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psnet.ahrq.gov/issue/updating-eindhoven-clarifying-features-patient-safety-near-miss
March 13, 2024 - Study
Updating Eindhoven: clarifying the features of a patient safety near miss.
Citation Text:
Woodier N, Burnett C, Sampson P, et al. Updating Eindhoven: clarifying the features of a patient safety near miss. J Patient Saf Risk Manag. 2024;29(4):195-201. doi:10.1177/25160435241247096. …
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psnet.ahrq.gov/issue/analysis-medical-malpractice-claims-against-medical-oncologists-national-database
July 02, 2019 - Study
An analysis of medical malpractice claims against medical oncologists from a national database: implications for safer practice.
Citation Text:
Doolin JW, Schaffer AC, Tishler RB, et al. An analysis of medical malpractice claims against medical oncologists from a national database:…
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psnet.ahrq.gov/issue/learning-overcome-hierarchical-pressures-achieve-safer-patient-care-interprofessional
November 18, 2016 - Commentary
Learning to overcome hierarchical pressures to achieve safer patient care: an interprofessional simulation for nursing, medical, and physician assistant students.
Citation Text:
Reeves SA, Denault D, Huntington JT, et al. Learning to Overcome Hierarchical Pressures to Achieve …
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psnet.ahrq.gov/issue/economic-value-pharmacist-led-medication-reconciliation-reducing-medication-errors-after
March 04, 2009 - Study
Economic value of pharmacist-led medication reconciliation for reducing medication errors after hospital discharge.
Citation Text:
Najafzadeh M, Schnipper JL, Shrank WH, et al. Economic value of pharmacist-led medication reconciliation for reducing medication errors after hospital …
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psnet.ahrq.gov/issue/electronic-tools-support-medication-reconciliation-systematic-review
August 18, 2021 - Review
Electronic tools to support medication reconciliation—a systematic review.
Citation Text:
Marien S, Krug B, Spinewine A. Electronic tools to support medication reconciliation: a systematic review. J Am Med Inform Assoc. 2017;24(1):227-240. doi:10.1093/jamia/ocw068.
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psnet.ahrq.gov/issue/thresholds-rules-and-defensive-strategies-how-physicians-learn-their-prior-diagnosis-related
April 15, 2020 - Study
Thresholds, rules and defensive strategies: how physicians learn from their prior diagnosis-related experiences.
Citation Text:
Donner-Banzhoff N, Müller B, Beyer M, et al. Thresholds, rules and defensive strategies: how physicians learn from their prior diagnosis-related experienc…
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psnet.ahrq.gov/issue/detection-adverse-drug-events-using-electronic-trigger-tool
October 02, 2013 - Study
Detection of adverse drug events using an electronic trigger tool.
Citation Text:
Lim D, Melucci J, Rizer MK, et al. Detection of adverse drug events using an electronic trigger tool. Am J Health Syst Pharm. 2016;73(17 Suppl 4):S112-20. doi:10.2146/ajhp150481.
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psnet.ahrq.gov/issue/association-measured-quality-and-future-financial-performance-among-hospitals-performing
May 04, 2022 - Study
Association of measured quality and future financial performance among hospitals performing cardiac surgery.
Citation Text:
Enumah SJ, Sundt TM, Chang DC. Association of measured quality and future financial performance among hospitals performing cardiac surgery. J Healthc Manag. 2…
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psnet.ahrq.gov/issue/are-opioid-infusions-used-inappropriately-end-life-results-qualitysafety-project
November 16, 2022 - Study
Are opioid infusions used inappropriately at end of life? Results from a quality/safety project.
Citation Text:
Yeh JC, Chae SG, Kennedy PJ, et al. Are opioid infusions used inappropriately at end of life? Results from a quality/safety project. J Pain Symptom Manage. 2022;64(3):e13…
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psnet.ahrq.gov/issue/residents-feel-unprepared-and-unsupervised-leaders-cardiac-arrest-teams-teaching-hospitals
February 07, 2024 - Study
Residents feel unprepared and unsupervised as leaders of cardiac arrest teams in teaching hospitals: a survey of internal medicine residents.
Citation Text:
Hayes CW, Rhee A, Detsky ME, et al. Residents feel unprepared and unsupervised as leaders of cardiac arrest teams in teachi…
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psnet.ahrq.gov/issue/clinical-alerts-decrease-high-risk-medication-use-older-adults
September 02, 2015 - Commentary
Clinical alerts to decrease high-risk medication use in older adults.
Citation Text:
Lord-Adem W, Brandt NJ. Clinical Alerts to Decrease High-Risk Medication Use in Older Adults. J Gerontol Nurs. 2017;43(7):7-12. doi:10.3928/00989134-20170614-04.
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psnet.ahrq.gov/issue/association-between-physician-depressive-symptoms-and-medical-errors-systematic-review-and
January 12, 2022 - Review
Emerging Classic
Association between physician depressive symptoms and medical errors: A systematic review and meta-analysis
Citation Text:
Pereira-Lima K, Mata DA, Loureiro SR, et al. Association Between Physician Depressive Symptoms and Medical Errors: …
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psnet.ahrq.gov/issue/systematic-narrative-review-coroners-prevention-future-deaths-reports-pfds-tool-patient
October 19, 2022 - Review
A systematic narrative review of coroners’ Prevention of Future Deaths reports (PFDs): a tool for patient safety in hospitals.
Citation Text:
Bremner BT, Heneghan CJ, Aronson JK, et al. A systematic narrative review of coroners’ Prevention of Future Deaths reports (PFDs): a tool f…
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psnet.ahrq.gov/issue/association-past-and-future-paid-medical-malpractice-claims
February 01, 2023 - Study
Association of past and future paid medical malpractice claims.
Citation Text:
Hyman DA, Lerner J, Magid DJ, et al. Association of past and future paid medical malpractice claims. JAMA Health Forum. 2023;4(2):e225436. doi:10.1001/jamahealthforum.2022.5436.
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psnet.ahrq.gov/issue/educator-toolkits-second-victim-syndrome-mindfulness-and-meditation-and-positive-psychology
June 28, 2023 - Commentary
Educator toolkits on second victim syndrome, mindfulness and meditation, and positive psychology: the 2017 Resident Wellness Consensus Summit.
Citation Text:
Chung AS, Smart J, Zdradzinski M, et al. Educator Toolkits on Second Victim Syndrome, Mindfulness and Meditation, and P…
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psnet.ahrq.gov/issue/standardizing-opioid-prescriptions-patients-after-ambulatory-oncologic-surgery-reduces
October 19, 2022 - Study
Standardizing opioid prescriptions to patients after ambulatory oncologic surgery reduces overprescription.
Citation Text:
Fearon NJ, Benfante N, Assel M, et al. Standardizing Opioid Prescriptions to Patients After Ambulatory Oncologic Surgery Reduces Overprescription. Jt Comm J Qu…
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psnet.ahrq.gov/issue/increasing-medication-error-reporting-rates-while-reducing-harm-through-simultaneous-cultural
April 24, 2018 - Study
Increasing medication error reporting rates while reducing harm through simultaneous cultural and system-level interventions in an intensive care unit.
Citation Text:
Abstoss KM, Shaw BE, Owens TA, et al. Increasing medication error reporting rates while reducing harm through sim…
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psnet.ahrq.gov/issue/challenges-nurses-efforts-retrieving-documenting-and-communicating-patient-care-information
November 18, 2016 - Study
Challenges to nurses' efforts of retrieving, documenting, and communicating patient care information.
Citation Text:
Keenan G, Yakel E, Lopez KD, et al. Challenges to nurses' efforts of retrieving, documenting, and communicating patient care information. J Am Med Inform Assoc. 2013…
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psnet.ahrq.gov/issue/electronic-error-reporting-systems-case-study-impact-nurse-reporting-medical-errors
June 07, 2023 - Study
Electronic error-reporting systems: a case study into the impact on nurse reporting of medical errors.
Citation Text:
Lederman R, Dreyfus S, Matchan J, et al. Electronic error-reporting systems: a case study into the impact on nurse reporting of medical errors. Nurs Outlook. 2013…
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www.ahrq.gov/news/newsroom/case-studies/cquips0703.html
October 01, 2014 - Military Hospitals Employ AHRQ Hospital Survey on Patient Safety Culture
Search All Impact Case Studies
May 2007
The Department of Defense Patient Safety Program chose AHRQ's Hospital Survey on Patient Safety Culture as an anonymous, Web-based initiative to assess staff attitudes and beliefs about patient…