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What stops hospital clinical staff from following protocols? An analysis of the incidence and factors behind the failure of bedside clinical staff to activate the rapid response system in a multi-campus Australian metropolitan healthcare service. | PSNet

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September 09, 2015 - Study What stops hospital clinical staff from following protocols? An analysis of the incidence and factors behind the failure of bedside clinical staff to activate the rapid response system in a multi-campus Australian metropolitan healthcare service. Citation Text: Shearer B, Marshal…

Effect of health information exchange on recognition of medication discrepancies is interrupted when data charges are introduced: results of a cluster-randomized controlled trial. | PSNet

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November 16, 2022 - Study Effect of health information exchange on recognition of medication discrepancies is interrupted when data charges are introduced: results of a cluster-randomized controlled trial. Citation Text: Boockvar K, Ho W, Pruskowski J, et al. Effect of health information exchange on recogni…

The impact of time at work and time off from work on rule compliance: the case of hand hygiene in health care. | PSNet

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May 18, 2022 - Study Classic The impact of time at work and time off from work on rule compliance: the case of hand hygiene in health care. Citation Text: Dai H, Milkman KL, Hofmann DA, et al. The impact of time at work and time off from work on rule compliance: the case of ha…

Patients and families as teachers: a mixed methods assessment of a collaborative learning model for medical error disclosure and prevention. | PSNet

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July 12, 2017 - Study Patients and families as teachers: a mixed methods assessment of a collaborative learning model for medical error disclosure and prevention. Citation Text: Langer T, Martinez W, Browning DM, et al. Patients and families as teachers: a mixed methods assessment of a collaborative lea…

Effect of increased inpatient attending physician supervision on medical errors, patient safety, and resident education: a randomized clinical trial. | PSNet

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December 07, 2011 - Study Emerging Classic Effect of increased inpatient attending physician supervision on medical errors, patient safety, and resident education: a randomized clinical trial. Citation Text: Finn KM, Metlay JP, Chang Y, et al. Effect of Increased Inpatient Attendin…

Assessing the impact of virtual medication history technicians on medication reconciliation discrepancies. | PSNet

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December 01, 2021 - EMERGING INNOVATIONS Assessing the impact of virtual medication history technicians on medication reconciliation discrepancies. Citation Text: Gadallah A, McGinnis B, Nguyen B, et al. Assessing the impact of virtual medication history technicians on medication reconciliation discrepancies. Int J C…

Biases in detection of apparent "weekend effect" on outcome with administrative coding data: population based study of stroke. | PSNet

psnet.ahrq.gov/issue/biases-detection-apparent-weekend-effect-outcome-administrative-coding-data-population-based

September 23, 2020 - Study Classic Biases in detection of apparent "weekend effect" on outcome with administrative coding data: population based study of stroke. Citation Text: Li L, Rothwell PM, Study OV. Biases in detection of apparent "weekend effect" on outcome with administrati…

A national implementation project to prevent catheter-associated urinary tract infection in nursing home residents. | PSNet

psnet.ahrq.gov/issue/national-implementation-project-prevent-catheter-associated-urinary-tract-infection-nursing

April 05, 2017 - Study Classic A national implementation project to prevent catheter-associated urinary tract infection in nursing home residents. Citation Text: Mody L, Greene T, Meddings J, et al. A National Implementation Project to Prevent Catheter-Associated Urinary Tract I…

Health disparities: impact of health disparities and treatment decision-making biases on cancer adverse effects among black cancer survivors. | PSNet

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October 14, 2020 - Commentary Health disparities: impact of health disparities and treatment decision-making biases on cancer adverse effects among black cancer survivors. Citation Text: Vo J, Gillman A, Mitchell K, et al. Health disparities: impact of health disparities and treatment decision-making biase…

Patient safety and telephone medicine: some lessons from closed claim case review. | PSNet

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May 18, 2022 - Study Patient safety and telephone medicine: some lessons from closed claim case review. Citation Text: Katz HP, Kaltsounis D, Halloran L, et al. Patient safety and telephone medicine : some lessons from closed claim case review. J Gen Intern Med. 2008;23(5):517-22. doi:10.1007/s11606-…

Intended and unintended consequences: changes in opioid prescribing practices for postsurgical, acute, and chronic pain indications following two policies in North Carolina, 2012-2018 - controlled and single-series interrupted time series analyses. | PSNet

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August 10, 2022 - Study Intended and unintended consequences: changes in opioid prescribing practices for postsurgical, acute, and chronic pain indications following two policies in North Carolina, 2012-2018 - controlled and single-series interrupted time series analyses. Citation Text: Maierhofer CN, Ran…

Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. | PSNet

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March 24, 2019 - Study Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. Citation Text: Lai J, Ma S, Wang Y, et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open. 20…

A standardized marking procedure for ENT operations to prevent wrong-site surgery: development, establishment and subsequent evaluation among patients and medical personnel. | PSNet

psnet.ahrq.gov/innovation/standardized-marking-procedure-ent-operations-prevent-wrong-site-surgery-development

February 01, 2013 - EMERGING INNOVATIONS A standardized marking procedure for ENT operations to prevent wrong-site surgery: development, establishment and subsequent evaluation among patients and medical personnel. Citation Text: Rohrmeier C, Abudan Al-Masry N, Keerl R, et al. A standardized marking procedure for ENT…

Missed diagnoses of acute myocardial infarction in the emergency department: variation by patient and facility characteristics. | PSNet

psnet.ahrq.gov/issue/missed-diagnoses-acute-myocardial-infarction-emergency-department-variation-patient-and

April 08, 2018 - Study Missed diagnoses of acute myocardial infarction in the emergency department: variation by patient and facility characteristics. Citation Text: Moy E, Barrett M, Coffey R, et al. Missed diagnoses of acute myocardial infarction in the emergency department: variation by patient and fa…

Speaking up about traditional and professionalism-related patient safety threats: a national survey of interns and residents. | PSNet

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November 20, 2015 - Study Classic Speaking up about traditional and professionalism-related patient safety threats: a national survey of interns and residents. Citation Text: Martinez W, Lehmann LS, Thomas EJ, et al. Speaking up about traditional and professionalism-related patient…

Antecedent treat-and-release diagnoses prior to sepsis hospitalization among adult emergency department patients: a look-back analysis employing insurance claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) methodology. | PSNet

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May 12, 2021 - Study Antecedent treat-and-release diagnoses prior to sepsis hospitalization among adult emergency department patients: a look-back analysis employing insurance claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) methodology. Citation Text: Nassery N, Horberg MA, …

Use of an electronic clinical decision support system in primary care to assess inappropriate polypharmacy in young seniors with multimorbidity: observational, descriptive, cross-sectional study | PSNet

psnet.ahrq.gov/issue/use-electronic-clinical-decision-support-system-primary-care-assess-inappropriate

October 21, 2020 - Study Use of an electronic clinical decision support system in primary care to assess inappropriate polypharmacy in young seniors with multimorbidity: observational, descriptive, cross-sectional study Citation Text: Rogero-Blanco E, Lopez-Rodriguez JA, Sanz-Cuesta T, et al. Use of an ele…

A high-reliability organization framework for health care: a multiyear implementation strategy and associated outcomes. | PSNet

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November 17, 2021 - Study A high-reliability organization framework for health care: a multiyear implementation strategy and associated outcomes. Citation Text: Sculli GL, Pendley-Louis R, Neily J, et al. A high-reliability organization framework for health care: a multiyear implementation strategy and asso…

The cost of quality: an academic health center's annual costs for its quality and patient safety infrastructure. | PSNet

psnet.ahrq.gov/issue/cost-quality-academic-health-centers-annual-costs-its-quality-and-patient-safety

October 14, 2020 - Study The cost of quality: an academic health center's annual costs for its quality and patient safety infrastructure. Citation Text: Blanchfield BB, Demehin AA, Cummings CT, et al. The cost of quality: an academic health center's annual costs for its quality and patient safety infrastru…

"Good care is slow enough to be able to pay attention": primary care time scarcity and patient safety. | PSNet

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August 04, 2015 - Study "Good care is slow enough to be able to pay attention": primary care time scarcity and patient safety. Citation Text: Satterwhite S, Nguyen M-LT, Honcharov V, et al. "Good care is slow enough to be able to pay attention": primary care time scarcity and patient safety. J Gen Intern …

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