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4361. Root cause analysis of ICU adverse events in the Veterans Health Administration. | PSNet
      psnet.ahrq.gov/issue/root-cause-analysis-icu-adverse-events-veterans-health-administration
      June 23, 2021 - Study Root cause analysis of ICU adverse events in the Veterans Health Administration. Citation Text: Corwin GS, Mills PD, Shanawani H, et al. Root Cause Analysis of ICU Adverse Events in the Veterans Health Administration. Jt Comm J Qual Patient Saf. 2017;43(11):580-590. doi:10.1016/j.j…

4362. Prescribing patterns of heart failure-exacerbating medications following a heart failure hospitalization. | PSNet
      psnet.ahrq.gov/issue/prescribing-patterns-heart-failure-exacerbating-medications-following-heart-failure
      January 26, 2022 - Study Prescribing patterns of heart failure-exacerbating medications following a heart failure hospitalization. Citation Text: Goyal P, Kneifati-Hayek J, Archambault A, et al. Prescribing patterns of heart failure-exacerbating medications following a heart failure hospitalization. JACC H…

4363. Care Deficiencies and Leaders' Inadequate Reviews of a Patient Who Died at the Lt. Col. Luke Weathers, Jr. VA Medical Center in Memphis, Tennessee. | PSNet
      psnet.ahrq.gov/issue/care-deficiencies-and-leaders-inadequate-reviews-patient-who-died-lt-col-luke-weathers-jr-va
      April 10, 2024 - Book/Report Care Deficiencies and Leaders' Inadequate Reviews of a Patient Who Died at the Lt. Col. Luke Weathers, Jr. VA Medical Center in Memphis, Tennessee. Citation Text: Care Deficiencies and Leaders' Inadequate Reviews of a Patient Who Died at the Lt. Col. Luke Weathers, Jr. VA Me…

4364. A novel approach for assessing bias during team-based clinical decision-making. | PSNet
      psnet.ahrq.gov/issue/novel-approach-assessing-bias-during-team-based-clinical-decision-making
      April 10, 2024 - Study A novel approach for assessing bias during team-based clinical decision-making. Citation Text: Pool N, Hebdon M, de Groot E, et al. A novel approach for assessing bias during team-based clinical decision-making. Front in Public Health. 2023;11:1014773. doi:10.3389/fpubh.2023.101477…

4365. Evaluating a patient safety learning laboratory to create an interdisciplinary ecosystem for health care innovation. | PSNet
      psnet.ahrq.gov/issue/evaluating-patient-safety-learning-laboratory-create-interdisciplinary-ecosystem-health-care
      December 21, 2022 - Study Evaluating a patient safety learning laboratory to create an interdisciplinary ecosystem for health care innovation. Citation Text: Atkinson MK, Benneyan JC, Bambury EA, et al. Evaluating a patient safety learning laboratory to create an interdisciplinary ecosystem for health care …

4366. Emergency department monitor alarms rarely change clinical management: an observational study. | PSNet
      psnet.ahrq.gov/issue/emergency-department-monitor-alarms-rarely-change-clinical-management-observational-study
      September 30, 2020 - Study Emergency department monitor alarms rarely change clinical management: an observational study. Citation Text: Fleischman W, Ciliberto B, Rozanski N, et al. Emergency department monitor alarms rarely change clinical management: an observational study. Am J Emerg Med. 2020;38(6):1072…

4367. How to make medication error reporting systems work—factors associated with their successful development and implementation. | PSNet
      psnet.ahrq.gov/issue/how-make-medication-error-reporting-systems-work-factors-associated-their-successful
      December 05, 2012 - Study How to make medication error reporting systems work—factors associated with their successful development and implementation. Citation Text: Holmström A-R, Laaksonen R, Airaksinen M. How to make medication error reporting systems work--Factors associated with their successful develo…

4368. Direct oral anticoagulant-related medication incidents and pharmacists' interventions in hospital in-patients: evaluation using Reason's accident causation theory. | PSNet
      psnet.ahrq.gov/issue/direct-oral-anticoagulant-related-medication-incidents-and-pharmacists-interventions-hospital
      January 12, 2022 - Study Direct oral anticoagulant-related medication incidents and pharmacists' interventions in hospital in-patients: evaluation using Reason's accident causation theory. Citation Text: Haque H, Alrowily A, Jalal Z, et al. Direct oral anticoagulant-related medication incidents and pharmac…

4369. Standardizing medication reconciliation in a pediatric emergency department. | PSNet
      psnet.ahrq.gov/issue/standardizing-medication-reconciliation-pediatric-emergency-department
      March 10, 2019 - Study Standardizing medication reconciliation in a pediatric emergency department. Citation Text: Sheth S, Bialostozky M, Hollenbach K, et al. Standardizing medication reconciliation in a pediatric emergency department. Pediatrics. 2024;153(2):e2023061964. doi:10.1542/peds.2023-061964. …

4370. Development of a research agenda to identify evidence-based strategies to improve physician wellness and reduce burnout. | PSNet
      psnet.ahrq.gov/issue/development-research-agenda-identify-evidence-based-strategies-improve-physician-wellness-and
      June 01, 2022 - Commentary Development of a research agenda to identify evidence-based strategies to improve physician wellness and reduce burnout. Citation Text: Dyrbye LN, Trockel M, Frank E, et al. Development of a Research Agenda to Identify Evidence-Based Strategies to Improve Physician Wellness an…

4371. Sustaining and spreading the reduction of adverse drug events in a multicenter collaborative. | PSNet
      psnet.ahrq.gov/issue/sustaining-and-spreading-reduction-adverse-drug-events-multicenter-collaborative
      November 16, 2022 - Study Sustaining and spreading the reduction of adverse drug events in a multicenter collaborative. Citation Text: Tham E, Calmes HM, Poppy A, et al. Sustaining and spreading the reduction of adverse drug events in a multicenter collaborative. Pediatrics. 2011;128(2):e438-45. doi:10.1542…

4372. Perceptions of U.S. and U.K. incident reporting systems: a scoping review. | PSNet
      psnet.ahrq.gov/issue/perceptions-us-and-uk-incident-reporting-systems-scoping-review
      January 19, 2022 - Review Perceptions of U.S. and U.K. incident reporting systems: a scoping review. Citation Text: Gampetro PJ, Nickum A, Schultz CM. Perceptions of U.S. and U.K. incident reporting systems: a scoping review. J Patient Saf. 2024;20(5):360-365. doi:10.1097/pts.0000000000001231. Copy Citat…

4373. Health care provider factors associated with patient-reported adverse events and harm. | PSNet
      psnet.ahrq.gov/issue/health-care-provider-factors-associated-patient-reported-adverse-events-and-harm
      June 19, 2019 - Study Health care provider factors associated with patient-reported adverse events and harm. Citation Text: Giardina TD, Royse KE, Khanna A, et al. Health care provider factors associated with patient-reported adverse events and harm. Jt Comm J Qual Patient Saf. 2020;46(5):282-290. doi:…

4374. Completion of recommended tests and referrals in telehealth vs in-person visits. | PSNet
      psnet.ahrq.gov/issue/completion-recommended-tests-and-referrals-telehealth-vs-person-visits
      January 31, 2024 - Study Completion of recommended tests and referrals in telehealth vs in-person visits. Citation Text: Zhong A, Amat MJ, Anderson TS, et al. Completion of recommended tests and referrals in telehealth vs in-person visits. JAMA Netw Open. 2023;6(11):e2343417. doi:10.1001/jamanetworkopen.20…

4375. Implementation of patient safety structures and processes in the patient-centered medical home. | PSNet
      psnet.ahrq.gov/issue/implementation-patient-safety-structures-and-processes-patient-centered-medical-home
      September 28, 2022 - Study Implementation of patient safety structures and processes in the patient-centered medical home. Citation Text: Oberlander T, Scholle SH, Marsteller JA, et al. Implementation of patient safety structures and processes in the patient-centered medical home. J Healthc Qual. 2021;43(6):…

4376. Registered nurses' efforts to ensure safety for home-dwelling older patients. | PSNet
      psnet.ahrq.gov/issue/registered-nurses-efforts-ensure-safety-home-dwelling-older-patients
      July 19, 2019 - Study Registered nurses' efforts to ensure safety for home-dwelling older patients. Citation Text: Lindberg C, Fock J, Nilsen P, et al. Registered nurses' efforts to ensure safety for home‐dwelling older patients. Scand J Caring Sci. 2022. doi:10.1111/scs.13142. Copy Citation Forma…

4377. Description of the development and validation of the Canadian Paediatric Trigger Tool. | PSNet
      psnet.ahrq.gov/issue/description-development-and-validation-canadian-paediatric-trigger-tool
      January 25, 2017 - Study Description of the development and validation of the Canadian Paediatric Trigger Tool. Citation Text: Matlow A, Cronin CMG, Flintoft V, et al. Description of the development and validation of the Canadian Paediatric Trigger Tool. BMJ Qual Saf. 2011;20(5):416-23. doi:10.1136/bmjqs…

4378. Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. | PSNet
      psnet.ahrq.gov/issue/systematic-review-impact-health-information-technology-quality-efficiency-and-costs-medical
      March 30, 2022 - Review Classic Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Citation Text: Chaudhry B, Wang J, Wu S, et al. Systematic review: impact of health information technology on quality, efficiency, and …

4379. Unintended patient safety risks due to wireless smart infusion pump library update delays. | PSNet
      psnet.ahrq.gov/issue/unintended-patient-safety-risks-due-wireless-smart-infusion-pump-library-update-delays
      September 25, 2019 - Study Unintended patient safety risks due to wireless smart infusion pump library update delays. Citation Text: Hsu K-Y, DeLaurentis P, Bitan Y, et al. Unintended Patient Safety Risks Due to Wireless Smart Infusion Pump Library Update Delays. J Patient Saf. 2019;15(1):e8-e14. doi:10.1097…

4380. Medication reconciliation and patient safety in trauma: Applicability of existing strategies. | PSNet
      psnet.ahrq.gov/issue/medication-reconciliation-and-patient-safety-trauma-applicability-existing-strategies
      September 23, 2020 - Review Medication reconciliation and patient safety in trauma: Applicability of existing strategies. Citation Text: DeAntonio JH, Leichtle SW, Hobgood S, et al. Medication reconciliation and patient safety in trauma: Applicability of existing strategies. J Surg Res. 2019;246:482-489. doi…