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Root cause analyses of reported adverse events occurring during gastrointestinal scope and tube placement procedures in the Veterans Health Association. | PSNet

psnet.ahrq.gov/issue/root-cause-analyses-reported-adverse-events-occurring-during-gastrointestinal-scope-and-tube

November 17, 2021 - Study Root cause analyses of reported adverse events occurring during gastrointestinal scope and tube placement procedures in the Veterans Health Association. Citation Text: Soncrant C, Mills PD, Neily J, et al. Root cause analyses of reported adverse events occurring during gastrointest…

Physician prescribing of opioids to patients at increased risk of overdose from benzodiazepine use in the United States. | PSNet

psnet.ahrq.gov/issue/physician-prescribing-opioids-patients-increased-risk-overdose-benzodiazepine-use-united

September 27, 2016 - Study Emerging Classic Physician prescribing of opioids to patients at increased risk of overdose from benzodiazepine use in the United States. Citation Text: Ladapo JA, Larochelle MR, Chen A, et al. Physician Prescribing of Opioids to Patients at Increased Risk…

6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled trial. | PSNet

psnet.ahrq.gov/issue/6-pack-programme-decrease-fall-injuries-acute-hospitals-cluster-randomised-controlled-trial

December 21, 2014 - Study Classic 6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled trial. Citation Text: Barker AL, Morello RT, Wolfe R, et al. 6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled t…

Relationship between medication errors and adverse drug events. | PSNet

psnet.ahrq.gov/issue/relationship-between-medication-errors-and-adverse-drug-events

May 27, 2011 - Study Classic Relationship between medication errors and adverse drug events. Citation Text: Bates DW, Boyle DL, Vliet MBV, et al. Relationship between medication errors and adverse drug events. J Gen Intern Med. 1995;10(4):199-205. Copy Citation Format:…

Developing and aligning a safety event taxonomy for inpatient psychiatry. | PSNet

psnet.ahrq.gov/issue/developing-and-aligning-safety-event-taxonomy-inpatient-psychiatry

September 14, 2022 - Study Developing and aligning a safety event taxonomy for inpatient psychiatry. Citation Text: Barnes T, Fontaine T, Bautista C, et al. Developing and aligning a safety event taxonomy for inpatient psychiatry. J Patient Saf. 2022;18(4):e704-e713. doi:10.1097/pts.0000000000000935. Copy …

Improving safety by evaluating the impact of the supply chain and drug shortages on health-systems. | PSNet

psnet.ahrq.gov/issue/improving-safety-evaluating-impact-supply-chain-and-drug-shortages-health-systems

November 04, 2020 - Commentary Improving safety by evaluating the impact of the supply chain and drug shortages on health-systems. Citation Text: Patel V, Cieslak K, Hertig JB. Improving safety by evaluating the impact of the supply chain and drug shortages on health-systems. Hosp Pharm. 2023;58(2):120-124.…

Perceptions of the impact of a large-scale collaborative improvement programme: experience in the UK Safer Patients Initiative. | PSNet

psnet.ahrq.gov/issue/perceptions-impact-large-scale-collaborative-improvement-programme-experience-uk-safer

February 01, 2011 - Study Perceptions of the impact of a large-scale collaborative improvement programme: experience in the UK Safer Patients Initiative. Citation Text: Benn J, Burnett S, Parand A, et al. Perceptions of the impact of a large-scale collaborative improvement programme: experience in the UK …

Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication station. | PSNet

psnet.ahrq.gov/issue/designing-distractions-human-factors-approach-decreasing-interruptions-centralised-medication

July 27, 2018 - Study Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication station. Citation Text: Colligan L, Guerlain S, Steck SE, et al. Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication…

The effect of hospital-acquired Clostridium difficile infection on in-hospital mortality. | PSNet

psnet.ahrq.gov/issue/effect-hospital-acquired-clostridium-difficile-infection-hospital-mortality

April 22, 2011 - Study The effect of hospital-acquired Clostridium difficile infection on in-hospital mortality. Citation Text: Oake N, Taljaard M, van Walraven C, et al. The effect of hospital-acquired Clostridium difficile infection on in-hospital mortality. Arch Intern Med. 2010;170(20):1804-10. doi:1…

Accuracy in patient understanding of common medical phrases. | PSNet

psnet.ahrq.gov/issue/accuracy-patient-understanding-common-medical-phrases

November 30, 2022 - Study Accuracy in patient understanding of common medical phrases. Citation Text: Gotlieb R, Praska C, Hendrickson MA, et al. Accuracy in patient understanding of common medical phrases. JAMA Netw Open. 2022;5(11):e2242972. doi:10.1001/jamanetworkopen.2022.42972. Copy Citation Form…

The collapse of sensemaking in organizations: the Mann Gulch disaster. | PSNet

psnet.ahrq.gov/issue/collapse-sensemaking-organizations-mann-gulch-disaster

May 21, 2019 - Commentary Classic The collapse of sensemaking in organizations: the Mann Gulch disaster. Citation Text: Weick KE. The Collapse of Sensemaking in Organizations: The Mann Gulch Disaster. Admin Sci Q. 2006;38(4):628-652. doi:10.2307/2393339. Copy Citation Fo…

Supporting nurses in acute and emergency care settings to speak up. | PSNet

psnet.ahrq.gov/issue/supporting-nurses-acute-and-emergency-care-settings-speak

November 29, 2023 - Commentary Supporting nurses in acute and emergency care settings to speak up. Citation Text: Clarke-Romain B. Supporting nurses in acute and emergency care settings to speak up. Emerg Nurse. 2024;32(3):16-21. doi:10.7748/en.2023.e2162. Copy Citation Format: DOI Google Scho…

Methodological variability in detecting prescribing errors and consequences for the evaluation of interventions. | PSNet

psnet.ahrq.gov/issue/methodological-variability-detecting-prescribing-errors-and-consequences-evaluation

March 05, 2010 - Study Methodological variability in detecting prescribing errors and consequences for the evaluation of interventions. Citation Text: Franklin BD, Birch S, Savage I, et al. Methodological variability in detecting prescribing errors and consequences for the evaluation of interventions. …

Is one-pen, one-patient achievable in the hospital? A quality improvement project to reduce risks of inadvertent insulin pen sharing at a large academic medical center. | PSNet

psnet.ahrq.gov/issue/one-pen-one-patient-achievable-hospital-quality-improvement-project-reduce-risks-inadvertent

April 10, 2024 - Study Is one-pen, one-patient achievable in the hospital? A quality improvement project to reduce risks of inadvertent insulin pen sharing at a large academic medical center. Citation Text: Ho S, Stamm R, Hibbs M, et al. Is One-Pen, One-Patient Achievable in the Hospital? A Quality Impr…

STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. | PSNet

psnet.ahrq.gov/issue/stoppstart-criteria-potentially-inappropriate-prescribing-older-people-version-2

March 23, 2012 - Study STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Citation Text: O'Mahony D, O'Sullivan D, Byrne S, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015;44(2):213-218. doi:10.1093…

Use of an audit with feedback implementation strategy to promote medication error reporting by nurses. | PSNet

psnet.ahrq.gov/issue/use-audit-feedback-implementation-strategy-promote-medication-error-reporting-nurses

March 24, 2021 - Study Use of an audit with feedback implementation strategy to promote medication error reporting by nurses. Citation Text: Hutchinson A, Brotto V, Chapman A, et al. Use of an audit with feedback implementation strategy to promote medication error reporting by nurses. J Clin Nurs. 2020;2…

Root cause analysis of adverse events in an outpatient anticoagulation management consortium. | PSNet

psnet.ahrq.gov/issue/root-cause-analysis-adverse-events-outpatient-anticoagulation-management-consortium

March 28, 2012 - Study Root cause analysis of adverse events in an outpatient anticoagulation management consortium. Citation Text: Graves CM, Haymart B, Kline-Rogers E, et al. Root Cause Analysis of Adverse Events in an Outpatient Anticoagulation Management Consortium. Jt Comm J Qual Patient Saf. 2017;4…

Impact of health information technology on detection of potential adverse drug events at the ordering stage. | PSNet

psnet.ahrq.gov/issue/impact-health-information-technology-detection-potential-adverse-drug-events-ordering-stage

June 25, 2008 - Study Impact of health information technology on detection of potential adverse drug events at the ordering stage. Citation Text: Roberts LL, Ward MM, Brokel JM, et al. Impact of health information technology on detection of potential adverse drug events at the ordering stage. Am J Hea…

Quality and safety in hospital pediatrics during COVID-19: a national qualitative study. | PSNet

psnet.ahrq.gov/issue/quality-and-safety-hospital-pediatrics-during-covid-19-national-qualitative-study

November 17, 2021 - Study Quality and safety in hospital pediatrics during COVID-19: a national qualitative study. Citation Text: De Angulo NR, Penwill N, Pathak PR, et al. Quality and safety in hospital pediatrics during COVID-19: a national qualitative study. Hosp Pediatr. 2022;12(1):e2021006115. doi:10.1…

Impact of patient safety bundle and team-based training on obstetric hypertensive emergencies. | PSNet

psnet.ahrq.gov/issue/impact-patient-safety-bundle-and-team-based-training-obstetric-hypertensive-emergencies

July 21, 2021 - Study Impact of patient safety bundle and team-based training on obstetric hypertensive emergencies. Citation Text: Grogan L, Peterson E, Flatley M, et al. Impact of patient safety bundle and team-based training on obstetric hypertensive emergencies. Am J Perinatol. 2025;42(4):452-461. d…

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