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Disclosing large scale adverse events in the US Veterans Health Administration: lessons from media responses. | PSNet

psnet.ahrq.gov/issue/disclosing-large-scale-adverse-events-us-veterans-health-administration-lessons-media

August 18, 2021 - Study Disclosing large scale adverse events in the US Veterans Health Administration: lessons from media responses. Citation Text: Maguire EM, Bokhour BG, Asch SM, et al. Disclosing large scale adverse events in the US Veterans Health Administration: lessons from media responses. Public …

Association of overlapping surgery with perioperative outcomes. | PSNet

psnet.ahrq.gov/issue/association-overlapping-surgery-perioperative-outcomes

June 08, 2022 - Study Emerging Classic Association of overlapping surgery with perioperative outcomes. Citation Text: Sun E, Mello MM, Rishel CA, et al. Association of Overlapping Surgery With Perioperative Outcomes. JAMA. 2019;321(8):762-772. doi:10.1001/jama.2019.0711. Copy…

Incident and long-term opioid therapy among patients with psychiatric conditions and medications: a national study of commercial health care claims. | PSNet

psnet.ahrq.gov/issue/incident-and-long-term-opioid-therapy-among-patients-psychiatric-conditions-and-medications

November 16, 2022 - Study Incident and long-term opioid therapy among patients with psychiatric conditions and medications: a national study of commercial health care claims. Citation Text: Quinn PD, Hur K, Chang Z, et al. Incident and long-term opioid therapy among patients with psychiatric conditions and …

Enhancing departmental preparedness for COVID-19 using rapid-cycle in-situ simulation. | PSNet

psnet.ahrq.gov/issue/enhancing-departmental-preparedness-covid-19-using-rapid-cycle-situ-simulation

October 07, 2020 - Study Enhancing departmental preparedness for COVID-19 using rapid-cycle in-situ simulation. Citation Text: Dharamsi A, Hayman K, Yi S, et al. Enhancing departmental preparedness for COVID-19 using rapid-cycle in-situ simulation. J Hosp Infect. 2020;105(4):604-607. doi:10.1016/j.jhin.202…

Call me Ishmael: addressing the white whale of team communication in the operating room with labelled surgical caps at an academic medical centre. | PSNet

psnet.ahrq.gov/issue/call-me-ishmael-addressing-white-whale-team-communication-operating-room-labelled-surgical

November 16, 2022 - Study Call me Ishmael: addressing the white whale of team communication in the operating room with labelled surgical caps at an academic medical centre. Citation Text: Goldhaber NH, Mehta S, Longhurst CA, et al. Call me Ishmael: addressing the white whale of team communication in the ope…

Cohort study of diagnostic delay in the clinical pathway of patients with chronic wounds in the primary care setting. | PSNet

psnet.ahrq.gov/issue/cohort-study-diagnostic-delay-clinical-pathway-patients-chronic-wounds-primary-care-setting

November 18, 2020 - Study Cohort study of diagnostic delay in the clinical pathway of patients with chronic wounds in the primary care setting. Citation Text: Ahmajärvi K, Isoherranen K, Venermo M. Cohort study of diagnostic delay in the clinical pathway of patients with chronic wounds in the primary care s…

Taking the heat or taking the temperature? A qualitative study of a large-scale exercise in seeking to measure for improvement, not blame. | PSNet

psnet.ahrq.gov/issue/taking-heat-or-taking-temperature-qualitative-study-large-scale-exercise-seeking-measure

November 02, 2016 - Study Classic Taking the heat or taking the temperature? A qualitative study of a large-scale exercise in seeking to measure for improvement, not blame. Citation Text: Armstrong N, Brewster L, Tarrant C, et al. Taking the heat or taking the temperature? A qualit…

"The patient is awake and we need to stay calm": reconsidering indirect communication in the face of medical error and professionalism lapses. | PSNet

psnet.ahrq.gov/issue/patient-awake-and-we-need-stay-calm-reconsidering-indirect-communication-face-medical-error

October 11, 2023 - Study "The patient is awake and we need to stay calm": reconsidering indirect communication in the face of medical error and professionalism lapses. Citation Text: Taylor T, Columbus L, Banner H, et al. “The patient is awake and we need to stay calm”: reconsidering indirect communication…

Improving communication with primary care physicians at the time of hospital discharge. | PSNet

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November 16, 2022 - Study Improving communication with primary care physicians at the time of hospital discharge. Citation Text: Destino LA, Dixit A, Pantaleoni JL, et al. Improving Communication with Primary Care Physicians at the Time of Hospital Discharge. Jt Comm J Qual Patient Saf. 2017;43(2):80-88. do…

Involving patients and carers in patient safety in primary care: a qualitative study of a co-designed patient safety guide. | PSNet

psnet.ahrq.gov/issue/involving-patients-and-carers-patient-safety-primary-care-qualitative-study-co-designed

February 22, 2023 - Study Involving patients and carers in patient safety in primary care: a qualitative study of a co-designed patient safety guide. Citation Text: Morris RL, Giles SJ, Campbell S. Involving patients and carers in patient safety in primary care: a qualitative study of a co‐designed patient …

Effect of patient- and medication-related factors on inpatient medication reconciliation errors. | PSNet

psnet.ahrq.gov/issue/effect-patient-and-medication-related-factors-inpatient-medication-reconciliation-errors

May 08, 2017 - Study Effect of patient- and medication-related factors on inpatient medication reconciliation errors. Citation Text: Salanitro AH, Osborn CY, Schnipper JL, et al. Effect of patient- and medication-related factors on inpatient medication reconciliation errors. J Gen Intern Med. 2012;27(8…

Improving administration and documentation of enteral nutrition support therapy in a Veteran Affairs health care system: use of medication administration record and bar code scanning technology. | PSNet

psnet.ahrq.gov/issue/improving-administration-and-documentation-enteral-nutrition-support-therapy-veteran-affairs

September 09, 2020 - Study Improving administration and documentation of enteral nutrition support therapy in a Veteran Affairs health care system: use of medication administration record and bar code scanning technology. Citation Text: Chew MM, Rivas S, Chesser M, et al. Improving administration and documen…

Effectiveness of different nursing handover styles for ensuring continuity of information in hospitalised patients. | PSNet

psnet.ahrq.gov/issue/effectiveness-different-nursing-handover-styles-ensuring-continuity-information-hospitalised

May 19, 2018 - Review Effectiveness of different nursing handover styles for ensuring continuity of information in hospitalised patients. Citation Text: Smeulers M, Lucas C, Vermeulen H. Effectiveness of different nursing handover styles for ensuring continuity of information in hospitalised patients. …

High delayed and missed injury rate after inter-hospital transfer of severely injured trauma patients. | PSNet

psnet.ahrq.gov/issue/high-delayed-and-missed-injury-rate-after-inter-hospital-transfer-severely-injured-trauma

December 02, 2020 - Study High delayed and missed injury rate after inter-hospital transfer of severely injured trauma patients. Citation Text: Hensgens RL, El Moumni M, IJpma FFA, et al. High delayed and missed injury rate after inter-hospital transfer of severely injured trauma patients. Eur J Trauma Emer…

Risk from delayed or missed care and non-COVID-19 outcomes for older patients with chronic conditions during the pandemic. | PSNet

psnet.ahrq.gov/issue/risk-delayed-or-missed-care-and-non-covid-19-outcomes-older-patients-chronic-conditions

December 16, 2020 - Study Risk from delayed or missed care and non-COVID-19 outcomes for older patients with chronic conditions during the pandemic. Citation Text: Smith M, Vaughan Sarrazin M, Wang X, et al. Risk from delayed or missed care and non-COVID-19 outcomes for older patients with chronic condition…

The analysis of hospital readmission rates after the implementation of Hospital Readmissions Reduction Program. | PSNet

psnet.ahrq.gov/issue/analysis-hospital-readmission-rates-after-implementation-hospital-readmissions-reduction

October 12, 2022 - Study The analysis of hospital readmission rates after the implementation of Hospital Readmissions Reduction Program. Citation Text: Muchiri S, Azadeh-Fard N, Pakdil F. The analysis of hospital readmission rates after the implementation of hospital readmissions reduction program. J Patie…

Lessons learned in implementing a chronic opioid therapy management system. | PSNet

psnet.ahrq.gov/issue/lessons-learned-implementing-chronic-opioid-therapy-management-system

July 13, 2022 - Study Lessons learned in implementing a chronic opioid therapy management system. Citation Text: Carlile N, Fuller TE, Benneyan JC, et al. Lessons learned in implementing a chronic opioid therapy management system. J Patient Saf. 2022;18(8):e1142-e1149. doi:10.1097/pts.0000000000001039. …

Understanding preventable deaths in the geriatric trauma population: analysis of 3,452,339 patients from the Center of Medicare and Medicaid Services Database. | PSNet

psnet.ahrq.gov/issue/understanding-preventable-deaths-geriatric-trauma-population-analysis-3452339-patients-center

February 16, 2022 - Study Understanding preventable deaths in the geriatric trauma population: analysis of 3,452,339 patients from the Center of Medicare and Medicaid Services Database. Citation Text: Ang D, Nieto K, Sutherland M, et al. Understanding preventable deaths in the geriatric trauma population: a…

Interdisciplinary Quality Improvement Conference: using a revised morbidity and mortality format to focus on systems-based patient safety issues in a VA hospital: design and outcomes. | PSNet

psnet.ahrq.gov/issue/interdisciplinary-quality-improvement-conference-using-revised-morbidity-and-mortality-format

July 22, 2020 - Study Interdisciplinary Quality Improvement Conference: using a revised morbidity and mortality format to focus on systems-based patient safety issues in a VA hospital: design and outcomes. Citation Text: Gerstein WH, Ledford J, Cooper J, et al. Interdisciplinary Quality Improvement Conf…

We want to know: patient comfort speaking up about breakdowns in care and patient experience. | PSNet

psnet.ahrq.gov/issue/we-want-know-patient-comfort-speaking-about-breakdowns-care-and-patient-experience

May 20, 2020 - Study Emerging Classic We want to know: patient comfort speaking up about breakdowns in care and patient experience. Citation Text: Fisher K, Smith KM, Gallagher TH, et al. We want to know: patient comfort speaking up about breakdowns in care and patient experie…

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