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psnet.ahrq.gov/issue/development-and-applications-veterans-health-administrations-stratification-tool-opioid-risk
April 01, 2020 - Study
Development and applications of the Veterans Health Administration's Stratification Tool for Opioid Risk Mitigation (STORM) to improve opioid safety and prevent overdose and suicide.
Citation Text:
Oliva EM, Bowe T, Tavakoli S, et al. Development and applications of the Veterans He…
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psnet.ahrq.gov/issue/us-public-opinion-regarding-proposed-limits-resident-physician-work-hours
February 18, 2011 - Study
US public opinion regarding proposed limits on resident physician work hours.
Citation Text:
Blum AB, Raiszadeh F, Shea S, et al. US public opinion regarding proposed limits on resident physician work hours. BMC Med. 2010;8:33. doi:10.1186/1741-7015-8-33.
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psnet.ahrq.gov/issue/minding-gaps-assessing-communication-outcomes-electronic-preconsultation-exchange
November 30, 2016 - Study
Minding the gaps: assessing communication outcomes of electronic preconsultation exchange.
Citation Text:
Price EL, Sewell JL, Chen AH, et al. Minding the Gaps: Assessing Communication Outcomes of Electronic Preconsultation Exchange. Jt Comm J Qual Patient Saf. 2016;42(8):341-54.
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psnet.ahrq.gov/issue/speaking-about-traditional-and-professionalism-related-patient-safety-threats-national-survey
November 20, 2015 - Study
Classic
Speaking up about traditional and professionalism-related patient safety threats: a national survey of interns and residents.
Citation Text:
Martinez W, Lehmann LS, Thomas EJ, et al. Speaking up about traditional and professionalism-related patient…
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psnet.ahrq.gov/issue/impact-commercial-order-entry-system-prescribing-errors-amenable-computerised-decision
December 21, 2022 - Study
Impact of a commercial order entry system on prescribing errors amenable to computerised decision support in the hospital setting: a prospective pre–post study.
Citation Text:
Pontefract SK, Hodson J, Slee A, et al. Impact of a commercial order entry system on prescribing errors am…
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psnet.ahrq.gov/issue/engaging-patients-medication-reconciliation-patient-portal-following-hospital-discharge
February 03, 2011 - Study
Engaging patients in medication reconciliation via a patient portal following hospital discharge.
Citation Text:
Heyworth L, Paquin AM, Clark J, et al. Engaging patients in medication reconciliation via a patient portal following hospital discharge. J Am Med Inform Assoc. 2014;21(e…
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psnet.ahrq.gov/issue/electronic-health-record-based-real-time-analytics-program-patient-safety-surveillance-and
May 19, 2018 - Study
An electronic health record–based real-time analytics program for patient safety surveillance and improvement.
Citation Text:
Classen D, Li M, Miller S, et al. An Electronic Health Record-Based Real-Time Analytics Program For Patient Safety Surveillance And Improvement. Health Aff …
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psnet.ahrq.gov/issue/association-label-drug-use-and-adverse-drug-events-adult-population
February 03, 2011 - Study
Classic
Association of off-label drug use and adverse drug events in an adult population.
Citation Text:
Eguale T, Buckeridge DL, Verma A, et al. Association of Off-label Drug Use and Adverse Drug Events in an Adult Population. JAMA Intern Med. 2016;176(1)…
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psnet.ahrq.gov/issue/what-stops-hospital-clinical-staff-following-protocols-analysis-incidence-and-factors-behind
September 09, 2015 - Study
What stops hospital clinical staff from following protocols? An analysis of the incidence and factors behind the failure of bedside clinical staff to activate the rapid response system in a multi-campus Australian metropolitan healthcare service.
Citation Text:
Shearer B, Marshal…
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psnet.ahrq.gov/issue/communication-between-primary-and-secondary-care-deficits-and-danger
September 23, 2020 - Study
Communication between primary and secondary care: deficits and danger.
Citation Text:
Dinsdale E, Hannigan A, O’Connor R, et al. Communication between primary and secondary care: deficits and danger. Fam Pract. 2019;17(1):63-68. doi:10.1093/fampra/cmz037.
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psnet.ahrq.gov/issue/missed-acute-myocardial-infarction-emergency-department-standardizing-measurement
May 12, 2021 - Study
Missed acute myocardial infarction in the emergency department-standardizing measurement of misdiagnosis-related harms using the SPADE method.
Citation Text:
Sharp AL, Baecker A, Nassery N, et al. Missed acute myocardial infarction in the emergency department–standardizing measurem…
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psnet.ahrq.gov/issue/national-implementation-project-prevent-catheter-associated-urinary-tract-infection-nursing
April 05, 2017 - Study
Classic
A national implementation project to prevent catheter-associated urinary tract infection in nursing home residents.
Citation Text:
Mody L, Greene T, Meddings J, et al. A National Implementation Project to Prevent Catheter-Associated Urinary Tract I…
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psnet.ahrq.gov/issue/pharmacist-led-information-technology-intervention-medication-errors-pincer-multicentre
January 11, 2023 - Study
Classic
A pharmacist-led information technology intervention for medication errors (PINCER): a multicentre, cluster randomised, controlled trial and cost-effectiveness analysis.
Citation Text:
Avery A, Rodgers S, Cantrill JA, et al. A pharmacist-led info…
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psnet.ahrq.gov/issue/iatroref-study-medical-errors-are-associated-symptoms-depression-icu-staff-not-burnout-or
April 12, 2011 - Study
The Iatroref study: medical errors are associated with symptoms of depression in ICU staff but not burnout or safety culture.
Citation Text:
Garrouste-Orgeas M, Perrin M, Soufir L, et al. The Iatroref study: medical errors are associated with symptoms of depression in ICU staff but…
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psnet.ahrq.gov/issue/effect-hospital-multifaceted-clinical-pharmacist-intervention-risk-readmission-randomized
September 13, 2023 - Study
Classic
Effect of an in-hospital multifaceted clinical pharmacist intervention on the risk of readmission: a randomized clinical trial.
Citation Text:
Ravn-Nielsen LV, Duckert M-L, Lund ML, et al. Effect of an In-Hospital Multifaceted Clinical Pharmacist I…
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psnet.ahrq.gov/issue/tackling-ambulatory-safety-risks-through-patient-engagement-what-10000-patients-and-families
March 20, 2017 - Study
Tackling ambulatory safety risks through patient engagement: what 10,000 patients and families say about safety-related knowledge, behaviors, and attitudes after reading visit notes.
Citation Text:
Bell SK, Folcarelli P, Fossa A, et al. Tackling Ambulatory Safety Risks Through Pati…
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psnet.ahrq.gov/node/867698/psn-pdf
October 01, 2024 - Toolkit for MRSA Prevention in ICU & Non-ICU Settings.
October 1, 2024
Agency for Healthcare Research and Quality. Toolkit for MRSA Prevention in ICU & Non-ICU Settings.
October 2024.
https://psnet.ahrq.gov/issue/toolkit-mrsa-prevention-icu-non-icu-settings
Methicillin-resistant Staphylococcus aureus (MRSA) infect…
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psnet.ahrq.gov/node/73201/psn-pdf
March 04, 2024 - Diagnostic Safety Supplemental Item Set for Medical
Office SOPS.
March 4, 2024
Agency for Healthcare Research and Quality.
https://psnet.ahrq.gov/issue/diagnostic-safety-supplemental-item-set-medical-office-sops
Safe diagnosis in medical offices is challenged by staff workload, communication, and poor inform…
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psnet.ahrq.gov/node/36110/psn-pdf
April 04, 2024 - Sentinel Event Data Summary.
April 4, 2024
Joint Commission.
https://psnet.ahrq.gov/issue/sentinel-event-statistics-1995-2019
This website provides sentinel event data reported to The Joint Commission, which includes information on
sentinel events reported from January through December 2023. Falls, wrong surgery a…
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psnet.ahrq.gov/node/50595/psn-pdf
January 01, 2020 - Clinical reasoning as a core competency.
October 30, 2019
Connor DM, Durning SJ, Rencic J. Clinical Reasoning as a Core Competency. Acad Med.
2020;95(8):1166-1171. doi:10.1097/acm.0000000000003027.
https://psnet.ahrq.gov/issue/clinical-reasoning-core-competency
Enhancing clinical reasoning skill, particularly amon…