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psnet.ahrq.gov/issue/patient-perspectives-adverse-event-investigations-health-care
December 18, 2024 - Study
Patient perspectives on adverse event investigations in health care.
Citation Text:
Dijkstra-Eijkemans RI, Knap LJ, Elbers NA, et al. Patient perspectives on adverse event investigations in health care. BMC Health Serv Res. 2024;24(1):1044. doi:10.1186/s12913-024-11522-x.
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psnet.ahrq.gov/issue/involving-patients-andor-their-next-kin-serious-adverse-event-investigations-qualitative
September 25, 2024 - Study
Involving patients and/or their next of kin in serious adverse event investigations: a qualitative study on hospital perspectives.
Citation Text:
Knap LJ, Dijkstra-Eijkemans RI, Friele RD, et al. Involving patients and/or their next of kin in serious adverse event investigations: a…
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psnet.ahrq.gov/issue/learning-patient-safety-incidents-green-cross-method
June 14, 2023 - Study
Learning from patient safety incidents: The Green Cross method.
Citation Text:
Jacobsen HK, Ballangrud R, Birkeli GH. Learning from patient safety incidents: the Green Cross method. Nurs Crit Care. 2024;Epub Jun 26. doi:10.1111/nicc.13114.
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psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-reduce-risk-heparin-use
July 19, 2023 - Study
Failure mode and effects analysis to reduce risk of heparin use.
Citation Text:
Pino FA, Weidemann DK, Schroeder LL, et al. Failure mode and effects analysis to reduce risk of heparin use. Am J Health Syst Pharm. 2019;76(23):1972-1979. doi:10.1093/ajhp/zxz229.
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psnet.ahrq.gov/issue/characteristics-and-patient-impact-boarding-pediatric-emergency-department-2018-2022
October 19, 2022 - Study
Characteristics and patient impact of boarding in the pediatric emergency department, 2018-2022.
Citation Text:
Kappy B, Berkowitz D, Isbey S, et al. Characteristics and patient impact of boarding in the pediatric emergency department, 2018–2022. Am J Emerg Med. 2023;77:139-146. do…
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psnet.ahrq.gov/issue/factors-influencing-hospital-prescribing-errors-systematic-review
March 23, 2022 - Review
Factors influencing in-hospital prescribing errors: a systematic review.
Citation Text:
Mahomedradja RF, Schinkel M, Sigaloff KCE, et al. Factors influencing in‐hospital prescribing errors: a systematic review. Br J Clin Pharmacol. 2023;89(6):1724-1735. doi:10.1111/bcp.15694.
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psnet.ahrq.gov/issue/perceptions-hospital-electronic-health-record-ehr-training-support-and-patient-safety-staff
October 03, 2018 - Study
Perceptions of hospital electronic health record (EHR) training, support, and patient safety by staff position and tenure.
Citation Text:
Campione JR, Liu H. Perceptions of hospital electronic health record (EHR) training, support, and patient safety by staff position and tenure. B…
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psnet.ahrq.gov/issue/team-experiences-root-cause-analysis-process-after-sentinel-event-qualitative-case-study
October 07, 2020 - Study
Team experiences of the root cause analysis process after a sentinel event: a qualitative case study.
Citation Text:
Liepelt S, Sundal H, Kirchhoff R. Team experiences of the root cause analysis process after a sentinel event: a qualitative case study. BMC Health Serv Res. 2023;23(…
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psnet.ahrq.gov/issue/association-between-hospital-reported-leapfrog-safe-practices-scores-and-inpatient-mortality
January 23, 2020 - Study
Association between hospital-reported Leapfrog Safe Practices scores and inpatient mortality.
Citation Text:
Werner RM, McNutt RA. A New Strategy to Improve Quality. JAMA. 2009;301(13). doi:10.1001/jama.2009.423.
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psnet.ahrq.gov/issue/low-perfusion-and-missed-diagnosis-hypoxemia-pulse-oximetry-darkly-pigmented-skin-prospective
March 14, 2022 - Study
Low perfusion and missed diagnosis of hypoxemia by pulse oximetry in darkly pigmented skin: a prospective study.
Citation Text:
Gudelunas MK, Lipnick M, Hendrickson C, et al. Low perfusion and missed diagnosis of hypoxemia by pulse oximetry in darkly pigmented skin: a prospective s…
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psnet.ahrq.gov/web-mm/misdiagnosis-pelvic-mass-versus-pregnancy
November 25, 2020 - Sonography in obese and overweight pregnant women: clinical, medicolegal and technical issues .
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psnet.ahrq.gov/issue/does-nursing-home-compare-reflect-patient-safety-nursing-homes
February 10, 2015 - Study
Does Nursing Home Compare reflect patient safety in nursing homes?
Citation Text:
Brauner D, Werner RM, Shippee TP, et al. Does Nursing Home Compare Reflect Patient Safety In Nursing Homes? Health Aff (Millwood). 2018;37(11):1770-1778. doi:10.1377/hlthaff.2018.0721.
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psnet.ahrq.gov/issue/effect-visitation-restrictions-ed-error
July 01, 2016 - Study
The effect of visitation restrictions on ED error.
Citation Text:
Marks CM, Wolfe RE, Grossman SA. The effect of visitation restrictions on ED error. Intern Emerg Med. 2024;19(5):1425-1430. doi:10.1007/s11739-024-03537-3.
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psnet.ahrq.gov/issue/outcomes-quality-improvement-project-educating-nurses-medication-administration-and-errors
April 24, 2018 - Study
Outcomes of a quality improvement project for educating nurses on medication administration and errors in nursing homes.
Citation Text:
Tenhunen ML, Tanner EK, Dahlen R. Outcomes of a quality improvement project for educating nurses on medication administration and errors in nursin…
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psnet.ahrq.gov/innovations-exchange
May 01, 2021 - PROMPT program requires the participation of all healthcare providers who might be called on to manage a pregnant … women and is repeated annually.
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psnet.ahrq.gov/issue/patient-awake-and-we-need-stay-calm-reconsidering-indirect-communication-face-medical-error
October 11, 2023 - Study
"The patient is awake and we need to stay calm": reconsidering indirect communication in the face of medical error and professionalism lapses.
Citation Text:
Taylor T, Columbus L, Banner H, et al. “The patient is awake and we need to stay calm”: reconsidering indirect communication…
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psnet.ahrq.gov/node/33737/psn-pdf
September 01, 2012 - Affordable Care Act also created a $1.5 billion maternal and child home visitation
program, emphasizing pregnant … women and interventions to improve health outcomes.
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psnet.ahrq.gov/issue/finnish-emergency-medical-services-managers-and-medical-directors-perceptions-collaborating
December 02, 2020 - Study
Finnish emergency medical services managers' and medical directors' perceptions of collaborating with patients concerning patient safety issues: a qualitative study.
Citation Text:
Venesoja A, Tella S, Castrén M, et al. Finnish emergency medical services managers’ and medical direc…
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psnet.ahrq.gov/issue/delivery-inadequate-level-maternal-care-associated-severe-maternal-morbidity
September 29, 2021 - Study
Delivery at an inadequate level of maternal care is associated with severe maternal morbidity.
Citation Text:
Osei-Poku GK, Prentice JC, Easter SR, et al. Delivery at an inadequate level of maternal care is associated with severe maternal morbidity. Am J Obstet Gynecol. 2024;231(5)…
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psnet.ahrq.gov/issue/computer-based-provider-order-entry-cpoe
July 20, 2022 - Tool for Improving Patient Safety
March 29, 2023
Bleeding and in pain, a pregnant … woman in Louisiana couldn’t get answers.