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3901. Overstating inpatient deaths due to medical error erodes trust in healthcare and the patient safety movement. | PSNet
      psnet.ahrq.gov/issue/overstating-inpatient-deaths-due-medical-error-erodes-trust-healthcare-and-patient-safety
      April 01, 2020 - Commentary Overstating inpatient deaths due to medical error erodes trust in healthcare and the patient safety movement. Citation Text: Gunderson CG, Rodwin BA. Overstating inpatient deaths due to medical error erodes trust in healthcare and the patient safety movement. J Hosp Med. 2022;…

3902. 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…

3903. Safety participation at the direct care level: results of a patient questionnaire. | PSNet
      psnet.ahrq.gov/issue/safety-participation-direct-care-level-results-patient-questionnaire
      August 26, 2020 - Study Safety participation at the direct care level: results of a patient questionnaire. Citation Text: Duhn L, Gumapac N, Medves J. Safety participation at the direct care level: results of a patient questionnaire. Patient Exp J. 2021;8(1):59-68. doi:10.35680/2372-0247.1506. Copy Cita…

3904. Educating seniors to be patient safety self-advocates in primary care. | PSNet
      psnet.ahrq.gov/issue/educating-seniors-be-patient-safety-self-advocates-primary-care
      December 15, 2011 - Study Educating seniors to be patient safety self-advocates in primary care. Citation Text: Elder NC, Regan SL, Pallerla H, et al. Educating Seniors to Be Patient Safety Self-Advocates in Primary Care. J Patient Saf. 2008;4(2). doi:10.1097/pts.0b013e318175d806. Copy Citation Form…

3905. Hospitalisation for medication misadventures among older adults with and without dementia: a 5-year retrospective study. | PSNet
      psnet.ahrq.gov/issue/hospitalisation-medication-misadventures-among-older-adults-and-without-dementia-5-year
      August 18, 2021 - Study Hospitalisation for medication misadventures among older adults with and without dementia: a 5-year retrospective study. Citation Text: Mullan J, Burns P, Mohanan L, et al. Hospitalisation for medication misadventures among older adults with and without dementia: A 5-year retrospec…

3906. Why an open disclosure procedure is and is not followed after an avoidable adverse event. | PSNet
      psnet.ahrq.gov/issue/why-open-disclosure-procedure-and-not-followed-after-avoidable-adverse-event
      August 11, 2021 - Study Why an open disclosure procedure is and is not followed after an avoidable adverse event. Citation Text: Carrillo I, Mira JJ, Guilabert M, et al. Why an open disclosure procedure is and is not followed after an avoidable adverse event. J Patient Saf. 2021;17(6):e529-e533. doi:10.10…

3907. Improving medication error reporting in hospice care. | PSNet
      psnet.ahrq.gov/issue/improving-medication-error-reporting-hospice-care
      June 22, 2022 - Study Improving medication error reporting in hospice care. Citation Text: Boyer R, McPherson ML, Deshpande G, et al. Improving medication error reporting in hospice care. Am J Hosp Palliat Care. 2009;26(5):361-7. doi:10.1177/1049909109335145. Copy Citation Format: DOI Go…

3908. Quality of care transition, patient safety incidents, and patients' health status: a structural equation model on the complexity of the discharge process. | PSNet
      psnet.ahrq.gov/issue/quality-care-transition-patient-safety-incidents-and-patients-health-status-structural
      October 02, 2024 - Study Quality of care transition, patient safety incidents, and patients' health status: a structural equation model on the complexity of the discharge process. Citation Text: Marsall M, Hornung T, Bäuerle A, et al. Quality of care transition, patient safety incidents, and patients’ heal…

3909. A systems approach to evaluating ionizing radiation: six focus areas to improve quality, efficiency, and patient safety. | PSNet
      psnet.ahrq.gov/issue/systems-approach-evaluating-ionizing-radiation-six-focus-areas-improve-quality-efficiency-and
      March 14, 2016 - Commentary A systems approach to evaluating ionizing radiation: six focus areas to improve quality, efficiency, and patient safety. Citation Text: Perlin JB, Mower L, Bushe C. A systems approach to evaluating ionizing radiation: six focus areas to improve quality, efficiency, and patient…

3910. Unplanned return to theater: a quality of care and risk management index? | PSNet
      psnet.ahrq.gov/issue/unplanned-return-theater-quality-care-and-risk-management-index
      August 20, 2018 - Study Unplanned return to theater: a quality of care and risk management index? Citation Text: Pujol N, Merrer J, Lemaire B, et al. Unplanned return to theater: A quality of care and risk management index? Orthop Traumatol Surg Res. 2015;101(4):399-403. doi:10.1016/j.otsr.2015.03.013. …

3911. Is it rational to pursue zero suicides among patients in health care? | PSNet
      psnet.ahrq.gov/issue/it-rational-pursue-zero-suicides-among-patients-health-care
      October 18, 2023 - Commentary Is it rational to pursue zero suicides among patients in health care? Citation Text: Mokkenstorm JK, Kerkhof AJFM, Smit JH, et al. Is It Rational to Pursue Zero Suicides Among Patients in Health Care? Suicide Life Threat Behav. 2018;48(6):745-754. doi:10.1111/sltb.12396. Cop…

3912. Deaths among opioid users: impact of potential inappropriate prescribing practices. | PSNet
      psnet.ahrq.gov/issue/deaths-among-opioid-users-impact-potential-inappropriate-prescribing-practices
      October 19, 2011 - Study Deaths among opioid users: impact of potential inappropriate prescribing practices. Citation Text: Jayawardhana J, Abraham AJ, Perri M. Deaths among opioid users: impact of potential inappropriate prescribing practices. Am J Manag Care. 2019;25(4):e98-e103. Copy Citation Form…

3913. The quality, safety and content of telephone and face-to-face consultations: a comparative study. | PSNet
      psnet.ahrq.gov/issue/quality-safety-and-content-telephone-and-face-face-consultations-comparative-study
      August 04, 2021 - Study The quality, safety and content of telephone and face-to-face consultations: a comparative study. Citation Text: McKinstry B, Hammersley V, Burton C, et al. The quality, safety and content of telephone and face-to-face consultations: a comparative study. Qual Saf Health Care. 201…

3914. On O.R. Off? | PSNet
      psnet.ahrq.gov/web-mm/or
      August 22, 2013 - On O.R. Off? Citation Text: Leonard M. On O.R. Off?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Do…

3915. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49653/psn-pdf
      May 01, 2012 - The Forgotten Line May 1, 2012 Render ML. The Forgotten Line. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/forgotten-line The Case An 81-year-old man with a history of coronary artery disease, hypertension, cerebrovascular accidents, and chronic kidney disease was transferred to a referral hospital for p…

3916. Count and Be Counted: Preparing Future Pharmacists to Promote a Culture of Safety | PSNet
      psnet.ahrq.gov/perspective/count-and-be-counted-preparing-future-pharmacists-promote-culture-safety
      April 01, 2006 - Count and Be Counted: Preparing Future Pharmacists to Promote a Culture of Safety Brian K. Alldredge, PharmD; Mary Anne Koda-Kimble, PharmD | April 1, 2006  Also Read a Conversation View more articles from the same authors. Citation Text: Alldredge BK, Koda-Kimb…

3917. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60858/psn-pdf
      August 26, 2020 - When the Meds Don’t Reach the Bed August 26, 2020 Molla M, Le K, Mendoza P. When the Meds Don’t Reach the Bed. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/when-meds-dont-reach-bed The Case A 69-year-old man with cognitive impairment and marginal housing was admitted for acute exacerbation of chronic obs…

3918. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50698/psn-pdf
      November 27, 2019 - Missed Opportunities for Suicide Risk Assessment November 27, 2019 Xiong G, Kahn D. Missed Opportunities for Suicide Risk Assessment. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment Disclosure of Relevant Financial Relationships: As a provider accredited by the Acc…

3919. The Next Step: Use of a Pre-Operative Checklist to Prevent Missteps | PSNet
      psnet.ahrq.gov/web-mm/next-step-use-pre-operative-checklist-prevent-missteps
      April 24, 2018 - The Next Step: Use of a Pre-Operative Checklist to Prevent Missteps Citation Text: Sauder C, Kleber KT. The Next Step: Use of a Pre-Operative Checklist to Prevent Missteps. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy …

3920. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.84_slideshow.ppt
      December 01, 2004 - Spotlight Case [MONTH] 2003 Spotlight Case December 2004 Discharge Fumbles Source and Credits This presentation is based on the Dec. 2004 AHRQ WebM&M Spotlight Case in Hospital Medicine See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Alan Forster, M…