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4201. The impact of post-fall huddles on repeat fall rates and perceptions of safety culture: a quasi-experimental evaluation of a patient safety demonstration project | PSNet
      psnet.ahrq.gov/issue/impact-post-fall-huddles-repeat-fall-rates-and-perceptions-safety-culture-quasi-experimental
      December 30, 2014 - Journal Article The impact of post-fall huddles on repeat fall rates and perceptions of safety culture: a quasi-experimental evaluation of a patient safety demonstration project Citation Text: Jones KJ, Crowe J, Allen JA, et al. The impact of post-fall huddles on repeat fall rates and pe…

4202. Improved pain resolution in hospitalized patients through targeting of pain mismanagement as medical error. | PSNet
      psnet.ahrq.gov/issue/improved-pain-resolution-hospitalized-patients-through-targeting-pain-mismanagement-medical
      March 24, 2019 - Study Improved pain resolution in hospitalized patients through targeting of pain mismanagement as medical error. Citation Text: Okon TR, Lutz PS, Liang H. Improved pain resolution in hospitalized patients through targeting of pain mismanagement as medical error. J Pain Symptom Manage.…

4203. Medical misadventures as errors and mistakes and motor vehicular accidents in the disproportionate burden of childhood mortality among Blacks/African Americans in the United States: CDC Dataset, 1968-2015. | PSNet
      psnet.ahrq.gov/issue/medical-misadventures-errors-and-mistakes-and-motor-vehicular-accidents-disproportionate
      March 05, 2025 - Study Medical misadventures as errors and mistakes and motor vehicular accidents in the disproportionate burden of childhood mortality among Blacks/African Americans in the United States: CDC Dataset, 1968-2015. Citation Text: Holmes L, Enwere M, Mason R, et al. Medical misadventures as …

4204. Effectiveness of interventions to improve adverse drug reaction reporting by healthcare professionals over the last decade: A systematic review | PSNet
      psnet.ahrq.gov/issue/effectiveness-interventions-improve-adverse-drug-reaction-reporting-healthcare-professionals
      August 28, 2024 - Review Effectiveness of interventions to improve adverse drug reaction reporting by healthcare professionals over the last decade: A systematic review Citation Text: Li R, Zaidi STR, Chen T, et al. Effectiveness of interventions to improve adverse drug reaction reporting by healthcare pr…

4205. Liability reform should make patients safer: "Avoidable classes of events" are a key improvement. | PSNet
      psnet.ahrq.gov/issue/liability-reform-should-make-patients-safer-avoidable-classes-events-are-key-improvement
      July 26, 2023 - Commentary Liability reform should make patients safer: "Avoidable classes of events" are a key improvement. Citation Text: Bovbjerg RR, Tancredi LR. Liability reform should make patients safer: "avoidable classes of events" are a key improvement. J Law Med Ethics. 2005;33(3):478-500. …

4206. Improvement in the detection of adverse drug events by the use of electronic health and prescription records: an evaluation of two trigger tools. | PSNet
      psnet.ahrq.gov/issue/improvement-detection-adverse-drug-events-use-electronic-health-and-prescription-records
      September 23, 2020 - Study Improvement in the detection of adverse drug events by the use of electronic health and prescription records: an evaluation of two trigger tools. Citation Text: Nwulu U, Nirantharakumar K, Odesanya R, et al. Improvement in the detection of adverse drug events by the use of electr…

4207. The association between sepsis and potential medical injury among hospitalized patients. | PSNet
      psnet.ahrq.gov/issue/association-between-sepsis-and-potential-medical-injury-among-hospitalized-patients
      July 15, 2014 - Study The association between sepsis and potential medical injury among hospitalized patients. Citation Text: Liu V, Turk BJ, Rizk NW, et al. The association between sepsis and potential medical injury among hospitalized patients. Chest. 2012;142(3):606-613. doi:10.1378/chest.11-2556. …

4208. Comparison of internal medicine and general surgery residents' assessments of risk of postsurgical complications in surgically complex patients. | PSNet
      psnet.ahrq.gov/issue/comparison-internal-medicine-and-general-surgery-residents-assessments-risk-postsurgical
      September 27, 2017 - Study Comparison of internal medicine and general surgery residents' assessments of risk of postsurgical complications in surgically complex patients. Citation Text: Healy JM, Davis KA, Pei KY. Comparison of Internal Medicine and General Surgery Residents' Assessments of Risk of Postsurg…

4209. Relationship of staff information sharing and advice networks to patient safety outcomes. | PSNet
      psnet.ahrq.gov/issue/relationship-staff-information-sharing-and-advice-networks-patient-safety-outcomes
      June 22, 2011 - Study Relationship of staff information sharing and advice networks to patient safety outcomes. Citation Text: Brewer BB, Carley KM, Benham-Hutchins MM, et al. Relationship of Staff Information Sharing and Advice Networks to Patient Safety Outcomes. J Nurs Adm. 2018;48(9):437-444. doi:10…

4210. ED handoffs: observed practices and communication errors. | PSNet
      psnet.ahrq.gov/issue/ed-handoffs-observed-practices-and-communication-errors
      October 19, 2022 - Study ED handoffs: observed practices and communication errors. Citation Text: Maughan BC, Lei L, Cydulka RK. ED handoffs: observed practices and communication errors. Am J Emerg Med. 2011;29(5):502-11. doi:10.1016/j.ajem.2009.12.004. Copy Citation Format: DOI Google Scho…

4211. Using risk stratification to reduce medical errors in cervical cancer prevention. | PSNet
      psnet.ahrq.gov/issue/using-risk-stratification-reduce-medical-errors-cervical-cancer-prevention
      September 05, 2012 - Commentary Using risk stratification to reduce medical errors in cervical cancer prevention. Citation Text: Perkins RB, Cain JM, Feldman S. Using Risk Stratification to Reduce Medical Errors in Cervical Cancer Prevention. JAMA Intern Med. 2017;177(10):1411-1412. doi:10.1001/jamainternmed…

4212. Evaluation of interventions to improve inpatient hospital documentation within electronic health records: a systematic review. | PSNet
      psnet.ahrq.gov/issue/evaluation-interventions-improve-inpatient-hospital-documentation-within-electronic-health
      June 28, 2011 - Review Evaluation of interventions to improve inpatient hospital documentation within electronic health records: a systematic review. Citation Text: Wiebe N, Varela LO, Niven DJ, et al. Evaluation of interventions to improve inpatient hospital documentation within electronic health recor…

4213. Trends in the prevalence of intraoperative adverse events at two academic hospitals after implementation of a mandatory reporting system. | PSNet
      psnet.ahrq.gov/issue/trends-prevalence-intraoperative-adverse-events-two-academic-hospitals-after-implementation
      August 09, 2017 - Study Trends in the prevalence of intraoperative adverse events at two academic hospitals after implementation of a mandatory reporting system. Citation Text: Wanderer JP, Gratch DM, St Jacques P, et al. Trends in the Prevalence of Intraoperative Adverse Events at Two Academic Hospitals …

4214. Assessing the impact of an electronic chemotherapy order verification checklist on pharmacist reported errors in oncology infusion centers of a health-system. | PSNet
      psnet.ahrq.gov/issue/assessing-impact-electronic-chemotherapy-order-verification-checklist-pharmacist-reported
      January 22, 2016 - Study Assessing the impact of an electronic chemotherapy order verification checklist on pharmacist reported errors in oncology infusion centers of a health-system. Citation Text: Wat SK (S), Wesolowski B, Cierniak K, et al. Assessing the impact of an electronic chemotherapy order verifi…

4215. Experiential learning through local implementation of a national chief resident in quality and patient safety curriculum. | PSNet
      psnet.ahrq.gov/issue/experiential-learning-through-local-implementation-national-chief-resident-quality-and
      November 16, 2022 - Commentary Experiential learning through local implementation of a national chief resident in quality and patient safety curriculum. Citation Text: Ronan MV, Menon A, Swamy L, et al. Experiential Learning Through Local Implementation of a National Chief Resident in Quality and Patient Sa…

4216. The SQUIRE Guidelines: an evaluation from the field, 5 years post release. | PSNet
      psnet.ahrq.gov/issue/squire-guidelines-evaluation-field-5-years-post-release
      November 18, 2016 - Study The SQUIRE Guidelines: an evaluation from the field, 5 years post release. Citation Text: Davies L, Batalden P, Davidoff F, et al. The SQUIRE Guidelines: an evaluation from the field, 5 years post release. BMJ Qual Saf. 2015;24(12):769-75. doi:10.1136/bmjqs-2015-004116. Copy Cita…

4217. The second victim of unanticipated adverse events. | PSNet
      psnet.ahrq.gov/issue/second-victim-unanticipated-adverse-events
      February 12, 2020 - Commentary The second victim of unanticipated adverse events. Citation Text: Chen S, Skidmore S, Ferrigno BN, et al. The second victim of unanticipated adverse events. J Thorac Cardiovasc Surg. 2023;166(3):890-894. doi:10.1016/j.jtcvs.2022.09.010. Copy Citation Format: DOI …

4218. A hospital is not just a factory, but a complex adaptive system—implications for perioperative care. | PSNet
      psnet.ahrq.gov/issue/hospital-not-just-factory-complex-adaptive-system-implications-perioperative-care
      May 11, 2019 - Commentary A hospital is not just a factory, but a complex adaptive system—implications for perioperative care. Citation Text: Mahajan A, Islam SD, Schwartz MJ, et al. A Hospital Is Not Just a Factory, but a Complex Adaptive System-Implications for Perioperative Care. Anesth Analg. 2017;…

4219. Cognitive bias during clinical decision-making and its influence on patient outcomes in the emergency department: a scoping review. | PSNet
      psnet.ahrq.gov/issue/cognitive-bias-during-clinical-decision-making-and-its-influence-patient-outcomes-emergency
      September 21, 2022 - Review Cognitive bias during clinical decision-making and its influence on patient outcomes in the emergency department: a scoping review. Citation Text: Jala S, Fry M, Elliott R. Cognitive bias during clinical decision‐making and its influence on patient outcomes in the emergency depart…

4220. Socio-technical issues and challenges in implementing safe patient handovers: insights from ethnographic case studies. | PSNet
      psnet.ahrq.gov/issue/socio-technical-issues-and-challenges-implementing-safe-patient-handovers-insights
      July 19, 2023 - Study Socio-technical issues and challenges in implementing safe patient handovers: insights from ethnographic case studies. Citation Text: Balka E, Tolar M, Coates S, et al. Socio-technical issues and challenges in implementing safe patient handovers: insights from ethnographic case st…