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Unanticipated death after discharge home from the emergency department. | PSNet

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November 16, 2022 - Study Unanticipated death after discharge home from the emergency department. Citation Text: Sklar DP, Crandall CS, Loeliger E, et al. Unanticipated Death After Discharge Home From the Emergency Department. Ann Emerg Med. 2007;49(6). doi:10.1016/j.annemergmed.2006.11.018. Copy Citati…

"To err is human" but disclosure must be taught: a simulation-based assessment study. | PSNet

psnet.ahrq.gov/issue/err-human-disclosure-must-be-taught-simulation-based-assessment-study

August 04, 2021 - Study "To err is human" but disclosure must be taught: a simulation-based assessment study. Citation Text: Crimmins AC, Wong AH, Bonz JW, et al. "To Err Is Human" but Disclosure Must be Taught: A Simulation-Based Assessment Study. Simul Healthc. 2018;13(2):107-116. doi:10.1097/SIH.000000…

Is it possible to identify risks for injurious falls in hospitalized patients? | PSNet

psnet.ahrq.gov/issue/it-possible-identify-risks-injurious-falls-hospitalized-patients

December 12, 2012 - Study Is it possible to identify risks for injurious falls in hospitalized patients? Citation Text: Mion LC, Chandler M, Waters TM, et al. Is it possible to identify risks for injurious falls in hospitalized patients? Jt Comm J Qual Patient Saf. 2012;38(9):408-13. Copy Citation For…

Impact of out-of-hours admission on patient mortality: longitudinal analysis in a tertiary acute hospital. | PSNet

psnet.ahrq.gov/issue/impact-out-hours-admission-patient-mortality-longitudinal-analysis-tertiary-acute-hospital

July 21, 2017 - Study Impact of out-of-hours admission on patient mortality: longitudinal analysis in a tertiary acute hospital. Citation Text: Han L, Sutton M, Clough S, et al. Impact of out-of-hours admission on patient mortality: longitudinal analysis in a tertiary acute hospital. BMJ Qual Saf. 2018;…

A review of healthcare failure mode and effects analysis (HFMEA) in radiotherapy. | PSNet

psnet.ahrq.gov/issue/review-healthcare-failure-mode-and-effects-analysis-hfmea-radiotherapy

June 13, 2011 - Review A review of healthcare failure mode and effects analysis (HFMEA) in radiotherapy. Citation Text: Giardina M, Cantone MC, Tomarchio E, et al. A Review of Healthcare Failure Mode and Effects Analysis (HFMEA) in Radiotherapy. Health Phys. 2016;111(4):317-26. doi:10.1097/HP.0000000000…

ASPEN survey of parenteral nutrition access issues: how the system fails the patients. | PSNet

psnet.ahrq.gov/issue/aspen-survey-parenteral-nutrition-access-issues-how-system-fails-patients

October 02, 2013 - Study ASPEN survey of parenteral nutrition access issues: how the system fails the patients. Citation Text: Mirtallo JM, Allen P, Book WM, et al. ASPEN survey of parenteral nutrition access issues: how the system fails the patient. Nutr Clin Pract. 2024;39(5):1164-1181. doi:10.1002/ncp.1…

Who applies an intervention to influence cultural attributes in a quality improvement collaborative? | PSNet

psnet.ahrq.gov/issue/who-applies-intervention-influence-cultural-attributes-quality-improvement-collaborative

January 22, 2016 - Study Who applies an intervention to influence cultural attributes in a quality improvement collaborative? Citation Text: Hsu Y-J, Marsteller JA. Who Applies an Intervention to Influence Cultural Attributes in a Quality Improvement Collaborative? J Patient Saf. 2020;16(1):1-6. Copy Cit…

Accuracy of send-out test ordering: a College of American Pathologists Q-Probes study of ordering accuracy in 97 clinical laboratories. | PSNet

psnet.ahrq.gov/issue/accuracy-send-out-test-ordering-college-american-pathologists-q-probes-study-ordering

November 12, 2008 - Study Accuracy of send-out test ordering: a College of American Pathologists Q-Probes study of ordering accuracy in 97 clinical laboratories. Citation Text: Valenstein PN, Walsh MK, Stankovic AK. Accuracy of send-out test ordering: a College of American Pathologists Q-Probes study of o…

Competition and health plan performance: evidence from health maintenance organization insurance markets. | PSNet

psnet.ahrq.gov/issue/competition-and-health-plan-performance-evidence-health-maintenance-organization-insurance

July 14, 2009 - Study Competition and health plan performance: evidence from health maintenance organization insurance markets. Citation Text: Scanlon D, Swaminathan S, Chernew M, et al. Competition and health plan performance: evidence from health maintenance organization insurance markets. Med Care.…

Passing the baton: a grounded practical theory of handoff communication between multidisciplinary providers in two Department of Veterans Affairs outpatient settings. | PSNet

psnet.ahrq.gov/issue/passing-baton-grounded-practical-theory-handoff-communication-between-multidisciplinary

November 16, 2022 - Study Passing the baton: a grounded practical theory of handoff communication between multidisciplinary providers in two Department of Veterans Affairs outpatient settings. Citation Text: Koenig CJ, Maguen S, Daley A, et al. Passing the baton: a grounded practical theory of handoff commu…

Does the patient's payer matter in hospital patient safety?: a study of urban hospitals. | PSNet

psnet.ahrq.gov/issue/does-patients-payer-matter-hospital-patient-safety-study-urban-hospitals

November 05, 2008 - Study Does the patient's payer matter in hospital patient safety?: a study of urban hospitals. Citation Text: Clement JP, Lindrooth R, Chukmaitov AS, et al. Does the patient's payer matter in hospital patient safety?: a study of urban hospitals. Med Care. 2007;45(2):131-8. Copy Citat…

Why didn't you call me? Factors junior learners consider when deciding whether to call their supervisor. | PSNet

psnet.ahrq.gov/issue/why-didnt-you-call-me-factors-junior-learners-consider-when-deciding-whether-call-their

July 14, 2021 - Study Why didn't you call me? Factors junior learners consider when deciding whether to call their supervisor. Citation Text: Alibhai KM, Zabolotniuk TR, Raîche I, et al. Why didn't you call me? Factors junior learners consider when deciding whether to call their supervisor. J Surg Educ.…

No harm found when nurse anesthetists work without supervision by physicians. | PSNet

psnet.ahrq.gov/issue/no-harm-found-when-nurse-anesthetists-work-without-supervision-physicians

August 04, 2021 - Study No harm found when nurse anesthetists work without supervision by physicians. Citation Text: Dulisse B, Cromwell J. No harm found when nurse anesthetists work without supervision by physicians. Health Aff (Millwood). 2010;29(8):1469-1475. doi:10.1377/hlthaff.2008.0966. Copy Citat…

Under-reporting of deaths to the coroner by doctors: a retrospective review of deaths in two hospitals in Melbourne, Australia. | PSNet

psnet.ahrq.gov/issue/under-reporting-deaths-coroner-doctors-retrospective-review-deaths-two-hospitals-melbourne

April 24, 2018 - Study Under-reporting of deaths to the coroner by doctors: a retrospective review of deaths in two hospitals in Melbourne, Australia. Citation Text: Charles A, Ranson D, Bohensky M, et al. Under-reporting of deaths to the coroner by doctors: a retrospective review of deaths in two hosp…

Cognitive bias during clinical decision-making and its influence on patient outcomes in the emergency department: a scoping review. | PSNet

psnet.ahrq.gov/issue/cognitive-bias-during-clinical-decision-making-and-its-influence-patient-outcomes-emergency

September 21, 2022 - Review Cognitive bias during clinical decision-making and its influence on patient outcomes in the emergency department: a scoping review. Citation Text: Jala S, Fry M, Elliott R. Cognitive bias during clinical decision‐making and its influence on patient outcomes in the emergency depart…

Avoiding the unintended consequences of growth in medical care: how might more be worse? | PSNet

psnet.ahrq.gov/issue/avoiding-unintended-consequences-growth-medical-care-how-might-more-be-worse

April 24, 2018 - Commentary Classic Avoiding the unintended consequences of growth in medical care: how might more be worse? Citation Text: Fisher ES, Welch HG. Avoiding the unintended consequences of growth in medical care: how might more be worse? JAMA. 1999;281(5):446-53. …

Medication errors resulting in harm: using chargemaster data to determine association with cost of hospitalization and length of stay. | PSNet

psnet.ahrq.gov/issue/medication-errors-resulting-harm-using-chargemaster-data-determine-association-cost

June 02, 2021 - Study Medication errors resulting in harm: using chargemaster data to determine association with cost of hospitalization and length of stay. Citation Text: McCarthy BC, Tuiskula KA, Driscoll TP, et al. Medication errors resulting in harm: Using chargemaster data to determine association …

Empowering frontline nurses: a structured intervention enables nurses to improve medication administration accuracy. | PSNet

psnet.ahrq.gov/issue/empowering-frontline-nurses-structured-intervention-enables-nurses-improve-medication

March 13, 2012 - Study Empowering frontline nurses: a structured intervention enables nurses to improve medication administration accuracy. Citation Text: Kliger J, Blegen MA, Gootee D, et al. Empowering frontline nurses: a structured intervention enables nurses to improve medication administration accur…

The host hospital 24-hour underreferral rate: an automated measure of call-center safety. | PSNet

psnet.ahrq.gov/issue/host-hospital-24-hour-underreferral-rate-automated-measure-call-center-safety

September 23, 2020 - Study The host hospital 24-hour underreferral rate: an automated measure of call-center safety. Citation Text: Hirsh DA, Simon HK, Massey R, et al. The host hospital 24-hour underreferral rate: an automated measure of call-center safety. Pediatrics. 2007;119(6):1139-1144. Copy Citati…

Novel telephone-based interactive voice response system for incident reporting. | PSNet

psnet.ahrq.gov/issue/novel-telephone-based-interactive-voice-response-system-incident-reporting

September 08, 2021 - Study Novel telephone-based interactive voice response system for incident reporting. Citation Text: McNiven B, Brown AD. Novel telephone-based interactive voice response system for incident reporting. Jt Comm J Qual Patient Saf. 2021;47(12):809-813. doi:10.1016/j.jcjq.2021.09.010. Cop…

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