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psnet.ahrq.gov/issue/use-unsolicited-patient-observations-identify-surgeons-increased-risk-postoperative
July 10, 2019 - Study
Classic
Use of unsolicited patient observations to identify surgeons with increased risk for postoperative complications.
Citation Text:
Cooper WO, Guillamondegui O, Hines J, et al. Use of Unsolicited Patient Observations to Identify Surgeons With Increase…
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psnet.ahrq.gov/issue/impact-coronavirus-disease-2019-covid-19-healthcare-associated-infections-2020-summary-data
February 07, 2022 - Study
The impact of coronavirus disease 2019 (COVID-19) on healthcare-associated infections in 2020: a summary of data reported to the National Healthcare Safety Network.
Citation Text:
Weiner-Lastinger LM, Pattabiraman V, Konnor RY, et al. The impact of coronavirus disease 2019 (COVID-1…
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psnet.ahrq.gov/issue/detectability-medication-errors-stoppstart-based-medication-review-older-people-prior
August 18, 2021 - Study
Detectability of medication errors with a STOPP/START-based medication review in older people prior to a potentially preventable drug-related hospital admission.
Citation Text:
Sallevelt BTGM, Egberts TCG, Huibers CJA, et al. Detectability of medication errors with a STOPP/START-ba…
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psnet.ahrq.gov/issue/performance-trigger-tool-detecting-drug-related-hospital-admissions-older-people-analysis
December 21, 2022 - Study
Performance of a trigger tool for detecting drug-related hospital admissions in older people: analysis from the OPERAM trial.
Citation Text:
Zerah L, Henrard S, Thevelin S, et al. Performance of a trigger tool for detecting drug-related hospital admissions in older people: analysis…
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psnet.ahrq.gov/innovation/reducing-hospital-harm-establishing-command-centre-foster-situational-awareness
June 29, 2022 - EMERGING INNOVATIONS
Reducing hospital harm: establishing a command centre to foster situational awareness.
Citation Text:
Collins B. Reducing hospital harm: establishing a command centre to foster situational awareness. Healthc Q. 2022;25(2):75-81. doi:10.12927/hcq.2022.26885.
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psnet.ahrq.gov/issue/safe-practice-recommendations-use-copy-forward-nursing-flow-sheets-hospital-settings
May 18, 2022 - Study
Safe practice recommendations for the use of copy-forward with nursing flow sheets in hospital settings.
Citation Text:
Patterson ES, Sillars DM, Staggers N, et al. Safe Practice Recommendations for the Use of Copy-Forward with Nursing Flow Sheets in Hospital Settings. Jt Comm J Qu…
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psnet.ahrq.gov/issue/interdisciplinary-collaboration-across-secondary-and-primary-care-improve-medication-safety
December 21, 2022 - Study
Interdisciplinary collaboration across secondary and primary care to improve medication safety in the elderly (The IMMENSE study) - a randomized controlled trial.
Citation Text:
Johansen JS, Halvorsen KH, Svendsen K, et al. Interdisciplinary collaboration across secondary and prima…
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psnet.ahrq.gov/issue/do-patients-disruptive-behaviours-influence-accuracy-doctors-diagnosis-randomised-experiment
July 03, 2014 - Study
Do patients' disruptive behaviours influence the accuracy of a doctor's diagnosis? A randomised experiment.
Citation Text:
Schmidt HG, Van Gog T, Schuit SC, et al. Do patients' disruptive behaviours influence the accuracy of a doctor's diagnosis? A randomised experiment. BMJ Qual S…
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psnet.ahrq.gov/issue/effect-computerized-provider-order-entry-clinical-decision-support-adverse-drug-events-long
February 26, 2009 - Study
Effect of computerized provider order entry with clinical decision support on adverse drug events in the long-term care setting.
Citation Text:
Gurwitz JH, Field T, Rochon P, et al. Effect of computerized provider order entry with clinical decision support on adverse drug events …
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psnet.ahrq.gov/issue/association-changing-hospital-readmission-rates-mortality-rates-after-hospital-discharge
August 20, 2018 - Study
Classic
Association of changing hospital readmission rates with mortality rates after hospital discharge.
Citation Text:
Dharmarajan K, Wang Y, Lin Z, et al. Association of Changing Hospital Readmission Rates With Mortality Rates After Hospital Discharge. …
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psnet.ahrq.gov/issue/using-medication-containers-during-pharmacist-transitional-care-visits-and-impact-medication
March 08, 2023 - Study
Using medication containers during pharmacist transitional care visits and impact on medication discrepancies identified and hospital readmission risk.
Citation Text:
Herges JR, Garrison GM, Mara KC, et al. Using medication containers during pharmacist transitional care visits and …
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psnet.ahrq.gov/issue/communication-between-primary-and-secondary-care-deficits-and-danger
September 23, 2020 - Study
Communication between primary and secondary care: deficits and danger.
Citation Text:
Dinsdale E, Hannigan A, O’Connor R, et al. Communication between primary and secondary care: deficits and danger. Fam Pract. 2019;17(1):63-68. doi:10.1093/fampra/cmz037.
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psnet.ahrq.gov/issue/single-room-hospital-accommodation-associated-differences-healthcare-associated-infection
June 21, 2016 - Study
Is single room hospital accommodation associated with differences in healthcare-associated infection, falls, pressure ulcers or medication errors? A natural experiment with non-equivalent controls.
Citation Text:
Simon M, Maben J, Murrells T, et al. Is single room hospital accommod…
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psnet.ahrq.gov/issue/incidence-nosocomial-covid-19-patients-hospitalized-large-us-academic-medical-center
October 14, 2020 - Study
Emerging Classic
Incidence of nosocomial COVID-19 in patients hospitalized at a large US academic medical center.
Citation Text:
Rhee C, Baker M, Vaidya V, et al. Incidence of nosocomial COVID-19 in patients hospitalized at a large US academic medical cent…
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psnet.ahrq.gov/node/49682/psn-pdf
April 01, 2013 - ; (v)
if the former, how confident am I that my neurological exam skills would have identified important … diagnostic
delays
Ineffective triage/referral to physicians with correct
expertise
Faulty knowledge or skills
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psnet.ahrq.gov/node/72613/psn-pdf
December 22, 2020 - So it's really very specific to hand skills or a sudden movement. … up to speed really, really quickly, procedurally, cognitively, and you know all of these
other side skills
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psnet.ahrq.gov/innovation/michigan-hospital-medicine-safety-consortium-hms-finds-infectious-diseases-id-physician
July 23, 2024 - Resources Used and Skills Needed
The consortium recommends starting the initiative by establishing … Selecting local champions Engaging in baseline data collection and benchmarking
Resources Used and Skills
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psnet.ahrq.gov/node/33688/psn-pdf
October 01, 2009 - It takes a lot of time, it takes money, it takes data analysis skills, but it pays off because you are … , said was
that you can teach people what the right thing is, you can make sure that they have the skills
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psnet.ahrq.gov/innovation/affordable-housing-community-offers-seniors-onsite-health-care-coordination-and-support
March 27, 2024 - Resources Used and Skills Needed
Staffing : For every 70-100 person panel of program participants … Resources Used and Skills Needed
Staffing : For every 70-100 person panel of program participants
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psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event
July 01, 2017 - records for other deviations, assessing processes through direct observation of staff, or assessing skills … testing of samples, or external proficiency testing of samples; and (6) assessment of problem-solving skills