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  1. Wrong-patient orders in obstetrics. | PSNet

    psnet.ahrq.gov/issue/wrong-patient-orders-obstetrics
    September 23, 2020 - Study Wrong-patient orders in obstetrics. Citation Text: Kern-Goldberger AR, Kneifati-Hayek J, Fernandes Y, et al. Wrong-patient orders in obstetrics. Obstet Gynecol. 2021;138(2):229-235. doi:10.1097/aog.0000000000004474. Copy Citation Format: DOI Google Scholar BibTeX EndN…

  2. Handoff strategies in settings with high consequences for failure: lessons for health care operations. | PSNet

    psnet.ahrq.gov/issue/handoff-strategies-settings-high-consequences-failure-lessons-health-care-operations
    March 14, 2018 - Study Classic Handoff strategies in settings with high consequences for failure: lessons for health care operations. Citation Text: Patterson ES. Handoff strategies in settings with high consequences for failure: lessons for health care operations. Int J Qual …

  3. Interhospital transfer patients discharged by academic hospitalists and general internists: characteristics and outcomes. | PSNet

    psnet.ahrq.gov/issue/interhospital-transfer-patients-discharged-academic-hospitalists-and-general-internists
    August 01, 2018 - Study Interhospital transfer patients discharged by academic hospitalists and general internists: characteristics and outcomes. Citation Text: Sokol-Hessner L, White AA, Davis KF, et al. Interhospital transfer patients discharged by academic hospitalists and general internists: Character…

  4. Automated detection of look-alike/sound-alike medication errors. | PSNet

    psnet.ahrq.gov/issue/automated-detection-look-alikesound-alike-medication-errors
    August 28, 2019 - Study Automated detection of look-alike/sound-alike medication errors. Citation Text: Rash-Foanio C, Galanter W, Bryson M, et al. Automated detection of look-alike/sound-alike medication errors. Am J Health Syst Pharm. 2017;74(7):521-527. doi:10.2146/ajhp150690. Copy Citation Forma…

  5. It's like sending a message in a bottle: a qualitative study of the consequences of one-way communication technologies in hospitals. | PSNet

    psnet.ahrq.gov/issue/its-sending-message-bottle-qualitative-study-consequences-one-way-communication-technologies
    December 02, 2020 - Study It's like sending a message in a bottle: a qualitative study of the consequences of one-way communication technologies in hospitals. Citation Text: Lafferty M, Harrod M, Krein SL, et al. It’s like sending a message in a bottle: a qualitative study of the consequences of one-way com…

  6. Inappropriate medication in a national sample of US elderly patients receiving home health care. | PSNet

    psnet.ahrq.gov/issue/inappropriate-medication-national-sample-us-elderly-patients-receiving-home-health-care
    September 09, 2020 - Study Inappropriate medication in a national sample of US elderly patients receiving home health care. Citation Text: Bao Y, Shao H, Bishop TF, et al. Inappropriate medication in a national sample of US elderly patients receiving home health care. J Gen Intern Med. 2012;27(3):304-310. do…

  7. Retrospective cohort study of wrong-patient imaging order errors: how many reach the patient? | PSNet

    psnet.ahrq.gov/issue/retrospective-cohort-study-wrong-patient-imaging-order-errors-how-many-reach-patient
    February 22, 2023 - Study Retrospective cohort study of wrong-patient imaging order errors: how many reach the patient? Citation Text: Kneifati-Hayek JZ, Geist E, Applebaum JR, et al. Retrospective cohort study of wrong-patient imaging order errors: how many reach the patient? BMJ Qual Saf. 2024;33(2):132-1…

  8. Evaluating the impact of radio frequency identification retained surgical instruments tracking on patient safety: literature review. | PSNet

    psnet.ahrq.gov/issue/evaluating-impact-radio-frequency-identification-retained-surgical-instruments-tracking
    August 03, 2022 - Review Evaluating the impact of radio frequency identification retained surgical instruments tracking on patient safety: literature review. Citation Text: Schnock KO, Biggs B, Fladger A, et al. Evaluating the impact of radio frequency identification retained surgical instruments tracking…

  9. Assessing the potential adoption and usefulness of concurrent, action-oriented, electronic adverse drug event triggers designed for the outpatient setting. | PSNet

    psnet.ahrq.gov/issue/assessing-potential-adoption-and-usefulness-concurrent-action-oriented-electronic-adverse
    October 01, 2014 - Study Assessing the potential adoption and usefulness of concurrent, action-oriented, electronic adverse drug event triggers designed for the outpatient setting. Citation Text: Mull HJ, Rosen AK, Shimada SL, et al. Assessing the potential adoption and usefulness of concurrent, action-ori…

  10. Personal health records: a randomized trial of effects on elder medication safety. | PSNet

    psnet.ahrq.gov/issue/personal-health-records-randomized-trial-effects-elder-medication-safety
    November 16, 2022 - Study Personal health records: a randomized trial of effects on elder medication safety. Citation Text: Chrischilles EA, Hourcade JP, Doucette W, et al. Personal health records: a randomized trial of effects on elder medication safety. J Am Med Inform Assoc. 2014;21(4):679-86. doi:10.113…

  11. An electronic checklist improves transfer and retention of critical information at intraoperative handoff of care. | PSNet

    psnet.ahrq.gov/issue/electronic-checklist-improves-transfer-and-retention-critical-information-intraoperative
    July 21, 2021 - Study An electronic checklist improves transfer and retention of critical information at intraoperative handoff of care. Citation Text: Agarwala A, Firth PG, Albrecht MA, et al. An electronic checklist improves transfer and retention of critical information at intraoperative handoff of c…

  12. Tracking progress in improving diagnosis: a framework for defining undesirable diagnostic events. | PSNet

    psnet.ahrq.gov/issue/tracking-progress-improving-diagnosis-framework-defining-undesirable-diagnostic-events
    September 01, 2021 - Commentary Classic Tracking progress in improving diagnosis: a framework for defining undesirable diagnostic events. Citation Text: Olson A, Graber ML, Singh H. Tracking Progress in Improving Diagnosis: A Framework for Defining Undesirable Diagnostic Events. J G…

  13. Creating champions for health care quality and safety. | PSNet

    psnet.ahrq.gov/issue/creating-champions-health-care-quality-and-safety
    August 04, 2021 - Study Creating champions for health care quality and safety. Citation Text: Holland R, Meyers D, Hildebrand C, et al. Creating champions for health care quality and safety. Am J Med Qual. 2010;25(2):102-108. doi:10.1177/1062860609352108. Copy Citation Format: DOI Google S…

  14. Medication report reduces number of medication errors when elderly patients are discharged from hospital. | PSNet

    psnet.ahrq.gov/issue/medication-report-reduces-number-medication-errors-when-elderly-patients-are-discharged
    February 04, 2009 - Study Medication report reduces number of medication errors when elderly patients are discharged from hospital. Citation Text: Midlöv P, Holmdahl L, Eriksson T, et al. Medication report reduces number of medication errors when elderly patients are discharged from hospital. Pharm World…

  15. Predicting self-intercepted medication ordering errors using machine learning. | PSNet

    psnet.ahrq.gov/issue/predicting-self-intercepted-medication-ordering-errors-using-machine-learning
    May 13, 2020 - Study Predicting self-intercepted medication ordering errors using machine learning. Citation Text: King CR, Abraham J, Fritz BA, et al. Predicting self-intercepted medication ordering errors using machine learning. PLoS One. 2021;16(7):e0254358. doi:10.1371/journal.pone.0254358. Copy …

  16. Communicating certainty in pathology reports: interpretation differences among staff pathologists, clinicians, and residents in a multicenter study. | PSNet

    psnet.ahrq.gov/issue/communicating-certainty-pathology-reports-interpretation-differences-among-staff-pathologists
    January 23, 2017 - Study Communicating certainty in pathology reports: interpretation differences among staff pathologists, clinicians, and residents in a multicenter study. Citation Text: Gibson BA, McKinnon E, Bentley RC, et al. Communicating certainty in pathology reports: interpretation differences amo…

  17. The effectiveness of checklists and error reporting systems in enhancing patient safety and reducing medical errors in hospital settings: a narrative review. | PSNet

    psnet.ahrq.gov/issue/effectiveness-checklists-and-error-reporting-systems-enhancing-patient-safety-and-reducing
    August 03, 2017 - Review The effectiveness of checklists and error reporting systems in enhancing patient safety and reducing medical errors in hospital settings: a narrative review. Citation Text: Chance EA, Florence D, Sardi Abdoul I. The effectiveness of checklists and error reporting systems in enhanc…

  18. Real time patient safety audits: improving safety every day. | PSNet

    psnet.ahrq.gov/issue/real-time-patient-safety-audits-improving-safety-every-day
    April 14, 2021 - Study Real time patient safety audits: improving safety every day. Citation Text: Ursprung R. Real time patient safety audits: improving safety every day. Qual Saf Health Care. 2005;14(4):284-289. doi:10.1136/qshc.2004.012542. Copy Citation Format: DOI Google Scholar BibT…

  19. Patient-led training on patient safety: a pilot study to test the feasibility and acceptability of an educational intervention. | PSNet

    psnet.ahrq.gov/issue/patient-led-training-patient-safety-pilot-study-test-feasibility-and-acceptability
    April 24, 2017 - Study Patient-led training on patient safety: a pilot study to test the feasibility and acceptability of an educational intervention. Citation Text: Jha V, Winterbottom A, Symons J, et al. Patient-led training on patient safety: a pilot study to test the feasibility and acceptability …

  20. Enteral nutrition: an underappreciated source of patient safety events. | PSNet

    psnet.ahrq.gov/issue/enteral-nutrition-underappreciated-source-patient-safety-events
    February 01, 2023 - Study Enteral nutrition: an underappreciated source of patient safety events. Citation Text: Citty SW, Chew M, Hiller LD, et al. Enteral nutrition: an underappreciated source of patient safety events. Nutr Clin Prac. 2024;39(4):784-799. doi:10.1002/ncp.11153. Copy Citation Format: …
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