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2921. Identifying and characterizing preventable adverse drug events for prioritizing pharmacist intervention in hospitals. | PSNet
      psnet.ahrq.gov/issue/identifying-and-characterizing-preventable-adverse-drug-events-prioritizing-pharmacist
      July 15, 2010 - Study Identifying and characterizing preventable adverse drug events for prioritizing pharmacist intervention in hospitals. Citation Text: Jeon N, Staley B, Johns T, et al. Identifying and characterizing preventable adverse drug events for prioritizing pharmacist intervention in hospital…

2922. Two sides of the safety coin?: how patient engagement and safety climate jointly affect error occurrence in hospital units. | PSNet
      psnet.ahrq.gov/issue/two-sides-safety-coin-how-patient-engagement-and-safety-climate-jointly-affect-error
      March 11, 2020 - Study Two sides of the safety coin?: how patient engagement and safety climate jointly affect error occurrence in hospital units. Citation Text: Schiffinger M, Latzke M, Steyrer J. Two sides of the safety coin?: How patient engagement and safety climate jointly affect error occurrence in…

2923. Machine learning evaluation of inequities and disparities associated with nurse sensitive indicator safety events. | PSNet
      psnet.ahrq.gov/issue/machine-learning-evaluation-inequities-and-disparities-associated-nurse-sensitive-indicator
      July 19, 2023 - Study Machine learning evaluation of inequities and disparities associated with nurse sensitive indicator safety events. Citation Text: Georgantes ER, Gunturkun F, McGreevy TJ, et al. Machine learning evaluation of inequities and disparities associated with nurse sensitive indicator safe…

2924. Introduction of a rapid response system at a United States Veterans Affairs hospital reduced cardiac arrests. | PSNet
      psnet.ahrq.gov/issue/introduction-rapid-response-system-united-states-veterans-affairs-hospital-reduced-cardiac
      January 02, 2017 - Study Introduction of a rapid response system at a United States Veterans Affairs hospital reduced cardiac arrests. Citation Text: Lighthall GK, Parast L, Rapoport L, et al. Introduction of a rapid response system at a United States veterans affairs hospital reduced cardiac arrests. Anes…

2925. Empowerment failure: how shortcomings in physician communication unwittingly undermine patient autonomy. | PSNet
      psnet.ahrq.gov/issue/empowerment-failure-how-shortcomings-physician-communication-unwittingly-undermine-patient
      January 17, 2019 - Study Empowerment failure: how shortcomings in physician communication unwittingly undermine patient autonomy. Citation Text: Ubel PA, Scherr KA, Fagerlin A. Empowerment Failure: How Shortcomings in Physician Communication Unwittingly Undermine Patient Autonomy. Am J Bioeth. 2017;17(11):…

2926. Neurobehavioral performance of residents after heavy night call vs after alcohol ingestion. | PSNet
      psnet.ahrq.gov/issue/neurobehavioral-performance-residents-after-heavy-night-call-vs-after-alcohol-ingestion
      June 22, 2022 - Study Neurobehavioral performance of residents after heavy night call vs after alcohol ingestion. Citation Text: Arnedt JT, Owens J, Crouch M, et al. Neurobehavioral Performance of Residents After Heavy Night Call vs After Alcohol Ingestion. JAMA. 2005;294(9). doi:10.1001/jama.294.9.10…

2927. Standardizing patient safety event reporting between care delivered or purchased by the Veterans Health Administration (VHA). | PSNet
      psnet.ahrq.gov/issue/standardizing-patient-safety-event-reporting-between-care-delivered-or-purchased-veterans
      June 26, 2024 - Study Standardizing patient safety event reporting between care delivered or purchased by the Veterans Health Administration (VHA). Citation Text: Rosen AK, Beilstein-Wedel E, Chan J, et al. Standardizing patient safety event reporting between care delivered or purchased by the Veterans …

2928. What quality and safety of care for patients admitted to clinically inappropriate wards: a systematic review. | PSNet
      psnet.ahrq.gov/issue/what-quality-and-safety-care-patients-admitted-clinically-inappropriate-wards-systematic
      February 15, 2023 - Review What quality and safety of care for patients admitted to clinically inappropriate wards: a systematic review. Citation Text: La Regina M, Guarneri F, Romano E, et al. What Quality and Safety of Care for Patients Admitted to Clinically Inappropriate Wards: a Systematic Review. J Ge…

2929. Differences in the rates of patient safety events by payer: implications for providers and policymakers. | PSNet
      psnet.ahrq.gov/issue/differences-rates-patient-safety-events-payer-implications-providers-and-policymakers
      November 16, 2022 - Study Differences in the rates of patient safety events by payer: implications for providers and policymakers. Citation Text: Spencer CS, Roberts ET, Gaskin DJ. Differences in the rates of patient safety events by payer: implications for providers and policymakers. Med Care. 2015;53(6):5…

2930. Stakeholder perspectives on handovers between hospital staff and general practitioners: an evaluation through the microsystems lens. | PSNet
      psnet.ahrq.gov/issue/stakeholder-perspectives-handovers-between-hospital-staff-and-general-practitioners
      October 03, 2012 - Study Stakeholder perspectives on handovers between hospital staff and general practitioners: an evaluation through the microsystems lens. Citation Text: Göbel B, Zwart DLM, Hesselink G, et al. Stakeholder perspectives on handovers between hospital staff and general practitioners: an e…

2931. Strength of improvement recommendations from injurious fall investigations: a retrospective multi-incident analysis. | PSNet
      psnet.ahrq.gov/issue/strength-improvement-recommendations-injurious-fall-investigations-retrospective-multi
      August 17, 2022 - Study Strength of improvement recommendations from injurious fall investigations: a retrospective multi-incident analysis. Citation Text: Paulik O, Hallen J, Lapkin S, et al. Strength of improvement recommendations from injurious fall investigations: a retrospective multi-incident analys…

2932. Seen through their eyes: residents' reflections on the cognitive and contextual components of diagnostic errors in medicine. | PSNet
      psnet.ahrq.gov/issue/seen-through-their-eyes-residents-reflections-cognitive-and-contextual-components-diagnostic
      November 18, 2013 - Study Seen through their eyes: residents' reflections on the cognitive and contextual components of diagnostic errors in medicine. Citation Text: Ogdie AR, Reilly JB, Pang WG, et al. Seen through their eyes: residents' reflections on the cognitive and contextual components of diagnostic…

2933. Post-operative mortality, missed care and nurse staffing in nine countries: a cross-sectional study. | PSNet
      psnet.ahrq.gov/issue/post-operative-mortality-missed-care-and-nurse-staffing-nine-countries-cross-sectional-study
      December 12, 2014 - Study Classic Post-operative mortality, missed care and nurse staffing in nine countries: a cross-sectional study. Citation Text: Ball JE, Bruyneel L, Aiken LH, et al. Post-operative mortality, missed care and nurse staffing in nine countries: A cross-sectional …

2934. Strengthening Patient Engagement to Improve Care and Shared Decision Making - Emerging Research | Digital Healthcare Research
      digital.ahrq.gov/2020-year-review/research-summary/strengthening-patient-engagement-improve-care-and-shared-decision-making-emerging-research
      January 01, 2020 - Strengthening Patient Engagement to Improve Care and Shared Decision Making - Emerging Research Using Technology to Support Patient-Centered, Shared Decision Making in Care and Treatment Decisions Patient-centered shared decision making refers to the collaborative effort of a healthc…

2935. Facilitators and barriers of care transitions - comparing the perspectives of hospital and community healthcare staff. | PSNet
      psnet.ahrq.gov/issue/facilitators-and-barriers-care-transitions-comparing-perspectives-hospital-and-community
      July 21, 2021 - Study Facilitators and barriers of care transitions - comparing the perspectives of hospital and community healthcare staff. Citation Text: Carman E-M, Fray M, Waterson P. Facilitators and barriers of care transitions - comparing the perspectives of hospital and community healthcare staf…

2936. AHRQ Issues Report to Congress on Burden of Sepsis in U.S. Hospital Care | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/newsroom/press-releases/sepsis-report-to-congress.html
      September 01, 2024 - AHRQ Issues Report to Congress on Burden of Sepsis in U.S. Hospital Care Report finds the emergence of COVID-19 significantly changed the epidemiology of sepsis Press Release Date: September 16, 2024 The number of sepsis-related inpatient stays at non-federal acute care hospitals in the United States increased …

2937. Scalable Digital Communication Intervention to Support Older Adults and Care Partners Transitioning Home After Major Surgery | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/scalable-digital-communication-intervention-support-older-adults-and-care
      January 01, 2024 - Scalable Digital Communication Intervention to Support Older Adults and Care Partners Transitioning Home After Major Surgery Project Description Publications Creating a mobile application to support care transitions for older adults after surgery has the potential to prov…

2938. From board to bedside: how the application of financial structures to safety and quality can drive accountability in a large health care system. | PSNet
      psnet.ahrq.gov/issue/board-bedside-how-application-financial-structures-safety-and-quality-can-drive
      January 29, 2015 - Study From board to bedside: how the application of financial structures to safety and quality can drive accountability in a large health care system. Citation Text: Austin M, Demski R, Callender T, et al. From Board to Bedside: How the Application of Financial Structures to Safety and Q…

2939. Measuring psychological safety and local learning to enable high reliability organisational change. | PSNet
      psnet.ahrq.gov/issue/measuring-psychological-safety-and-local-learning-enable-high-reliability-organisational
      May 05, 2021 - Study Measuring psychological safety and local learning to enable high reliability organisational change. Citation Text: Cartland J, Green M, Kamm D, et al. Measuring psychological safety and local learning to enable high reliability organisational change. BMJ Open Qual. 2022;11(4):e0017…

2940. Impact of a national QI programme on reducing electronic health record notifications to clinicians. | PSNet
      psnet.ahrq.gov/issue/impact-national-qi-programme-reducing-electronic-health-record-notifications-clinicians
      February 24, 2021 - Study Classic Impact of a national QI programme on reducing electronic health record notifications to clinicians. Citation Text: Shah T, Patel-Teague S, Kroupa L, et al. Impact of a national QI programme on reducing electronic health record notifications to clin…