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  1. A primer on PDSA: executing plan–do–study–act cycles in practice, not just in name. | PSNet

    psnet.ahrq.gov/issue/primer-pdsa-executing-plan-do-study-act-cycles-practice-not-just-name
    December 04, 2016 - Review A primer on PDSA: executing plan–do–study–act cycles in practice, not just in name. Citation Text: Leis JA, Shojania KG. A primer on PDSA: executing plan-do-study-act cycles in practice, not just in name. BMJ Qual Saf. 2017;26(7):572-577. doi:10.1136/bmjqs-2016-006245. Copy Cita…

  2. Understanding diagnostic safety in emergency medicine: a case‐by‐case review of closed ED malpractice claims. | PSNet

    psnet.ahrq.gov/issue/understanding-diagnostic-safety-emergency-medicine-case-case-review-closed-ed-malpractice
    May 11, 2019 - Study Understanding diagnostic safety in emergency medicine: a case‐by‐case review of closed ED malpractice claims. Citation Text: Lemoine N, Dajer A, Konwinski J, et al. Understanding diagnostic safety in emergency medicine: A case-by-case review of closed ED malpractice claims. J Healt…

  3. Preventing medical injury. | PSNet

    psnet.ahrq.gov/issue/preventing-medical-injury
    February 18, 2011 - Study Classic Preventing medical injury. Citation Text: Leape LL, Lawthers AG, Brennan TA, et al. Preventing medical injury. QRB - Qual Rev Bull. 1993;19(5):144-149. doi:10.1016/s0097-5990(16)30608-x. Copy Citation Format: DOI Google Scholar BibTeX…

  4. Drug-related-problem outcomes and program satisfaction from a comprehensive brown bag medication review. | PSNet

    psnet.ahrq.gov/issue/drug-related-problem-outcomes-and-program-satisfaction-comprehensive-brown-bag-medication
    September 23, 2020 - Review Drug-related-problem outcomes and program satisfaction from a comprehensive brown bag medication review. Citation Text: O'Connell MB, Chang F, Tocco A, et al. Drug-Related-Problem Outcomes and Program Satisfaction from a Comprehensive Brown Bag Medication Review. J Am Geriatr Soc.…

  5. Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. | PSNet

    psnet.ahrq.gov/issue/prescription-long-acting-opioids-and-mortality-patients-chronic-noncancer-pain
    August 08, 2018 - Study Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. Citation Text: Ray WA, Chung CP, Murray KT, et al. Prescription of Long-Acting Opioids and Mortality in Patients With Chronic Noncancer Pain. JAMA. 2016;315(22):2415-23. doi:10.1001/jama.2016…

  6. Spreading a medication administration intervention organizationwide in six hospitals. | PSNet

    psnet.ahrq.gov/issue/spreading-medication-administration-intervention-organizationwide-six-hospitals
    January 03, 2017 - Study Spreading a medication administration intervention organizationwide in six hospitals. Citation Text: Kliger J, Singer SJ, Hoffman F, et al. Spreading a medication administration intervention organizationwide in six hospitals. Jt Comm J Qual Patient Saf. 2012;38(2):51-60. Copy C…

  7. Missed, rationed or unfinished nursing care: a scoping review of patient outcomes. | PSNet

    psnet.ahrq.gov/issue/missed-rationed-or-unfinished-nursing-care-scoping-review-patient-outcomes
    May 29, 2024 - Review Missed, rationed or unfinished nursing care: a scoping review of patient outcomes. Citation Text: Kalánková D, Kirwan M, Bartoníčková D, et al. Missed, rationed or unfinished nursing care: A scoping review of patient outcomes. J Nurs Manag. 2020;28(8):1783-1797. doi:10.1111/jonm.1…

  8. Evaluating the implementation of Project Re-Engineered Discharge (RED) in five Veterans Health Administration (VHA) hospitals. | PSNet

    psnet.ahrq.gov/issue/evaluating-implementation-project-re-engineered-discharge-red-five-veterans-health
    June 26, 2024 - Study Evaluating the implementation of Project Re-Engineered Discharge (RED) in five Veterans Health Administration (VHA) hospitals. Citation Text: Sullivan JL, Shin MH, Engle RL, et al. Evaluating the Implementation of Project Re-Engineered Discharge (RED) in Five Veterans Health Admini…

  9. Impact of team performance on the surgical safety checklist on patient outcomes: an operating room black box analysis. | PSNet

    psnet.ahrq.gov/issue/impact-team-performance-surgical-safety-checklist-patient-outcomes-operating-room-black-box
    March 20, 2024 - Study Impact of team performance on the surgical safety checklist on patient outcomes: an operating room black box analysis. Citation Text: Al Abbas AI, Meier J, Daniel W, et al. Impact of team performance on the surgical safety checklist on patient outcomes: an operating room black box …

  10. Standard admission order sets promote ordering of unnecessary investigations: a quasi-randomised evaluation in a simulated setting. | PSNet

    psnet.ahrq.gov/issue/standard-admission-order-sets-promote-ordering-unnecessary-investigations-quasi-randomised
    March 24, 2021 - Study Standard admission order sets promote ordering of unnecessary investigations: a quasi-randomised evaluation in a simulated setting. Citation Text: Leis B, Frost A, Bryce R, et al. Standard admission order sets promote ordering of unnecessary investigations: a quasi-randomised evalu…

  11. Racial and ethnic bias in the diagnosis of alcohol use disorder in veterans. | PSNet

    psnet.ahrq.gov/issue/racial-and-ethnic-bias-diagnosis-alcohol-use-disorder-veterans
    September 23, 2020 - Study Racial and ethnic bias in the diagnosis of alcohol use disorder in veterans. Citation Text: Vickers-Smith R, Justice AC, Becker WC, et al. Racial and ethnic bias in the diagnosis of alcohol use disorder in veterans. Am J Psych. 2023;180(6):426-436. doi:10.1176/appi.ajp.21111097. …

  12. Adverse drug events and medication problems in "Hospital at Home" patients. | PSNet

    psnet.ahrq.gov/issue/adverse-drug-events-and-medication-problems-hospital-home-patients
    December 16, 2020 - Study Adverse drug events and medication problems in "Hospital at Home" patients. Citation Text: Mann E, Zepeda O, Soones T, et al. Adverse drug events and medication problems in "Hospital at Home" patients. Home Health Care Serv Q. 2018;37(3):177-186. doi:10.1080/01621424.2018.1454372. …

  13. Nursing turbulence in critical care: relationships with nursing workload and patient safety. | PSNet

    psnet.ahrq.gov/issue/nursing-turbulence-critical-care-relationships-nursing-workload-and-patient-safety
    October 19, 2022 - Study Nursing turbulence in critical care: relationships with nursing workload and patient safety. Citation Text: Browne J, Braden CJ. Nursing turbulence in critical care: relationships with nursing workload and patient safety. Am J Crit Care. 2020;29(3):182-191. doi:10.4037/ajcc2020180.…

  14. Hospital at Home: setting a regulatory course to ensure safe, high-quality care. | PSNet

    psnet.ahrq.gov/issue/hospital-home-setting-regulatory-course-ensure-safe-high-quality-care
    June 30, 2021 - Commentary Hospital at Home: setting a regulatory course to ensure safe, high-quality care. Citation Text: DeCherrie LV, Leff B, Levine DM, et al. Hospital at Home: setting a regulatory course to ensure safe, high-quality care. Jt Comm J Qual Patient Saf. 2022;48(3):180-184. doi:10.1016/…

  15. US internal medicine program director perceptions of alignment of graduate medical education and institutional resources for engaging residents in quality and safety. | PSNet

    psnet.ahrq.gov/issue/us-internal-medicine-program-director-perceptions-alignment-graduate-medical-education-and
    July 02, 2014 - Study US internal medicine program director perceptions of alignment of graduate medical education and institutional resources for engaging residents in quality and safety. Citation Text: Chacko KM, Halvorsen AJ, Swenson SL, et al. US Internal Medicine Program Director Perceptions of Ali…

  16. Is bias in the eye of the beholder? A vignette study to assess recognition of cognitive biases in clinical case workups. | PSNet

    psnet.ahrq.gov/issue/bias-eye-beholder-vignette-study-assess-recognition-cognitive-biases-clinical-case-workups
    September 26, 2016 - Study Is bias in the eye of the beholder? A vignette study to assess recognition of cognitive biases in clinical case workups. Citation Text: Zwaan L, Monteiro SD, Sherbino J, et al. Is bias in the eye of the beholder? A vignette study to assess recognition of cognitive biases in clinica…

  17. The impact of the 80-hour work week on appropriate resident case coverage. | PSNet

    psnet.ahrq.gov/issue/impact-80-hour-work-week-appropriate-resident-case-coverage
    June 18, 2008 - Study The impact of the 80-hour work week on appropriate resident case coverage. Citation Text: Shin S, Britt R, Doviak M, et al. The Impact of the 80-Hour Work Week on Appropriate Resident Case Coverage. Journal of Surgical Research. 2009;162(1). doi:10.1016/j.jss.2009.12.003. Copy …

  18. The Henry Ford Production System: reduction of surgical pathology in-process misidentification defects by bar code-specified work process standardization. | PSNet

    psnet.ahrq.gov/issue/henry-ford-production-system-reduction-surgical-pathology-process-misidentification-defects
    July 16, 2013 - Study The Henry Ford Production System: reduction of surgical pathology in-process misidentification defects by bar code-specified work process standardization. Citation Text: Zarbo RJ, Tuthill M, D'Angelo R, et al. The Henry Ford Production System: reduction of surgical pathology in-p…

  19. Wrong administration route of medications in the domestic setting: a review of an underestimated public health topic. | PSNet

    psnet.ahrq.gov/issue/wrong-administration-route-medications-domestic-setting-review-underestimated-public-health
    December 15, 2021 - Review Wrong administration route of medications in the domestic setting: a review of an underestimated public health topic. Citation Text: Gualano MR, Lo Moro G, Voglino G, et al. Wrong administration route of medications in the domestic setting: a review of an underestimated public hea…

  20. Prescription opioid analgesics commonly unused after surgery: a systematic review. | PSNet

    psnet.ahrq.gov/issue/prescription-opioid-analgesics-commonly-unused-after-surgery-systematic-review
    March 30, 2022 - Review Prescription opioid analgesics commonly unused after surgery: a systematic review. Citation Text: Bicket MC, Long JJ, Pronovost PJ, et al. Prescription Opioid Analgesics Commonly Unused After Surgery. JAMA Surg. 2017;152(11):1066-1071. doi:10.1001/jamasurg.2017.0831. Copy Citati…
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