive-deviance-within-healthcare-organisations-systematic
    July 19, 2019 - Review What methods are used to apply positive deviance within healthcare organisations? A systematic review. Citation Text: Baxter R, Taylor N, Kellar I, et al. What methods are used to apply positive deviance within healthcare organisations? A systematic review. BMJ Qual Saf. 2016;25(3…

  12. Status of patient safety culture in community pharmacy settings: a systematic review. | PSNet

    psnet.ahrq.gov/issue/status-patient-safety-culture-community-pharmacy-settings-systematic-review
    March 04, 2020 - Review Status of patient safety culture in community pharmacy settings: a systematic review. Citation Text: Kwon K-E, Nam DR, Lee M-S, et al. Status of patient safety culture in community pharmacy settings: a systematic review. J Patient Saf. 2023;19(6):353-361. doi:10.1097/pts.000000000…

  13. More than algorithms: an analysis of safety events involving ML-enabled medical devices reported to the FDA. | PSNet

    psnet.ahrq.gov/issue/more-algorithms-analysis-safety-events-involving-ml-enabled-medical-devices-reported-fda
    May 01, 2019 - Study More than algorithms: an analysis of safety events involving ML-enabled medical devices reported to the FDA. Citation Text: Lyell D, Wang Y, Coiera E, et al. More than algorithms: an analysis of safety events involving ML-enabled medical devices reported to the FDA. J Am Med Inform…

  14. Adverse events and patient outcomes among hospitalized children cared for by general pediatricians vs hospitalists. | PSNet

    psnet.ahrq.gov/issue/adverse-events-and-patient-outcomes-among-hospitalized-children-cared-general-pediatricians
    March 23, 2016 - Study Adverse events and patient outcomes among hospitalized children cared for by general pediatricians vs hospitalists. Citation Text: Basco WT. Comparing the Care of Pediatric Hospitalists With That of General Pediatricians. JAMA Netw Open. 2018;1(8). doi:10.1001/jamanetworkopen.2018.…

  15. Prescription opioid dose reductions and potential adverse events: a multi-site observational cohort study in diverse US health systems. | PSNet

    psnet.ahrq.gov/issue/prescription-opioid-dose-reductions-and-potential-adverse-events-multi-site-observational
    March 04, 2020 - Study Prescription opioid dose reductions and potential adverse events: a multi-site observational cohort study in diverse US health systems. Citation Text: Metz VE, Ray GT, Palzes V, et al. Prescription opioid dose reductions and potential adverse events: a multi-site observational coho…

  16. An evaluation of the effects of human factors and ergonomics on health care and patient safety practices: a systematic review. | PSNet

    psnet.ahrq.gov/issue/evaluation-effects-human-factors-and-ergonomics-health-care-and-patient-safety-practices
    June 29, 2022 - Review An evaluation of the effects of human factors and ergonomics on health care and patient safety practices: a systematic review. Citation Text: Mao X, Jia P, Zhang L, et al. An Evaluation of the Effects of Human Factors and Ergonomics on Health Care and Patient Safety Practices: A S…

  17. Prevalence and predictors of delayed clinical diagnosis of Type 2 diabetes: a longitudinal cohort study. | PSNet

    psnet.ahrq.gov/issue/prevalence-and-predictors-delayed-clinical-diagnosis-type-2-diabetes-longitudinal-cohort
    August 04, 2021 - Study Prevalence and predictors of delayed clinical diagnosis of Type 2 diabetes: a longitudinal cohort study. Citation Text: Gopalan A, Mishra P, Alexeeff SE, et al. Prevalence and predictors of delayed clinical diagnosis of Type 2 diabetes: a longitudinal cohort study. Diabet Med. 2018…

  18. Another medical malpractice crisis?: Try something different. | PSNet

    psnet.ahrq.gov/issue/another-medical-malpractice-crisis-try-something-different
    November 11, 2020 - Commentary Another medical malpractice crisis?: Try something different. Citation Text: Sage WM, Boothman RC, Gallagher TH. Another medical malpractice crisis?: Try something different. JAMA. 2020;324(14):1395-1396. doi:10.1001/jama.2020.16557. Copy Citation Format: DOI Goo…

  19. 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…

  20. The effect of an electronic SBAR communication tool on documentation of acute events in the pediatric intensive care unit. | PSNet

    psnet.ahrq.gov/issue/effect-electronic-sbar-communication-tool-documentation-acute-events-pediatric-intensive-care
    August 12, 2015 - Study The effect of an electronic SBAR communication tool on documentation of acute events in the pediatric intensive care unit. Citation Text: Panesar RS, Albert B, Messina C, et al. The Effect of an Electronic SBAR Communication Tool on Documentation of Acute Events in the Pediatric In…
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