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  1. Optimizing Medication Management During the Covid-19 Pandemic: Implementation Guide for Post-acute and Long Term Care. | PSNet

    psnet.ahrq.gov/issue/optimizing-medication-management-during-covid-19-pandemic-implementation-guide-post-acute-and
    August 16, 2023 - Study Optimizing Medication Management During the Covid-19 Pandemic: Implementation Guide for Post-acute and Long Term Care. Citation Text: Brandt N, Steinman MA. Optimizing Medication Management During the COVID‐19 Pandemic: An Implementation Guide for Post‐Acute and Long‐Term Care. J A…

  2. A comprehensive quality assurance program for personnel and procedures in radiation oncology: value of voluntary error reporting and checklists. | PSNet

    psnet.ahrq.gov/issue/comprehensive-quality-assurance-program-personnel-and-procedures-radiation-oncology-value
    November 18, 2020 - Study A comprehensive quality assurance program for personnel and procedures in radiation oncology: value of voluntary error reporting and checklists. Citation Text: Kalapurakal JA, Zafirovski A, Smith J, et al. A comprehensive quality assurance program for personnel and procedures in …

  3. Multicomponent pharmacist intervention did not reduce clinically important medication errors for ambulatory patients initiating direct oral anticoagulants. | PSNet

    psnet.ahrq.gov/issue/multicomponent-pharmacist-intervention-did-not-reduce-clinically-important-medication-errors
    March 17, 2021 - Study Multicomponent pharmacist intervention did not reduce clinically important medication errors for ambulatory patients initiating direct oral anticoagulants. Citation Text: Kapoor A, Patel P, Mbusa D, et al. Multicomponent pharmacist intervention did not reduce clinically important m…

  4. Facilitated self-reported anaesthetic medication errors before and after implementation of a safety bundle and barcode-based safety system. | PSNet

    psnet.ahrq.gov/issue/facilitated-self-reported-anaesthetic-medication-errors-and-after-implementation-safety
    February 09, 2011 - Study Facilitated self-reported anaesthetic medication errors before and after implementation of a safety bundle and barcode-based safety system. Citation Text: Bowdle TA, Jelacic S, Nair B, et al. Facilitated self-reported anaesthetic medication errors before and after implementation of…

  5. The Economic Measurement of Medical Errors. | PSNet

    psnet.ahrq.gov/issue/economic-measurement-medical-errors
    March 23, 2022 - Book/Report The Economic Measurement of Medical Errors. Citation Text: The Economic Measurement of Medical Errors. Shreve J, van Den Bos J, Gray T, Halford M, Rustagi K, Ziemkiewicz E. Schaumburg, IL: The Society of Actuaries; 2010. Copy Citation Save Save t…

  6. The effects of hospital-physician financial integration on adverse incident rate: an agency theory perspective. | PSNet

    psnet.ahrq.gov/issue/effects-hospital-physician-financial-integration-adverse-incident-rate-agency-theory
    August 10, 2022 - Study The effects of hospital-physician financial integration on adverse incident rate: an agency theory perspective. Citation Text: Upadhyay S, Weech-Maldonado R, Opoku-Agyeman W. The effects of hospital-physician financial integration on adverse incident rate: an agency theory perspect…

  7. Trauma resuscitation errors and computer-assisted decision support. | PSNet

    psnet.ahrq.gov/issue/trauma-resuscitation-errors-and-computer-assisted-decision-support
    January 28, 2010 - Study Trauma resuscitation errors and computer-assisted decision support. Citation Text: FitzGerald M, Cameron P, Mackenzie CF, et al. Trauma resuscitation errors and computer-assisted decision support. Arch Surg. 2011;146(2):218-25. doi:10.1001/archsurg.2010.333. Copy Citation F…

  8. Drug-related problems in medical wards with a computerized physician order entry system. | PSNet

    psnet.ahrq.gov/issue/drug-related-problems-medical-wards-computerized-physician-order-entry-system
    December 01, 2010 - Study Drug-related problems in medical wards with a computerized physician order entry system. Citation Text: Bedouch P, Allenet B, Grass A, et al. Drug-related problems in medical wards with a computerized physician order entry system. J Clin Pharm Ther. 2009;34(2):187-95. doi:10.1111…

  9. Are language barriers associated with serious medical events in hospitalized pediatric patients? | PSNet

    psnet.ahrq.gov/issue/are-language-barriers-associated-serious-medical-events-hospitalized-pediatric-patients
    November 16, 2022 - Study Classic Are language barriers associated with serious medical events in hospitalized pediatric patients? Citation Text: Cohen AL. Are Language Barriers Associated With Serious Medical Events in Hospitalized Pediatric Patients? Pediatrics. 2005;116(3):575…

  10. Long-term impacts faced by patients and families after harmful healthcare events. | PSNet

    psnet.ahrq.gov/issue/long-term-impacts-faced-patients-and-families-after-harmful-healthcare-events
    December 01, 2021 - Study Long-term impacts faced by patients and families after harmful healthcare events. Citation Text: Ottosen MJ, Sedlock E, Aigbe AO, et al. Long-term impacts faced by patients and families after harmful healthcare events. J Patient Saf. 2021;17(8):e1145-e1151. doi:10.1097/pts.00000000…

  11. Implementation of a standardized tool for root cause analysis selection. | PSNet

    psnet.ahrq.gov/issue/implementation-standardized-tool-root-cause-analysis-selection
    November 06, 2024 - Study Implementation of a standardized tool for root cause analysis selection. Citation Text: Wahlstedt E, Levy BE, Scott E, et al. Implementation of a standardized tool for root cause analysis selection. J Patient Saf. 2025;21(2):101-105. doi:10.1097/pts.0000000000001291. Copy Citatio…

  12. Impact of team performance on the surgical safety checklist on patient outcomes: an operating room black box analysis. | PSNet

    psnet.ahrq.gov/issue/impact-team-performance-surgical-safety-checklist-patient-outcomes-operating-room-black-box
    March 20, 2024 - Study Impact of team performance on the surgical safety checklist on patient outcomes: an operating room black box analysis. Citation Text: Al Abbas AI, Meier J, Daniel W, et al. Impact of team performance on the surgical safety checklist on patient outcomes: an operating room black box …

  13. Accidental deaths, saved lives, and improved quality. | PSNet

    psnet.ahrq.gov/issue/accidental-deaths-saved-lives-and-improved-quality
    February 04, 2015 - Commentary Classic Accidental deaths, saved lives, and improved quality. Citation Text: Brennan TA, Gawande AA, Thomas EJ, et al. Accidental Deaths, Saved Lives, and Improved Quality. New England Journal of Medicine. 2005;353(13). doi:10.1056/nejmsb051157. C…

  14. Coordinating care across diseases, settings, and clinicians: a key role for the generalist in practice. | PSNet

    psnet.ahrq.gov/issue/coordinating-care-across-diseases-settings-and-clinicians-key-role-generalist-practice
    July 01, 2020 - Review Coordinating care across diseases, settings, and clinicians: a key role for the generalist in practice. Citation Text: Stille CJ, Jerant A, Bell D, et al. Coordinating care across diseases, settings, and clinicians: a key role for the generalist in practice. Ann Intern Med. 2005…

  15. An intervention to decrease patient identification band errors in a children's hospital. | PSNet

    psnet.ahrq.gov/issue/intervention-decrease-patient-identification-band-errors-childrens-hospital
    October 06, 2016 - Study An intervention to decrease patient identification band errors in a children's hospital. Citation Text: Hain PD, Joers B, Rush M, et al. An intervention to decrease patient identification band errors in a children's hospital. Qual Saf Health Care. 2010;19(3):244-7. doi:10.1136/qs…

  16. Time-series analysis of health care–associated infections in a new hospital with all private rooms. | PSNet

    psnet.ahrq.gov/issue/time-series-analysis-health-care-associated-infections-new-hospital-all-private-rooms
    July 31, 2019 - Study Time-series analysis of health care–associated infections in a new hospital with all private rooms. Citation Text: McDonald EG, Dendukuri N, Frenette C, et al. Time-Series Analysis of Health Care-Associated Infections in a New Hospital With All Private Rooms. JAMA Intern Med. 2019.…

  17. Discrepancies in written versus calculated durations in opioid prescriptions: pre-post study. | PSNet

    psnet.ahrq.gov/issue/discrepancies-written-versus-calculated-durations-opioid-prescriptions-pre-post-study
    October 19, 2022 - Study Discrepancies in written versus calculated durations in opioid prescriptions: pre-post study. Citation Text: Slovis BH, Kairys J, Babula B, et al. Discrepancies in written versus calculated durations in opioid prescriptions: pre-post study. JMIR Med Inform. 2020;8(3). doi:10.2196/1…

  18. Defining optimal length of opioid pain medication prescription after common surgical procedures. | PSNet

    psnet.ahrq.gov/issue/defining-optimal-length-opioid-pain-medication-prescription-after-common-surgical-procedures
    August 15, 2018 - Study Defining optimal length of opioid pain medication prescription after common surgical procedures. Citation Text: Scully RE, Schoenfeld AJ, Jiang W, et al. Defining Optimal Length of Opioid Pain Medication Prescription After Common Surgical Procedures. JAMA Surg. 2018;153(1):37-43. d…

  19. Are physicians safely prescribing opioids for chronic noncancer pain? A systematic review of current evidence. | PSNet

    psnet.ahrq.gov/issue/are-physicians-safely-prescribing-opioids-chronic-noncancer-pain-systematic-review-current
    November 07, 2018 - Review Are physicians safely prescribing opioids for chronic noncancer pain? A systematic review of current evidence. Citation Text: Tournebize J, Gibaja V, Muszczak A, et al. Are Physicians Safely Prescribing Opioids for Chronic Noncancer Pain? A Systematic Review of Current Evidence. P…

  20. Considering chance in quality and safety performance measures: an analysis of performance reports by boards in English NHS trusts. | PSNet

    psnet.ahrq.gov/issue/considering-chance-quality-and-safety-performance-measures-analysis-performance-reports
    October 27, 2021 - Study Considering chance in quality and safety performance measures: an analysis of performance reports by boards in English NHS trusts. Citation Text: Anhøj J, Hellesøe A-MB. The problem with red, amber, green: the need to avoid distraction by random variation in organisational performa…
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