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9901. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867384/psn-pdf
      December 18, 2024 - Involving patients and/or their next of kin in serious adverse event investigations: a qualitative study on hospital perspectives. December 18, 2024 Knap LJ, Dijkstra-Eijkemans RI, Friele RD, et al. Involving patients and/or their next of kin in serious adverse event investigations: a qualitative study on hospital…

9902. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72568/psn-pdf
      January 01, 2021 - Alternatives to opioid education and a prescription drug monitoring program cumulatively decreased outpatient opioid prescriptions. December 16, 2020 Sigal A, Shah A, Onderdonk A, et al. Alternatives to opioid education and a prescription drug monitoring program cumulatively decreased outpatient opioid prescriptio…

9903. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45701/psn-pdf
      December 21, 2016 - Clinical decision support for drug related events: moving towards better prevention. December 21, 2016 Kane-Gill SL, Achanta A, Kellum JA, et al. Clinical decision support for drug related events: Moving towards better prevention. World J Crit Care Med. 2016;5(4):204-211. https://psnet.ahrq.gov/issue/clinical-deci…

9904. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36997/psn-pdf
      June 29, 2011 - Dispensing errors in community pharmacy: perceived influence of sociotechnical factors. June 29, 2011 Szeinbach S, Seoane-Vazquez E, Parekh A, et al. Dispensing errors in community pharmacy: perceived influence of sociotechnical factors. Int J Qual Health Care. 2007;19(4):203-9. https://psnet.ahrq.gov/issue/dispen…

9905. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74203/psn-pdf
      December 22, 2021 - Surgical safety checklist audits may be misleading! Improving the implementation and adherence of the surgical safety checklist: a quality improvement project. December 22, 2021 Brown B, Bermingham S, Vermeulen M, et al. Surgical safety checklist audits may be misleading! Improving the implementation and adherence…

9906. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74692/psn-pdf
      January 26, 2022 - Changes made to orders placed by overnight admitting residents on teaching rounds the next day. January 26, 2022 Chiel L, Freiman E, Yarahuan J, et al. Changes made to orders placed by overnight admitting residents on teaching rounds the next day. Hosp Pediatr. 2021;12(1):e35-e38. doi:10.1542/hpeds.2021-005823. ht…

9907. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35906/psn-pdf
      May 27, 2011 - Error reduction in pediatric chemotherapy: computerized order entry and failure modes and effects analysis. May 27, 2011 Kim G, Chen AR, Arceci RJ, et al. Error reduction in pediatric chemotherapy: computerized order entry and failure modes and effects analysis. Arch Pediatr Adolesc Med. 2006;160(5):495-8. https:/…

9908. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/851647/psn-pdf
      July 26, 2023 - Statewide perinatal quality improvement, teamwork, and communication activities in Oklahoma and Texas. July 26, 2023 Stierman EK, O'Brien BT, Stagg J, et al. Statewide perinatal quality improvement, teamwork, and communication activities in Oklahoma and Texas. Qual Manag Health Care. 2023;32(3):177-188. doi:10.109…

9909. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45967/psn-pdf
      July 05, 2017 - Root-cause analysis: swatting at mosquitoes versus draining the swamp. July 5, 2017 Trbovich PL, Shojania KG. Root-cause analysis: swatting at mosquitoes versus draining the swamp. BMJ Qual Saf. 2017;26(5):350-353. doi:10.1136/bmjqs-2016-006229. https://psnet.ahrq.gov/issue/root-cause-analysis-swatting-mosquitoes-…

9910. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/840147/psn-pdf
      November 16, 2022 - Electronic diagnostic support in emergency physician triage: qualitative study with thematic analysis of interviews. November 16, 2022 Sibbald M, Abdulla B, Keuhl A, et al. Electronic diagnostic support in emergency physician triage: qualitative study with thematic analysis of interviews. JMIR Hum Factors. 2022;9(…

9911. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47198/psn-pdf
      August 22, 2018 - Health IT Safe Practices for Closing the Loop. August 22, 2018 Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI; August 2018. https://psnet.ahrq.gov/issue/health-it-safe-practices-closing-loop Inadequate follow-up of test results can contribute to missed and delayed diagnoses. Developing optimal…

9912. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36902/psn-pdf
      June 09, 2010 - Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality. June 9, 2010 Catchpole K, de Leval MR, McEwan A, et al. Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality. Paediatr …

9913. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60540/psn-pdf
      November 01, 2016 - Quality improvement initiatives lead to reduction in nulliparous term singleton vertex cesarean delivery rate. November 1, 2016 Vadnais MA, Hacker MR, Shah NT, et al. Quality improvement initiatives lead to reduction in nulliparous term singleton vertex cesarean delivery rate. Jt Comm J Qual Patient Saf. 2016;43(2)…

9914. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/862988/psn-pdf
      February 21, 2024 - Identifying and classifying diagnostic errors in acute care across hospitals: early lessons from the Utility of Predictive Systems in Diagnostic Errors (UPSIDE) study. February 21, 2024 Dalal AK, Schnipper JL, Raffel K, et al. Identifying and classifying diagnostic errors in acute care across hospitals: early less…

9915. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36386/psn-pdf
      July 14, 2010 - Learning from different lenses: reports of medical errors in primary care by clinicians, staff, and patients: a project of the American Academy of Family Physicians National Research Network. July 14, 2010 Phillips RL, Dovey SM, Graham D, et al. Learning From Different Lenses: Reports of Medical Errors in Primary…

9916. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853959/psn-pdf
      September 27, 2023 - Scaling up a diagnostic pause at the ICU-to-ward transition: an exploration of barriers and facilitators to implementation of the ICU-PAUSE handoff tool. September 27, 2023 Cornell EG, Harris E, McCune E, et al. Scaling up a diagnostic pause at the ICU-to-ward transition: an exploration of barriers and facilitator…

9917. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836984/psn-pdf
      April 27, 2022 - A 6-year thematic review of reported incidents associated with cardiopulmonary resuscitation calls in a United Kingdom hospital. April 27, 2022 Beed M, Hussain S, Woodier N, et al. A 6-year thematic review of reported incidents associated with cardiopulmonary resuscitation calls in a United Kingdom hospital. J Pat…

9918. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/764398/psn-pdf
      March 02, 2022 - What do we really know about crew resource management in healthcare?: An umbrella review on crew resource management and its effectiveness. March 2, 2022 Buljac-Samardzic M, Dekker-van Doorn CM, Maynard MT. What do we really know about crew resource management in healthcare?: An umbrella review on crew resource ma…

9919. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41211/psn-pdf
      January 03, 2017 - He thought the "lady in the door" was the "lady in the window": a qualitative study of patient identification practices. January 3, 2017 Phipps E, Turkel M, Mackenzie ER, et al. He thought the "lady in the door" was the "lady in the window": a qualitative study of patient identification practices. Jt Comm J Qual P…

9920. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836824/psn-pdf
      March 30, 2022 - Collaborative case review: a systems-based approach to patient safety event investigation and analysis. March 30, 2022 Lacson R, Khorasani R, Fiumara K, et al. Collaborative case review: a systems-based approach to patient safety event investigation and analysis. J Patient Saf. 2022;18(2):e522-e527. doi:10.1097/pt…