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Does root cause analysis improve patient safety? A systematic review at the Department of Veterans Affairs. | PSNet

psnet.ahrq.gov/issue/does-root-cause-analysis-improve-patient-safety-systematic-review-department-veterans-affairs

March 24, 2021 - Review Does root cause analysis improve patient safety? A systematic review at the Department of Veterans Affairs. Citation Text: Shah F, Falconer EA, Cimiotti JP. Does root cause analysis improve patient safety? A systematic review at the Department of Veterans Affairs. Qual Manag Healt…

What are the experiences of team members involved in root cause analysis? A qualitative study. | PSNet

psnet.ahrq.gov/issue/what-are-experiences-team-members-involved-root-cause-analysis-qualitative-study

August 16, 2023 - Study What are the experiences of team members involved in root cause analysis? A qualitative study. Citation Text: Willis R, Jones T, Hoiles J, et al. What are the experiences of team members involved in root cause analysis? A qualitative study. BMC Health Serv Res. 2023;23(1):1152. doi…

Our current approach to root cause analysis: is it contributing to our failure to improve patient safety? | PSNet

psnet.ahrq.gov/issue/our-current-approach-root-cause-analysis-it-contributing-our-failure-improve-patient-safety

October 23, 2013 - Study Classic Our current approach to root cause analysis: is it contributing to our failure to improve patient safety? Citation Text: Kellogg KM, Hettinger Z, Shah M, et al. Our current approach to root cause analysis: is it contributing to our failure to impro…

Incidence, nature and causes of avoidable significant harm in primary care in England: retrospective case note review. | PSNet

psnet.ahrq.gov/issue/incidence-nature-and-causes-avoidable-significant-harm-primary-care-england-retrospective

November 13, 2019 - Study Incidence, nature and causes of avoidable significant harm in primary care in England: retrospective case note review. Citation Text: Avery AJ, Sheehan C, Bell BG, et al. Incidence, nature and causes of avoidable significant harm in primary care in England: retrospective case note …

Creating a high-reliability health care system: improving performance on core processes of care at Johns Hopkins Medicine. | PSNet

psnet.ahrq.gov/issue/creating-high-reliability-health-care-system-improving-performance-core-processes-care-johns

January 27, 2016 - Study Creating a high-reliability health care system: improving performance on core processes of care at Johns Hopkins Medicine. Citation Text: Pronovost P, Armstrong M, Demski R, et al. Creating a high-reliability health care system: improving performance on core processes of care at Jo…

Potentially preventable 30-day hospital readmissions at a children's hospital. | PSNet

psnet.ahrq.gov/issue/potentially-preventable-30-day-hospital-readmissions-childrens-hospital

July 11, 2017 - Study Potentially preventable 30-day hospital readmissions at a children's hospital. Citation Text: Toomey SL, Peltz A, Loren S, et al. Potentially Preventable 30-Day Hospital Readmissions at a Children's Hospital. Pediatrics. 2016;138(2). doi:10.1542/peds.2015-4182. Copy Citation …

The MedSafer study-electronic decision support for deprescribing in hospitalized older adults: a cluster randomized clinical trial. | PSNet

psnet.ahrq.gov/issue/medsafer-study-electronic-decision-support-deprescribing-hospitalized-older-adults-cluster

July 31, 2019 - Study The MedSafer study-electronic decision support for deprescribing in hospitalized older adults: a cluster randomized clinical trial. Citation Text: McDonald EG, Wu PE, Rashidi B, et al. The MedSafer study-electronic decision support for deprescribing in hospitalized older adults: a …

Medication overdoses leading to emergency department visits among children. | PSNet

psnet.ahrq.gov/issue/medication-overdoses-leading-emergency-department-visits-among-children

March 05, 2008 - Study Medication overdoses leading to emergency department visits among children. Citation Text: Schillie SF, Shehab N, Thomas KE, et al. Medication overdoses leading to emergency department visits among children. Am J Prev Med. 2009;37(3):181-7. doi:10.1016/j.amepre.2009.05.018. Cop…

Improving the specificity of drug-drug interaction alerts: can it be done? | PSNet

psnet.ahrq.gov/issue/improving-specificity-drug-drug-interaction-alerts-can-it-be-done

September 07, 2022 - Study Improving the specificity of drug-drug interaction alerts: can it be done? Citation Text: Reese T, Wright A, Liu S, et al. Improving the specificity of drug-drug interaction alerts: Can it be done? Am J Health Syst Pharm. 2022;79(13):1086-1095. doi:10.1093/ajhp/zxac045. Copy Cita…

Outpatient insulin-related adverse events due to mix-up errors: findings from two national surveillance systems, United States, 2012-2017. | PSNet

psnet.ahrq.gov/issue/outpatient-insulin-related-adverse-events-due-mix-errors-findings-two-national-surveillance

March 10, 2021 - Study Outpatient insulin-related adverse events due to mix-up errors: findings from two national surveillance systems, United States, 2012-2017. Citation Text: Geller AI, Conrad AO, Weidle NJ, et al. Outpatient insulin‐related adverse events due to mix‐up errors: Findings from two nation…

Electronic medication reconciliation tools aimed at healthcare professionals to support medication reconciliation: a systematic review. | PSNet

psnet.ahrq.gov/issue/electronic-medication-reconciliation-tools-aimed-healthcare-professionals-support-medication

December 02, 2020 - Review Electronic medication reconciliation tools aimed at healthcare professionals to support medication reconciliation: a systematic review. Citation Text: Ciudad-Gutiérrez P, del Valle-Moreno P, Lora-Escobar SJ, et al. Electronic medication reconciliation tools aimed at healthcare pro…

Standardized assessment of medication reconciliation in post-acute care. | PSNet

psnet.ahrq.gov/issue/standardized-assessment-medication-reconciliation-post-acute-care

December 16, 2020 - Study Standardized assessment of medication reconciliation in post-acute care. Citation Text: Fischer SH, Shih RA, McMullen TL, et al. Standardized assessment of medication reconciliation in post‐acute care. J Am Geriatr Soc. 2022;70(4):1047-1056. doi:10.1111/jgs.17655. Copy Citation …

Parent perceptions of children's hospital safety climate. | PSNet

psnet.ahrq.gov/issue/parent-perceptions-childrens-hospital-safety-climate

December 22, 2018 - Study Parent perceptions of children's hospital safety climate. Citation Text: Cox E, Carayon P, Hansen KW, et al. Parent perceptions of children's hospital safety climate. BMJ Qual Saf. 2013;22(8):664-71. doi:10.1136/bmjqs-2012-001727. Copy Citation Format: DOI Google Sc…

How can never event data be used to reflect or improve hospital safety performance? | PSNet

psnet.ahrq.gov/issue/how-can-never-event-data-be-used-reflect-or-improve-hospital-safety-performance

March 30, 2022 - Study How can never event data be used to reflect or improve hospital safety performance? Citation Text: Olivarius‐McAllister J, Pandit M, Sykes A, et al. How can never event data be used to reflect or improve hospital safety performance? Anaesthesia. 2021;76(12):1616-1624. doi:10.1111/a…

Insights into the problem of alarm fatigue with physiologic monitor devices: a comprehensive observational study of consecutive intensive care unit patients. | PSNet

psnet.ahrq.gov/issue/insights-problem-alarm-fatigue-physiologic-monitor-devices-comprehensive-observational-study

July 17, 2013 - Study Classic Insights into the problem of alarm fatigue with physiologic monitor devices: a comprehensive observational study of consecutive intensive care unit patients. Citation Text: Drew BJ, Harris P, Zègre-Hemsey JK, et al. Insights into the problem of ala…

Impact of the WHO Surgical Safety Checklist relative to its design and intended use: a systematic review and meta-meta-analysis. | PSNet

psnet.ahrq.gov/issue/impact-who-surgical-safety-checklist-relative-its-design-and-intended-use-systematic-review

March 17, 2021 - Review Impact of the WHO Surgical Safety Checklist relative to its design and intended use: a systematic review and meta-meta-analysis. Citation Text: Sotto KT, Burian BK, Brindle ME. Impact of the WHO Surgical Safety Checklist relative to its design and intended use: a systematic review…

Potential biases in machine learning algorithms using electronic health record data. | PSNet

psnet.ahrq.gov/issue/potential-biases-machine-learning-algorithms-using-electronic-health-record-data

June 12, 2019 - Commentary Classic Potential biases in machine learning algorithms using electronic health record data. Citation Text: Gianfrancesco MA, Tamang S, Yazdany J, et al. Potential Biases in Machine Learning Algorithms Using Electronic Health Record Data. JAMA Intern …

Changes in prevalence of health care-associated infections in U.S. hospitals. | PSNet

psnet.ahrq.gov/issue/changes-prevalence-health-care-associated-infections-us-hospitals

December 18, 2014 - Study Classic Changes in prevalence of health care-associated infections in U.S. hospitals. Citation Text: Magill SS, O'Leary E, Janelle SJ, et al. Changes in Prevalence of Health Care-Associated Infections in U.S. Hospitals. N Engl J Med. 2018;379(18):1732-1744…

Medication use leading to emergency department visits for adverse drug events in older adults. | PSNet

psnet.ahrq.gov/issue/medication-use-leading-emergency-department-visits-adverse-drug-events-older-adults

March 05, 2008 - Study Classic Medication use leading to emergency department visits for adverse drug events in older adults. Citation Text: Budnitz DS, Shehab N, Kegler SR, et al. Medication use leading to emergency department visits for adverse drug events in older adults. A…

Effect of Patient and Family Centered I-PASS on adverse event rates in hospitalized children with complex chronic conditions. | PSNet

psnet.ahrq.gov/issue/effect-patient-and-family-centered-i-pass-adverse-event-rates-hospitalized-children-complex

November 16, 2022 - Study Effect of Patient and Family Centered I-PASS on adverse event rates in hospitalized children with complex chronic conditions. Citation Text: Kuzma N, Khan A, Rickey L, et al. Effect of Patient and Family Centered I‐PASS on adverse event rates in hospitalized children with complex c…

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