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Communication-and-resolution programs: the challenges and lessons learned from six early adopters. | PSNet

psnet.ahrq.gov/issue/communication-and-resolution-programs-challenges-and-lessons-learned-six-early-adopters

September 29, 2017 - Study Classic Communication-and-resolution programs: the challenges and lessons learned from six early adopters. Citation Text: Mello MM, Boothman RC, McDonald TB, et al. Communication-and-resolution programs: the challenges and lessons learned from six early ad…

Learning from patients' experiences related to diagnostic errors is essential for progress in patient safety. | PSNet

psnet.ahrq.gov/issue/learning-patients-experiences-related-diagnostic-errors-essential-progress-patient-safety

May 20, 2020 - Study Emerging Classic Learning from patients' experiences related to diagnostic errors is essential for progress in patient safety. Citation Text: Giardina TD, Haskell H, Menon S, et al. Learning From Patients' Experiences Related To Diagnostic Errors Is Essent…

Disclosing adverse events in clinical practice: the delicate act of being open. | PSNet

psnet.ahrq.gov/issue/disclosing-adverse-events-clinical-practice-delicate-act-being-open

April 14, 2021 - Review Disclosing adverse events in clinical practice: the delicate act of being open. Citation Text: Myren BJ, de Hullu JA, Bastiaans S, et al. Disclosing adverse events in clinical practice: the delicate act of being open. Health Commun. 2022;37(2):191-201. doi:10.1080/10410236.2020.18…

Making soft intelligence hard: a multi-site qualitative study of challenges relating to voice about safety concerns. | PSNet

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June 16, 2021 - Study Emerging Classic Making soft intelligence hard: a multi-site qualitative study of challenges relating to voice about safety concerns. Citation Text: Martin G, Aveling E-L, Campbell A, et al. Making soft intelligence hard: a multi-site qualitative study of …

Incorrect surgical procedures within and outside of the operating room. | PSNet

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November 21, 2011 - Study Incorrect surgical procedures within and outside of the operating room. Citation Text: Neily J, Mills PD, Eldridge N, et al. Incorrect surgical procedures within and outside of the operating room. Arch Surg. 2009;144(11):1028-34. doi:10.1001/archsurg.2009.126. Copy Citation F…

Reducing failure to rescue rates in a paediatric in-patient setting: a 9-year quality improvement study. | PSNet

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January 18, 2023 - Study Reducing failure to rescue rates in a paediatric in-patient setting: a 9-year quality improvement study. Citation Text: McHale S, Marufu TC, Manning JC, et al. Reducing failure to rescue rates in a paediatric in‐patient setting: a 9‐year quality improvement study. Nurs Crit Care. 2…

Outcomes in two Massachusetts hospital systems give reason for optimism about communication-and-resolution programs. | PSNet

psnet.ahrq.gov/issue/outcomes-two-massachusetts-hospital-systems-give-reason-optimism-about-communication-and

December 19, 2018 - Study Outcomes in two Massachusetts hospital systems give reason for optimism about communication-and-resolution programs. Citation Text: Mello MM, Kachalia A, Roche S, et al. Outcomes In Two Massachusetts Hospital Systems Give Reason For Optimism About Communication-And-Resolution Progr…

Using Health Care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective risk analysis system. | PSNet

psnet.ahrq.gov/issue/using-health-care-failure-mode-and-effect-analysis-va-national-center-patient-safetys

January 17, 2012 - Study Classic Using Health Care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective risk analysis system. Citation Text: DeRosier JM, Stalhandske E, Bagian JP, et al. Using health care Failure Mode and Effect Analysis: the V…

Longitudinal evaluation of a pediatric rapid response system with realist evaluation framework. | PSNet

psnet.ahrq.gov/issue/longitudinal-evaluation-pediatric-rapid-response-system-realist-evaluation-framework

July 20, 2022 - Study Longitudinal evaluation of a pediatric rapid response system with realist evaluation framework. Citation Text: Acorda DE, Bracken J, Abela K, et al. Longitudinal evaluation of a pediatric rapid response system with realist evaluation framework. Jt Comm J Qual Patient Saf. 2022;48(4…

Incidence of adverse drug events and potential adverse drug events: implications for prevention. | PSNet

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February 10, 2011 - Study Classic Incidence of adverse drug events and potential adverse drug events: implications for prevention. Citation Text: Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. …

Characterising the nature of primary care patient safety incident reports in the England and Wales National Reporting and Learning System: a mixed-methods agenda-setting study for general practice. | PSNet

psnet.ahrq.gov/issue/characterising-nature-primary-care-patient-safety-incident-reports-england-and-wales-national

December 16, 2015 - Book/Report Characterising the nature of primary care patient safety incident reports in the England and Wales National Reporting and Learning System: a mixed-methods agenda-setting study for general practice. Citation Text: Carson-Stevens A, Hibbert P, Williams H, et al. Characterising …

US emergency department visits for outpatient adverse drug events, 2013–2014. | PSNet

psnet.ahrq.gov/issue/us-emergency-department-visits-outpatient-adverse-drug-events-2013-2014

February 23, 2018 - Study Classic US emergency department visits for outpatient adverse drug events, 2013–2014. Citation Text: Shehab N, Lovegrove MC, Geller AI, et al. US Emergency Department Visits for Outpatient Adverse Drug Events, 2013-2014. JAMA. 2016;316(20):2115-2125. doi:1…

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…

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…

Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. | PSNet

psnet.ahrq.gov/issue/deficits-communication-and-information-transfer-between-hospital-based-and-primary-care

January 25, 2017 - Review Classic Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. Citation Text: Kripalani S, LeFevre F, Phillips CO, et al. Deficits in communication a…

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…

High-priority drug-drug interaction clinical decision support overrides in a newly implemented commercial computerized provider order-entry system: override appropriateness and adverse drug events. | PSNet

psnet.ahrq.gov/issue/high-priority-drug-drug-interaction-clinical-decision-support-overrides-newly-implemented

March 09, 2022 - Study High-priority drug-drug interaction clinical decision support overrides in a newly implemented commercial computerized provider order-entry system: override appropriateness and adverse drug events. Citation Text: Edrees H, Amato MG, Wong A, et al. High-priority drug-drug interactio…

Electronic health record-based surveillance of diagnostic errors in primary care. | PSNet

psnet.ahrq.gov/issue/electronic-health-record-based-surveillance-diagnostic-errors-primary-care

April 09, 2013 - Study Electronic health record-based surveillance of diagnostic errors in primary care. Citation Text: Singh H, Giardina TD, Forjuoh SN, et al. Electronic health record-based surveillance of diagnostic errors in primary care. BMJ Qual Saf. 2012;21(2):93-100. doi:10.1136/bmjqs-2011-0003…

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…

The burden of opioid-related mortality in the United States. | PSNet

psnet.ahrq.gov/issue/burden-opioid-related-mortality-united-states

June 02, 2021 - Study Classic The burden of opioid-related mortality in the United States. Citation Text: Gomes T, Tadrous M, Mamdani MM, et al. The burden of opioid-related mortality in the United States. JAMA Netw Open. 2018;1(2):e180217. doi:10.1001/jamanetworkopen.2018.0217…

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