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  1. Assessment of unintentional duplicate orders by emergency department clinicians before and after implementation of a visual aid in the electronic health record ordering system. | PSNet

    psnet.ahrq.gov/issue/assessment-unintentional-duplicate-orders-emergency-department-clinicians-and-after
    October 19, 2022 - Study Assessment of unintentional duplicate orders by emergency department clinicians before and after implementation of a visual aid in the electronic health record ordering system. Citation Text: Horng S, Joseph JW, Calder S, et al. Assessment of Unintentional Duplicate Orders by Emerg…

  2. Lost information during the handover of critically injured trauma patients: a mixed-methods study. | PSNet

    psnet.ahrq.gov/issue/lost-information-during-handover-critically-injured-trauma-patients-mixed-methods-study
    October 04, 2023 - Study Lost information during the handover of critically injured trauma patients: a mixed-methods study. Citation Text: Zakrison TL, Rosenbloom B, McFarlan A, et al. Lost information during the handover of critically injured trauma patients: a mixed-methods study. BMJ Qual Saf. 2016;25(1…

  3. Unintended consequences: quantifying the benefits, iatrogenic harms and downstream cascade costs of musculoskeletal MRI in UK primary care. | PSNet

    psnet.ahrq.gov/issue/unintended-consequences-quantifying-benefits-iatrogenic-harms-and-downstream-cascade-costs
    March 17, 2021 - Study Unintended consequences: quantifying the benefits, iatrogenic harms and downstream cascade costs of musculoskeletal MRI in UK primary care. Citation Text: Sajid IM, Parkunan A, Frost K. Unintended consequences: quantifying the benefits, iatrogenic harms and downstream cascade costs…

  4. A systematic review of trauma crew resource management training: what can the United States and the United Kingdom learn from each other? | PSNet

    psnet.ahrq.gov/issue/systematic-review-trauma-crew-resource-management-training-what-can-united-states-and-united
    July 14, 2021 - Study A systematic review of trauma crew resource management training: what can the United States and the United Kingdom learn from each other? Citation Text: Ashcroft J, Wilkinson A, Khan M. A systematic review of trauma crew resource management training: what can the United States and …

  5. Improving medication safety with accurate preadmission medication lists and postdischarge education. | PSNet

    psnet.ahrq.gov/issue/improving-medication-safety-accurate-preadmission-medication-lists-and-postdischarge
    June 26, 2019 - Study Improving medication safety with accurate preadmission medication lists and postdischarge education. Citation Text: Gardella JE, Cardwell TB, Nnadi M. Improving medication safety with accurate preadmission medication lists and postdischarge education. Jt Comm J Qual Patient Saf. …

  6. The care transitions intervention: translating from efficacy to effectiveness. | PSNet

    psnet.ahrq.gov/issue/care-transitions-intervention-translating-efficacy-effectiveness
    August 18, 2021 - Study Classic The care transitions intervention: translating from efficacy to effectiveness. Citation Text: Voss R, Gardner R, Baier R, et al. The care transitions intervention: translating from efficacy to effectiveness. Arch Intern Med. 2011;171(14):1232-7. …

  7. Can first-year medical students acquire quality improvement knowledge prior to substantial clinical exposure? A mixed-methods evaluation of a pre-clerkship curriculum that uses education as the context for learning. | PSNet

    psnet.ahrq.gov/issue/can-first-year-medical-students-acquire-quality-improvement-knowledge-prior-substantial
    April 24, 2019 - Study Can first-year medical students acquire quality improvement knowledge prior to substantial clinical exposure? A mixed-methods evaluation of a pre-clerkship curriculum that uses education as the context for learning. Citation Text: Brown A, Nidumolu A, Stanhope A, et al. Can first-y…

  8. Implementation of the Centers for Medicare & Medicaid Services' nonpayment policy for preventable hospital-acquired conditions in rural and nonrural US hospitals. | PSNet

    psnet.ahrq.gov/issue/implementation-centers-medicare-medicaid-services-nonpayment-policy-preventable-hospital
    September 16, 2020 - Study Implementation of the Centers for Medicare & Medicaid Services' nonpayment policy for preventable hospital-acquired conditions in rural and nonrural US hospitals. Citation Text: Bae S-H, Yoder LH. Implementation of the Centers for Medicare & Medicaid Services' Nonpayment Policy for…

  9. Enhancing patient safety and quality of care by improving the usability of electronic health record systems: recommendations from AMIA. | PSNet

    psnet.ahrq.gov/issue/enhancing-patient-safety-and-quality-care-improving-usability-electronic-health-record
    March 04, 2011 - Commentary Enhancing patient safety and quality of care by improving the usability of electronic health record systems: recommendations from AMIA. Citation Text: Middleton B, Bloomrosen M, Dente MA, et al. Enhancing patient safety and quality of care by improving the usability of electro…

  10. Use of prescribing safety quality improvement reports in UK general practices: a qualitative assessment. | PSNet

    psnet.ahrq.gov/issue/use-prescribing-safety-quality-improvement-reports-uk-general-practices-qualitative
    December 08, 2021 - Study Use of prescribing safety quality improvement reports in UK general practices: a qualitative assessment. Citation Text: Khan NF, Booth HP, Myles P, et al. Use of prescribing safety quality improvement reports in UK general practices: a qualitative assessment. BMC Health Serv Res. 2…

  11. Agency for Healthcare Research and Quality pediatric indicators as a quality metric for surgery in children: do they predict adverse outcomes? | PSNet

    psnet.ahrq.gov/issue/agency-healthcare-research-and-quality-pediatric-indicators-quality-metric-surgery-children
    May 01, 2015 - Study Agency for Healthcare Research and Quality pediatric indicators as a quality metric for surgery in children: do they predict adverse outcomes? Citation Text: Rhee D, Zhang Y, Papandria DJ, et al. Agency for Healthcare Research and Quality pediatric indicators as a quality metric …

  12. Medication errors during medical emergencies in a large, tertiary care, academic medical center. | PSNet

    psnet.ahrq.gov/issue/medication-errors-during-medical-emergencies-large-tertiary-care-academic-medical-center
    July 31, 2013 - Study Medication errors during medical emergencies in a large, tertiary care, academic medical center. Citation Text: Gokhman R, Seybert AL, Phrampus P, et al. Medication errors during medical emergencies in a large, tertiary care, academic medical center. Resuscitation. 2012;83(4):482…

  13. Wrong-site surgery in Pennsylvania during 2015–2019: a study of variables associated with 368 events from 178 facilities. | PSNet

    psnet.ahrq.gov/issue/wrong-site-surgery-pennsylvania-during-2015-2019-study-variables-associated-368-events-178
    October 09, 2024 - Study Wrong-site surgery in Pennsylvania during 2015–2019: a study of variables associated with 368 events from 178 facilities. Citation Text: Yonash RA, Taylor M. Wrong-Site Surgery in Pennsylvania During 2015–2019: A Study of Variables Associated With 368 Events From 178 Facilities. …

  14. The impact of hospital-acquired conditions on Medicare program payments. | PSNet

    psnet.ahrq.gov/issue/impact-hospital-acquired-conditions-medicare-program-payments
    November 18, 2016 - Study The impact of hospital-acquired conditions on Medicare program payments. Citation Text: Kandilov AMG, Coomer NM, Dalton K. The impact of hospital-acquired conditions on Medicare program payments. Medicare Medicaid Res Rev. 2014;4(4). doi:10.5600/mmrr.004.04.a01. Copy Citation …

  15. Prescribing discrepancies likely to cause adverse drug events after patient transfer. | PSNet

    psnet.ahrq.gov/issue/prescribing-discrepancies-likely-cause-adverse-drug-events-after-patient-transfer
    December 08, 2010 - Study Prescribing discrepancies likely to cause adverse drug events after patient transfer. Citation Text: Boockvar KS, Liu S, Goldstein N, et al. Prescribing discrepancies likely to cause adverse drug events after patient transfer. Qual Saf Health Care. 2009;18(1):32-6. doi:10.1136/qshc…

  16. Communication of incidental imaging findings on inpatient discharge summaries after implementation of electronic health record notification system. | PSNet

    psnet.ahrq.gov/issue/communication-incidental-imaging-findings-inpatient-discharge-summaries-after-implementation
    August 19, 2020 - Study Communication of incidental imaging findings on inpatient discharge summaries after implementation of electronic health record notification system. Citation Text: Mattay G, Mallikarjun K, Grow P, et al. Communication of incidental imaging findings on inpatient discharge summaries a…

  17. Morning handover of on-call issues: opportunities for improvement. | PSNet

    psnet.ahrq.gov/issue/morning-handover-call-issues-opportunities-improvement
    September 26, 2012 - Study Morning handover of on-call issues: opportunities for improvement. Citation Text: Devlin MK, Kozij NK, Kiss A, et al. Morning handover of on-call issues: opportunities for improvement. JAMA Intern Med. 2014;174(9):1479-85. doi:10.1001/jamainternmed.2014.3033. Copy Citation Fo…

  18. Weekend hospitalization and additional risk of death: an analysis of inpatient data. | PSNet

    psnet.ahrq.gov/issue/weekend-hospitalization-and-additional-risk-death-analysis-inpatient-data
    September 23, 2015 - Study Weekend hospitalization and additional risk of death: an analysis of inpatient data. Citation Text: Freemantle N, Richardson M, Wood J, et al. Weekend hospitalization and additional risk of death: An analysis of inpatient data. J R Soc Med. 2012;105(2). doi:10.1258/jrsm.2012.1200…

  19. Development of a multicomponent intervention to decrease racial bias among healthcare staff. | PSNet

    psnet.ahrq.gov/issue/development-multicomponent-intervention-decrease-racial-bias-among-healthcare-staff
    September 23, 2020 - Study Development of a multicomponent intervention to decrease racial bias among healthcare staff. Citation Text: Tajeu GS, Juarez L, Williams JH, et al. Development of a multicomponent intervention to decrease racial bias among healthcare staff. J Gen Intern Med. 2022;37(8):1970-1979. d…

  20. Feasibility of prospective error reporting in home palliative care: a mixed methods study. | PSNet

    psnet.ahrq.gov/issue/feasibility-prospective-error-reporting-home-palliative-care-mixed-methods-study
    November 11, 2020 - Study Feasibility of prospective error reporting in home palliative care: a mixed methods study. Citation Text: Kurahashi AM, Kim G, Parry N, et al. Feasibility of prospective error reporting in home palliative care: a mixed methods study. Palliat Med. 2025;39(1):22-30. doi:10.1177/02692…
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