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psnet.ahrq.gov/node/45434/psn-pdf
September 22, 2017 - Organisational strategies to implement hospital pressure
ulcer prevention programmes: findings from a national
survey.
September 22, 2017
Soban LM, Kim L, Yuan AH, et al. Organisational strategies to implement hospital pressure ulcer
prevention programmes: findings from a national survey. J Nurs Manag. 2017;25(6):…
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psnet.ahrq.gov/node/863212/psn-pdf
February 28, 2024 - unDerstandIng the cauSes of mediCation errOrs and
adVerse drug evEnts for patients with mental illness in
community caRe (DISCOVER): a qualitative study.
February 28, 2024
Ayre MJ, Lewis PJ, Phipps DL, et al. unDerstandIng the cauSes of mediCation errOrs and adVerse drug
evEnts for patients with mental illness in …
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psnet.ahrq.gov/node/867338/psn-pdf
December 11, 2024 - Using patient experience surveys to identify potential
diagnostic safety breakdowns: a mixed methods study.
December 11, 2024
Baker KM, Brahier M, Penne M, et al. Using patient experience surveys to identify potential diagnostic
safety breakdowns: a mixed methods study. J Patient Saf. 2024;20(8):556-563.
doi:10.10…
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psnet.ahrq.gov/node/860392/psn-pdf
January 10, 2024 - Nurses' experience with presenteeism and the potential
consequences on patient safety: a qualitative study
among nurses at out-of-hours emergency primary care
facilities.
January 10, 2024
Moore A, Knutsen Glette M. Nurses’ experience with presenteeism and the potential consequences on
patient safety: a qualitativ…
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psnet.ahrq.gov/node/39579/psn-pdf
June 11, 2014 - Outpatient adverse drug events identified by screening
electronic health records.
June 11, 2014
Gandhi TK, Seger AC, Overhage M, et al. Outpatient adverse drug events identified by screening electronic
health records. J Patient Saf. 2010;6(2):91-6. doi:10.1097/PTS.0b013e3181dcae06.
https://psnet.ahrq.gov/issue/out…
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psnet.ahrq.gov/node/35462/psn-pdf
February 18, 2011 - Effect of the transformation of the Veterans Affairs Health
Care System on the quality of care.
February 18, 2011
Jha AK, Perlin JB, Kizer KW, et al. Effect of the transformation of the Veterans Affairs Health Care System
on the quality of care. N Engl J Med. 2003;348(22):2218-27.
https://psnet.ahrq.gov/issue/effe…
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psnet.ahrq.gov/node/60251/psn-pdf
April 22, 2020 - Exploring the association between organizational culture
and large-scale adverse events: evidence from the
Veterans Health Administration.
April 22, 2020
George J, Elwy AR, Charns MP, et al. Exploring the Association Between Organizational Culture and
Large-Scale Adverse Events: Evidence from the Veterans Health A…
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psnet.ahrq.gov/node/47141/psn-pdf
August 17, 2018 - Association of postoperative readmissions with surgical
quality using a Delphi consensus process to identify
relevant diagnosis codes.
August 17, 2018
Mull HJ, Graham LA, Morris MS, et al. Association of Postoperative Readmissions With Surgical Quality
Using a Delphi Consensus Process to Identify Relevant Diagnosi…
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psnet.ahrq.gov/node/73402/psn-pdf
June 16, 2021 - The role of the informal and formal organisation in voice
about concerns in healthcare: a qualitative interview
study.
June 16, 2021
Wu F, Dixon-Woods M, Aveling E-L, et al. The role of the informal and formal organisation in voice about
concerns in healthcare: a qualitative interview study. Soc Sci Med. 2021;280:…
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psnet.ahrq.gov/node/43787/psn-pdf
June 22, 2016 - Measuring variation in use of the WHO surgical safety
checklist in the operating room: a multicenter prospective
cross-sectional study.
June 22, 2016
Russ S, Rout S, Caris J, et al. Measuring variation in use of the WHO surgical safety checklist in the
operating room: a multicenter prospective cross-sectional stud…
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psnet.ahrq.gov/node/47813/psn-pdf
March 06, 2019 - Using a spare medication vial to store multiple
medications: a potentially fatal in-home medication error.
March 6, 2019
Leonard JB, Klein-Schwartz W. Using a spare medication vial to store multiple medications: A potentially
fatal in-home medication error. Ame J Health-syst Pharm. 2019;76(5):264-265. doi:10.1093/a…
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psnet.ahrq.gov/node/843329/psn-pdf
February 01, 2023 - Improving administration and documentation of enteral
nutrition support therapy in a Veteran Affairs health care
system: use of medication administration record and bar
code scanning technology.
February 1, 2023
Chew MM, Rivas S, Chesser M, et al. Improving administration and documentation of enteral nutrition
su…
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psnet.ahrq.gov/node/867038/psn-pdf
October 30, 2024 - From reporting to improving: how root cause analysis in
teams shape patient safety culture.
October 30, 2024
Tsamasiotis C, Fiard G, Bouzat P, et al. From reporting to improving: how root cause analysis in teams
shape patient safety culture. Risk Manag Healthc Policy. 2024;17:1847-1858. doi:10.2147/rmhp.s466852.
h…
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psnet.ahrq.gov/node/855433/psn-pdf
November 15, 2023 - Room for resilience: a qualitative study about
accountability mechanisms in the relation between work-
as-done (WAD) and work-as-imagined (WAI) in hospitals.
November 15, 2023
Weenink J-W, Tresfon J, van de Voort I, et al. Room for resilience: a qualitative study about accountability
mechanisms in the relation bet…
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psnet.ahrq.gov/node/837799/psn-pdf
August 10, 2022 - Effect of a pharmacy-based centralized intravenous
admixture service on the prevalence of medication errors:
a before-and-after study.
August 10, 2022
Jessurun JG, Hunfeld NGM, Van Rosmalen J, et al. Effect of a pharmacy-based centralized intravenous
admixture service on the prevalence of medication errors: a befo…
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psnet.ahrq.gov/node/37891/psn-pdf
June 09, 2011 - Classifying and predicting errors of inpatient medication
reconciliation.
June 9, 2011
Pippins JR, Gandhi TK, Hamann C, et al. Classifying and predicting errors of inpatient medication
reconciliation. J Gen Intern Med. 2008;23(9):1414-22. doi:10.1007/s11606-008-0687-9.
https://psnet.ahrq.gov/issue/classifying-and-…
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psnet.ahrq.gov/node/48163/psn-pdf
July 31, 2019 - The MedSafer Study: a controlled trial of an electronic
decision support tool for deprescribing in acute care.
July 31, 2019
McDonald EG, Wu PE, Rashidi B, et al. The MedSafer Study: A Controlled Trial of an Electronic Decision
Support Tool for Deprescribing in Acute Care. J Am Geriatr Soc. 2019;67(9):1843-1850.
d…
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psnet.ahrq.gov/node/837761/psn-pdf
August 03, 2022 - The effectiveness of improving healthcare teams' human
factor skills using simulation-based training: a systematic
review.
August 3, 2022
Abildgren L, Lebahn-Hadidi M, Mogensen CB, et al. The effectiveness of improving healthcare teams’
human factor skills using simulation-based training: a systematic review. Adv …
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psnet.ahrq.gov/node/60361/psn-pdf
May 20, 2020 - Novel, High-Impact Studies Evaluating Health System and
Healthcare Professional Responsiveness to COVID-19
(R01).
May 20, 2020
Rockville, MD: Agency for Healthcare Research and Quality; May 14, 2020.
https://psnet.ahrq.gov/issue/novel-high-impact-studies-evaluating-health-system-and-healthcare-
professional-respo…
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psnet.ahrq.gov/node/42419/psn-pdf
July 17, 2013 - Health IT Patient Safety Action and Surveillance Plan.
July 17, 2013
Washington, DC: Office of the National Coordinator for Health Information Technology; July 2, 2013.
https://psnet.ahrq.gov/issue/health-it-patient-safety-action-and-surveillance-plan
This report from the Department of Health and Human Services (HH…