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NICU medication errors: identifying a risk profile for medication errors in the neonatal intensive care unit. | PSNet

psnet.ahrq.gov/issue/nicu-medication-errors-identifying-risk-profile-medication-errors-neonatal-intensive-care

September 21, 2008 - Study NICU medication errors: identifying a risk profile for medication errors in the neonatal intensive care unit. Citation Text: Stavroudis TA, Shore AD, Morlock L, et al. NICU medication errors: identifying a risk profile for medication errors in the neonatal intensive care unit. J Pe…

Harmful medication errors involving unfractionated and low-molecular-weight heparin in three patient safety reporting programs. | PSNet

psnet.ahrq.gov/issue/harmful-medication-errors-involving-unfractionated-and-low-molecular-weight-heparin-three

October 23, 2018 - Study Harmful medication errors involving unfractionated and low-molecular-weight heparin in three patient safety reporting programs. Citation Text: Grissinger MC, Hicks RW, Keroack MA, et al. Harmful medication errors involving unfractionated and low-molecular-weight heparin in three pa…

Misdiagnosis of thoracic aortic emergencies occurs frequently among transfers to aortic referral centers: an analysis of over 3700 patients. | PSNet

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October 28, 2020 - Study Misdiagnosis of thoracic aortic emergencies occurs frequently among transfers to aortic referral centers: an analysis of over 3700 patients. Citation Text: Arnaoutakis GJ, Ogami T, Aranda‐Michel E, et al. Misdiagnosis of thoracic aortic emergencies occurs frequently among transfers…

Design and implementation of an automated email notification system for results of tests pending at discharge. | PSNet

psnet.ahrq.gov/issue/design-and-implementation-automated-email-notification-system-results-tests-pending-discharge

March 04, 2015 - Study Design and implementation of an automated email notification system for results of tests pending at discharge. Citation Text: Dalal A, Schnipper JL, Poon EG, et al. Design and implementation of an automated email notification system for results of tests pending at discharge. J Am M…

Reporting of death in US Food and Drug Administration medical device adverse event reports in categories other than death. | PSNet

psnet.ahrq.gov/issue/reporting-death-us-food-and-drug-administration-medical-device-adverse-event-reports

April 07, 2019 - Study Reporting of death in US Food and Drug Administration medical device adverse event reports in categories other than death. Citation Text: Lalani C, Kunwar EM, Kinard M, et al. Reporting of death in US Food and Drug Administration medical device adverse event reports in categories o…

Evaluating the implementation and impact of a pharmacy technician-supported medicines administration service designed to reduce omitted doses in hospitals: a qualitative study. | PSNet

psnet.ahrq.gov/issue/evaluating-implementation-and-impact-pharmacy-technician-supported-medicines-administration

November 14, 2018 - Study Evaluating the implementation and impact of a pharmacy technician-supported medicines administration service designed to reduce omitted doses in hospitals: a qualitative study. Citation Text: Seston EM, Ashcroft DM, Lamerton E, et al. Evaluating the implementation and impact of a p…

Performance of a fail-safe system to follow up abnormal mammograms in primary care. | PSNet

psnet.ahrq.gov/issue/performance-fail-safe-system-follow-abnormal-mammograms-primary-care

September 11, 2013 - Study Performance of a fail-safe system to follow up abnormal mammograms in primary care. Citation Text: Grossman E, Phillips RS, Weingart SN. Performance of a fail-safe system to follow up abnormal mammograms in primary care. J Patient Saf. 2010;6(3):172-179. Copy Citation Format:…

Clinical outcomes of a home-based medication reconciliation program after discharge from a skilled nursing facility. | PSNet

psnet.ahrq.gov/issue/clinical-outcomes-home-based-medication-reconciliation-program-after-discharge-skilled

March 21, 2017 - Study Clinical outcomes of a home-based medication reconciliation program after discharge from a skilled nursing facility. Citation Text: Delate T, Chester EA, Stubbings TW, et al. Clinical outcomes of a home-based medication reconciliation program after discharge from a skilled nursin…

Beating the weekend trend: increased mortality in older adult traumatic brain injury (TBI) patients admitted on weekends. | PSNet

psnet.ahrq.gov/issue/beating-weekend-trend-increased-mortality-older-adult-traumatic-brain-injury-tbi-patients

December 21, 2014 - Slideset Beating the weekend trend: increased mortality in older adult traumatic brain injury (TBI) patients admitted on weekends. Citation Text: Schneider EB, Hirani SA, Hambridge HL, et al. Beating the weekend trend: increased mortality in older adult traumatic brain injury (TBI) pat…

How do hospital inpatients conceptualise patient safety? A qualitative interview study using constructivist grounded theory. | PSNet

psnet.ahrq.gov/issue/how-do-hospital-inpatients-conceptualise-patient-safety-qualitative-interview-study-using

July 08, 2020 - Study How do hospital inpatients conceptualise patient safety? A qualitative interview study using constructivist grounded theory. Citation Text: Barrow E, Lear RA, Morbi A, et al. How do hospital inpatients conceptualise patient safety? A qualitative interview study using constructivist…

Factors influencing providers' willingness to deprescribe medications. | PSNet

psnet.ahrq.gov/issue/factors-influencing-providers-willingness-deprescribe-medications

November 17, 2021 - Study Factors influencing providers' willingness to deprescribe medications. Citation Text: Davila H, Rosen AK, Stolzmann K, et al. Factors influencing providers' willingness to deprescribe medications. J Am Coll Clin Pharm. 2022;5:15-25. doi:10.1002/jac5.1537. Copy Citation Format…

Examining the relationship of an all-cause harm patient safety measure and critical performance measures at the frontline of care. | PSNet

psnet.ahrq.gov/issue/examining-relationship-all-cause-harm-patient-safety-measure-and-critical-performance

May 19, 2018 - Study Examining the relationship of an all-cause harm patient safety measure and critical performance measures at the frontline of care. Citation Text: Sammer C, Hauck L, Jones C, et al. Examining the Relationship of an All-Cause Harm Patient Safety Measure and Critical Performance Measu…

Identifying electronic medication administration record (eMAR) usability issues from patient safety event reports. | PSNet

psnet.ahrq.gov/issue/identifying-electronic-medication-administration-record-emar-usability-issues-patient-safety

July 07, 2021 - Study Identifying electronic medication administration record (eMAR) usability issues from patient safety event reports. Citation Text: Iqbal AR, Parau CA, Kazi S, et al. Identifying electronic medication administration record (eMAR) usability issues from patient safety event reports. Jt…

Discrepancy between emergency department admission diagnosis and hospital discharge diagnosis and its impact on length of stay, up-triage to the intensive care unit, and mortality. | PSNet

psnet.ahrq.gov/issue/discrepancy-between-emergency-department-admission-diagnosis-and-hospital-discharge-diagnosis

December 08, 2021 - Study Discrepancy between emergency department admission diagnosis and hospital discharge diagnosis and its impact on length of stay, up-triage to the intensive care unit, and mortality. Citation Text: Bastakoti M, Muhailan M, Nassar A, et al. Discrepancy between emergency department adm…

Breakdowns in the initial patient-provider encounter are a frequent source of diagnostic error among ischemic stroke cases included in a large medical malpractice claims database. | PSNet

psnet.ahrq.gov/issue/breakdowns-initial-patient-provider-encounter-are-frequent-source-diagnostic-error-among

January 23, 2019 - Review Breakdowns in the initial patient-provider encounter are a frequent source of diagnostic error among ischemic stroke cases included in a large medical malpractice claims database. Citation Text: Liberman AL, Skillings J, Greenberg P, et al. Breakdowns in the initial patient-provid…

Symptom–Disease Pair Analysis of Diagnostic Error (SPADE): a conceptual framework and methodological approach for unearthing misdiagnosis-related harms using big data. | PSNet

psnet.ahrq.gov/issue/symptom-disease-pair-analysis-diagnostic-error-spade-conceptual-framework-and-methodological

October 23, 2019 - Review Classic Symptom–Disease Pair Analysis of Diagnostic Error (SPADE): a conceptual framework and methodological approach for unearthing misdiagnosis-related harms using big data. Citation Text: Liberman AL, Newman-Toker DE. Symptom-Disease Pair Analysis of D…

Inpatient fall prevention programs as a patient safety strategy: a systematic review. | PSNet

psnet.ahrq.gov/issue/inpatient-fall-prevention-programs-patient-safety-strategy-systematic-review

May 26, 2016 - Review Inpatient fall prevention programs as a patient safety strategy: a systematic review. Citation Text: Miake-Lye IM, Hempel S, Ganz DA, et al. Inpatient fall prevention programs as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):390-396. doi:10.732…

What can we learn from in-depth analysis of human errors resulting in diagnostic errors in the emergency department: an analysis of serious adverse event reports. | PSNet

psnet.ahrq.gov/issue/what-can-we-learn-depth-analysis-human-errors-resulting-diagnostic-errors-emergency

June 08, 2022 - Study What can we learn from in-depth analysis of human errors resulting in diagnostic errors in the emergency department: an analysis of serious adverse event reports. Citation Text: Baartmans MC, Hooftman J, Zwaan L, et al. What can we learn from in-depth analysis of human errors resul…

Effect of medication reconciliation at hospital admission on medication discrepancies during hospitalization and at discharge for geriatric patients. | PSNet

psnet.ahrq.gov/issue/effect-medication-reconciliation-hospital-admission-medication-discrepancies-during

August 26, 2020 - Study Effect of medication reconciliation at hospital admission on medication discrepancies during hospitalization and at discharge for geriatric patients. Citation Text: Cornu P, Steurbaut S, Leysen T, et al. Effect of medication reconciliation at hospital admission on medication disc…

A program to provide clinicians with feedback on their diagnostic performance in a learning health system. | PSNet

psnet.ahrq.gov/issue/program-provide-clinicians-feedback-their-diagnostic-performance-learning-health-system

October 12, 2022 - Study A program to provide clinicians with feedback on their diagnostic performance in a learning health system. Citation Text: Meyer AND, Upadhyay DK, Collins CA, et al. A program to provide clinicians with feedback on their diagnostic performance in a learning health system. Jt Comm J …

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