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  1. ED overcrowding is associated with an increased frequency of medication errors. | PSNet

    psnet.ahrq.gov/issue/ed-overcrowding-associated-increased-frequency-medication-errors
    August 20, 2018 - Study ED overcrowding is associated with an increased frequency of medication errors. Citation Text: Kulstad EB, Sikka R, Sweis RT, et al. ED overcrowding is associated with an increased frequency of medication errors. Am J Emerg Med. 2010;28(3):304-309. doi:10.1016/j.ajem.2008.12.014. …

  2. Computerized physician order entry with clinical decision support in long-term care facilities: costs and benefits to stakeholders. | PSNet

    psnet.ahrq.gov/issue/computerized-physician-order-entry-clinical-decision-support-long-term-care-facilities-costs
    March 29, 2010 - Review Computerized physician order entry with clinical decision support in long-term care facilities: costs and benefits to stakeholders. Citation Text: Subramanian S, Hoover S, Gilman BH, et al. Computerized physician order entry with clinical decision support in long-term care fac…

  3. Predictors of serious opioid-related adverse drug events in hospitalized patients. | PSNet

    psnet.ahrq.gov/issue/predictors-serious-opioid-related-adverse-drug-events-hospitalized-patients
    March 10, 2021 - Study Predictors of serious opioid-related adverse drug events in hospitalized patients. Citation Text: Minhaj FS, Rappaport SH, Foster J, et al. Predictors of serious opioid-related adverse drug events in hospitalized patients. J Patient Saf. 2020;17(8):e1585-e1588. doi:10.1097/pts.0000…

  4. Handshake antimicrobial stewardship as a model to recognize and prevent diagnostic errors. | PSNet

    psnet.ahrq.gov/issue/handshake-antimicrobial-stewardship-model-recognize-and-prevent-diagnostic-errors
    September 29, 2021 - Study Handshake antimicrobial stewardship as a model to recognize and prevent diagnostic errors. Citation Text: Searns JB, Williams MC, MacBrayne CE, et al. Handshake antimicrobial stewardship as a model to recognize and prevent diagnostic errors. Diagnosis (Berl). 2021;8(3):347-352. doi…

  5. How timely is diagnosis of lung cancer? Cohort study of individuals with lung cancer presenting in ambulatory care in the United States. | PSNet

    psnet.ahrq.gov/issue/how-timely-diagnosis-lung-cancer-cohort-study-individuals-lung-cancer-presenting-ambulatory
    September 14, 2022 - Study How timely is diagnosis of lung cancer? Cohort study of individuals with lung cancer presenting in ambulatory care in the United States. Citation Text: Zigman Suchsland M, Kowalski L, Burkhardt HA, et al. How timely is diagnosis of lung cancer? Cohort study of individuals with lung…

  6. Weight and size descriptors for drug dosing: too many options and too many errors. | PSNet

    psnet.ahrq.gov/issue/weight-and-size-descriptors-drug-dosing-too-many-options-and-too-many-errors
    April 06, 2022 - Commentary Weight and size descriptors for drug dosing: too many options and too many errors. Citation Text: Erstad BL, Romero AV, Barletta JF. Weight and size descriptors for drug dosing: Too many options and too many errors. Am J Health Syst Pharm. 2023;80(2):87-91. doi:10.1093/ajhp/zx…

  7. Impact of smart pump-electronic health record interoperability on patient safety and finances at a community hospital | PSNet

    psnet.ahrq.gov/issue/impact-smart-pump-electronic-health-record-interoperability-patient-safety-and-finances
    September 23, 2020 - Study Impact of smart pump-electronic health record interoperability on patient safety and finances at a community hospital Citation Text: Wei W, Coffey W, Adeola M, et al. Impact of smart pump-electronic health record interoperability on patient safety and finances at a community hospit…

  8. Effect of a real-time pediatric ICU safety bundle dashboard on quality improvement measures. | PSNet

    psnet.ahrq.gov/issue/effect-real-time-pediatric-icu-safety-bundle-dashboard-quality-improvement-measures
    June 21, 2015 - Study Effect of a real-time pediatric ICU safety bundle dashboard on quality improvement measures. Citation Text: Shaw SJ, Jacobs B, Stockwell DC, et al. Effect of a Real-Time Pediatric ICU Safety Bundle Dashboard on Quality Improvement Measures. Jt Comm J Qual Patient Saf. 2015;41(9):41…

  9. Smartphone use during inpatient attending rounds: prevalence, patterns and potential for distraction. | PSNet

    psnet.ahrq.gov/issue/smartphone-use-during-inpatient-attending-rounds-prevalence-patterns-and-potential
    June 24, 2010 - Study Smartphone use during inpatient attending rounds: prevalence, patterns and potential for distraction. Citation Text: Katz-Sidlow RJ, Ludwig A, Miller S, et al. Smartphone use during inpatient attending rounds: prevalence, patterns and potential for distraction. J Hosp Med. 2012;7(8…

  10. Impact of clinical decision support therapeutic interchanges on hospital discharge medication omissions and duplications. | PSNet

    psnet.ahrq.gov/issue/impact-clinical-decision-support-therapeutic-interchanges-hospital-discharge-medication
    July 29, 2020 - Study Impact of clinical decision support therapeutic interchanges on hospital discharge medication omissions and duplications. Citation Text: Maxwell E, Amerine J, Carlton G, et al. Impact of clinical decision support therapeutic interchanges on hospital discharge medication omissions a…

  11. Risk reduction strategy to decrease incidence of retained surgical items. | PSNet

    psnet.ahrq.gov/issue/risk-reduction-strategy-decrease-incidence-retained-surgical-items
    July 06, 2022 - Study Risk reduction strategy to decrease incidence of retained surgical items. Citation Text: Kaplan HJ, Spiera ZC, Feldman DL, et al. Risk reduction strategy to decrease incidence of retained surgical items. J Am Coll Surg. 2022;235(3):494-499. doi:10.1097/xcs.0000000000000264. Copy …

  12. Use of recalled devices in new device authorizations under the US Food and Drug Administration's 510(k) pathway and risk of subsequent recalls. | PSNet

    psnet.ahrq.gov/issue/use-recalled-devices-new-device-authorizations-under-us-food-and-drug-administrations-510k
    April 13, 2022 - Study Use of recalled devices in new device authorizations under the US Food and Drug Administration's 510(k) pathway and risk of subsequent recalls. Citation Text: Kramer DB, Yeh RW. Use of recalled devices in new device authorizations under the US Food and Drug Administration's 510(k) …

  13. Developing strategic recommendations for implementing smart pumps in advanced healthcare systems to improve intravenous medication safety. | PSNet

    psnet.ahrq.gov/issue/developing-strategic-recommendations-implementing-smart-pumps-advanced-healthcare-systems
    August 24, 2022 - Commentary Developing strategic recommendations for implementing smart pumps in advanced healthcare systems to improve intravenous medication safety. Citation Text: Sutherland A, Jones MD, Howlett M, et al. Developing strategic recommendations for implementing smart pumps in advanced hea…

  14. Why do systems for responding to concerns and complaints so often fail patients, families and healthcare staff? | PSNet

    psnet.ahrq.gov/issue/why-do-systems-responding-concerns-and-complaints-so-often-fail-patients-families-and
    June 16, 2021 - Study Why do systems for responding to concerns and complaints so often fail patients, families and healthcare staff? Citation Text: Martin GP, Chew S, Dixon-Woods M. Why do systems for responding to concerns and complaints so often fail patients, families and healthcare staff? A qualita…

  15. Occurrence, prevention, and management of the psychological effects of emerging virus outbreaks on healthcare workers: rapid review and meta-analysis. | PSNet

    psnet.ahrq.gov/issue/occurrence-prevention-and-management-psychological-effects-emerging-virus-outbreaks
    July 19, 2023 - Review Classic Occurrence, prevention, and management of the psychological effects of emerging virus outbreaks on healthcare workers: rapid review and meta-analysis. Citation Text: Kisely S, Warren N, McMahon L, et al. Occurrence, prevention, and management of t…

  16. Using the Global Trigger Tool in surgical and neurosurgical patients: a feasibility study. | PSNet

    psnet.ahrq.gov/issue/using-global-trigger-tool-surgical-and-neurosurgical-patients-feasibility-study
    June 09, 2021 - Study Using the Global Trigger Tool in surgical and neurosurgical patients: a feasibility study. Citation Text: Brösterhaus M, Hammer A, Gruber R, et al. Using the Global Trigger Tool in surgical and neurosurgical patients: a feasibility study. PLoS ONE. 2022;17(8):e0272853. doi:10.1371/…

  17. Why do healthcare professionals fail to escalate as per the early warning system (EWS) protocol? A qualitative evidence synthesis of the barriers and facilitators of escalation. | PSNet

    psnet.ahrq.gov/issue/why-do-healthcare-professionals-fail-escalate-early-warning-system-ews-protocol-qualitative
    August 25, 2021 - Review Emerging Classic Why do healthcare professionals fail to escalate as per the early warning system (EWS) protocol? A qualitative evidence synthesis of the barriers and facilitators of escalation. Citation Text: O’Neill SM, Clyne B, Bell M, et al. Why do h…

  18. Variations in surgical outcomes associated with hospital compliance with safety practices. | PSNet

    psnet.ahrq.gov/issue/variations-surgical-outcomes-associated-hospital-compliance-safety-practices
    June 14, 2017 - Study Variations in surgical outcomes associated with hospital compliance with safety practices. Citation Text: Brooke BS, Dominici F, Pronovost P, et al. Variations in surgical outcomes associated with hospital compliance with safety practices. Surgery. 2012;151(5):651-9. doi:10.1016/…

  19. Combined impact of Medicare's hospital pay for performance programs on quality and safety outcomes is mixed. | PSNet

    psnet.ahrq.gov/issue/combined-impact-medicares-hospital-pay-performance-programs-quality-and-safety-outcomes-mixed
    December 08, 2021 - Study Combined impact of Medicare's hospital pay for performance programs on quality and safety outcomes is mixed. Citation Text: Waters TM, Burns N, Kaplan CM, et al. Combined impact of Medicare’s hospital pay for performance programs on quality and safety outcomes is mixed. BMC Health …

  20. Health care workers' experiences of workplace incidents that posed a risk of patient and worker injury: a critical incident technique analysis. | PSNet

    psnet.ahrq.gov/issue/health-care-workers-experiences-workplace-incidents-posed-risk-patient-and-worker-injury
    June 23, 2021 - Study Health care workers' experiences of workplace incidents that posed a risk of patient and worker injury: a critical incident technique analysis. Citation Text: Strid EN, Wåhlin C, Ros A, et al. Health care workers’ experiences of workplace incidents that posed a risk of patient and …
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