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  1. Developing a process to measure actual harm from medication errors in paediatric inpatients: from design to implementation. | PSNet

    psnet.ahrq.gov/issue/developing-process-measure-actual-harm-medication-errors-paediatric-inpatients-design
    January 18, 2023 - Study Developing a process to measure actual harm from medication errors in paediatric inpatients: from design to implementation. Citation Text: Mumford V, Raban MZ, Li L, et al. Developing a process to measure actual harm from medication errors in paediatric inpatients: from design to i…

  2. Repurposing clinical decision support system data to measure dosing errors and clinician-level quality of care. | PSNet

    psnet.ahrq.gov/issue/repurposing-clinical-decision-support-system-data-measure-dosing-errors-and-clinician-level
    October 21, 2020 - Study Repurposing clinical decision support system data to measure dosing errors and clinician-level quality of care. Citation Text: Chin DL, Wilson MH, Trask AS, et al. Repurposing clinical decision support system data to measure dosing errors and clinician-level quality of care. J Med …

  3. The Veterans Affairs root cause analysis system in action. | PSNet

    psnet.ahrq.gov/issue/veterans-affairs-root-cause-analysis-system-action
    June 22, 2022 - Study Classic The Veterans Affairs root cause analysis system in action. Citation Text: Bagian JP, Gosbee JW, Lee CZ, et al. The Veterans Affairs Root Cause Analysis System in Action. Jt Comm J Qual Improv. 2016;28(10):531-545. doi:10.1016/s1070-3241(02)28057-8.…

  4. Inadequate hand-off communication. | PSNet

    psnet.ahrq.gov/issue/inadequate-hand-communication
    April 02, 2015 - Sentinel Event Alerts Inadequate hand-off communication. Citation Text: Inadequate hand-off communication. Sentinel event alert. 2017;58(58):1-6. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download C…

  5. Using radiofrequency technology to prevent retained sponges and improve patient outcomes. | PSNet

    psnet.ahrq.gov/issue/using-radiofrequency-technology-prevent-retained-sponges-and-improve-patient-outcomes
    November 25, 2020 - Study Using radiofrequency technology to prevent retained sponges and improve patient outcomes. Citation Text: Primiano M, Sparks D, Murphy J, et al. Using radiofrequency technology to prevent retained sponges and improve patient outcomes. AORN J. 2020;112(4):345-352. doi:10.1002/aorn.13…

  6. Health literacy-related safety events: a qualitative study of health literacy failures in patient safety events. | PSNet

    psnet.ahrq.gov/issue/health-literacy-related-safety-events-qualitative-study-health-literacy-failures-patient
    August 24, 2022 - Study Health literacy-related safety events: a qualitative study of health literacy failures in patient safety events. Citation Text: Morrison AK, Gibson C, Higgins C, et al. Health literacy-related safety events: a qualitative study of health literacy failures in patient safety events. …

  7. Effects of a multimodal transitional care intervention in patients at high risk of readmission: the TARGET-READ randomized clinical trial. | PSNet

    psnet.ahrq.gov/issue/effects-multimodal-transitional-care-intervention-patients-high-risk-readmission-target-read
    August 18, 2021 - Study Effects of a multimodal transitional care intervention in patients at high risk of readmission: the TARGET-READ randomized clinical trial. Citation Text: Donzé JD, John G, Genné D, et al. Effects of a multimodal transitional care intervention in patients at high risk of readmission…

  8. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. | PSNet

    psnet.ahrq.gov/issue/reengineered-hospital-discharge-program-decrease-rehospitalization-randomized-trial
    August 04, 2021 - Study A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Citation Text: Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150(3):178-87. Copy …

  9. Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients. | PSNet

    psnet.ahrq.gov/issue/root-cause-analysis-reports-help-identify-common-factors-delayed-diagnosis-and-treatment
    October 24, 2018 - Study Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients. Citation Text: Giardina TD, King BJ, Ignaczak AP, et al. Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients. Health A…

  10. Ensuring effective care transition communication: implementation of an electronic medical record-based tool for improved cancer treatment handoffs between clinic and infusion nurses. | PSNet

    psnet.ahrq.gov/issue/ensuring-effective-care-transition-communication-implementation-electronic-medical-record
    July 12, 2023 - Study Ensuring effective care transition communication: implementation of an electronic medical record-based tool for improved cancer treatment handoffs between clinic and infusion nurses. Citation Text: Pandya C, Clarke T, Scarsella E, et al. Ensuring Effective Care Transition Communica…

  11. Patient safety threats in information management using health information technology in ambulatory cancer care: an exploratory, prospective study. | PSNet

    psnet.ahrq.gov/issue/patient-safety-threats-information-management-using-health-information-technology-ambulatory
    April 01, 2020 - Study Patient safety threats in information management using health information technology in ambulatory cancer care: an exploratory, prospective study. Citation Text: Pfeiffer Y, Zimmermann C, Schwappach DLB. Patient safety threats in information management using health information tech…

  12. Predictive power of the "trigger tool" for the detection of adverse events in general surgery: a multicenter observational validation study. | PSNet

    psnet.ahrq.gov/issue/predictive-power-trigger-tool-detection-adverse-events-general-surgery-multicenter
    September 13, 2023 - Study Predictive power of the "trigger tool" for the detection of adverse events in general surgery: a multicenter observational validation study. Citation Text: Pérez Zapata AI, Rodríguez Cuéllar E, de la Fuente Bartolomé M, et al. Predictive power of the "Trigger Tool" for the detectio…

  13. A systems approach to analyzing and preventing hospital adverse events. | PSNet

    psnet.ahrq.gov/issue/systems-approach-analyzing-and-preventing-hospital-adverse-events
    March 30, 2022 - Study Emerging Classic A systems approach to analyzing and preventing hospital adverse events. Citation Text: Leveson N, Samost A, Dekker SWA, et al. A systems approach to analyzing and preventing hospital adverse events. J Patient Saf. 2020;16(2):162-167. doi:1…

  14. Assessing patients' perceptions of safety culture in the hospital setting: development and initial evaluation of the patients' perceptions of safety culture scale. | PSNet

    psnet.ahrq.gov/issue/assessing-patients-perceptions-safety-culture-hospital-setting-development-and-initial
    June 09, 2021 - Study Assessing patients' perceptions of safety culture in the hospital setting: development and initial evaluation of the patients' perceptions of safety culture scale. Citation Text: Monaca C, Bestmann B, Kattein M, et al. Assessing Patients' Perceptions of Safety Culture in the Hospit…

  15. Using Health Information Technology to Improve Health Care Quality in Primary Care Practices and in Transitions Between Care Settings - 2012 | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/using-health-information-technology-improve-health-care-quality-primary-care-va/annual-summary/2012
    January 01, 2012 - Using Health Information Technology to Improve Health Care Quality in Primary Care Practices and in Transitions Between Care Settings - 2012 Project Name Using Health Information Technology to Improve Health Care Quality in Primary Care Practices and in Transitions between Care Settings Prin…

  16. Evaluation of medication errors at the transition of care from an ICU to non-ICU location. | PSNet

    psnet.ahrq.gov/issue/evaluation-medication-errors-transition-care-icu-non-icu-location
    September 23, 2020 - Study Emerging Classic Evaluation of medication errors at the transition of care from an ICU to non-ICU location. Citation Text: Tully AP, Hammond DA, Li C, et al. Evaluation of Medication Errors at the Transition of Care From an ICU to Non-ICU Location. Crit Ca…

  17. Validation of a secondary screener for suicide risk: results from the Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE). | PSNet

    psnet.ahrq.gov/issue/validation-secondary-screener-suicide-risk-results-emergency-department-safety-assessment-and
    May 31, 2023 - Study Validation of a secondary screener for suicide risk: results from the Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE). Citation Text: Boudreaux ED, Larkin C, Camargo CA, et al. Validation of a secondary screener for suicide risk: results from the Emergency…

  18. Why do acute healthcare staff behave unprofessionally towards each other and how can these behaviours be reduced? A realist review. | PSNet

    psnet.ahrq.gov/issue/why-do-acute-healthcare-staff-behave-unprofessionally-towards-each-other-and-how-can-these
    July 24, 2024 - Review Why do acute healthcare staff behave unprofessionally towards each other and how can these behaviours be reduced? A realist review. Citation Text: Aunger JA, Abrams R, Westbrook JI, et al. Why do acute healthcare staff behave unprofessionally towards each other and how can these b…

  19. Health system redesign of cardiac monitoring oversight to optimize alarm management, safety, and staff engagement. | PSNet

    psnet.ahrq.gov/issue/health-system-redesign-cardiac-monitoring-oversight-optimize-alarm-management-safety-and
    February 15, 2023 - Study Health system redesign of cardiac monitoring oversight to optimize alarm management, safety, and staff engagement. Citation Text: Engel JR, Lindsay M, O'Brien S, et al. Health system redesign of cardiac monitoring oversight to optimize alarm management, safety, and staff engagement…

  20. Effect of illness severity and comorbidity on patient safety and adverse events. | PSNet

    psnet.ahrq.gov/issue/effect-illness-severity-and-comorbidity-patient-safety-and-adverse-events
    December 01, 2011 - Study Effect of illness severity and comorbidity on patient safety and adverse events. Citation Text: Naessens JM, Campbell CR, Shah ND, et al. Effect of illness severity and comorbidity on patient safety and adverse events. Am J Med Qual. 2012;27(1):48-57. doi:10.1177/1062860611413456…
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