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psnet.ahrq.gov/node/43785/psn-pdf
May 01, 2015 - Evaluation of the effectiveness of a surgical checklist in
Medicare patients.
May 1, 2015
Reames BN, Scally CP, Thumma JR, et al. Evaluation of the Effectiveness of a Surgical Checklist in
Medicare Patients. Med Care. 2015;53(1):87-94. doi:10.1097/MLR.0000000000000277.
https://psnet.ahrq.gov/issue/evaluation-effec…
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psnet.ahrq.gov/node/43128/psn-pdf
August 25, 2015 - Locating errors through networked surveillance: a
multimethod approach to peer assessment, hazard
identification, and prioritization of patient safety efforts in
cardiac surgery.
August 25, 2015
Thompson DA, Marsteller JA, Pronovost P, et al. Locating Errors Through Networked Surveillance: A
Multimethod Approach …
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psnet.ahrq.gov/node/47330/psn-pdf
September 19, 2018 - Patient and consumer safety risks when using
conversational assistants for medical information: an
observational study of Siri, Alexa, and Google Assistant.
September 19, 2018
Bickmore TW, Trinh H, Olafsson S, et al. Patient and consumer safety risks when using conversational
assistants for medical information: an…
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psnet.ahrq.gov/node/46112/psn-pdf
December 21, 2017 - Analysis of variations in the display of drug names in
computerized prescriber-order-entry systems.
December 21, 2017
Quist AJL, Hickman T-TT, Amato MG, et al. Analysis of variations in the display of drug names in
computerized prescriber-order-entry systems. American Journal of Health-System Pharmacy. 2017;74(7).
…
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psnet.ahrq.gov/node/44096/psn-pdf
November 03, 2015 - Incidence of "never events" among weekend admissions
versus weekday admissions to US hospitals: national
analysis.
November 3, 2015
Attenello FJ, Wen T, Cen SY, et al. Incidence of "never events" among weekend admissions versus
weekday admissions to US hospitals: national analysis. BMJ. 2015;350:h1460. doi:10.1136…
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psnet.ahrq.gov/node/44544/psn-pdf
October 07, 2015 - Systematic review on the prevalence, frequency and
comparative value of adverse events data in social media.
October 7, 2015
Golder S, Norman G, Loke YK. Systematic review on the prevalence, frequency and comparative value of
adverse events data in social media. Br J Clin Pharmacol. 2015;80(4):878-88. doi:10.1111/b…
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psnet.ahrq.gov/node/39016/psn-pdf
April 04, 2011 - Variation in hospital mortality associated with inpatient
surgery.
April 4, 2011
Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mortality associated with inpatient surgery. N
Engl J Med. 2009;361(14):1368-75. doi:10.1056/NEJMsa0903048.
https://psnet.ahrq.gov/issue/variation-hospital-mortality-associate…
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psnet.ahrq.gov/node/42548/psn-pdf
December 29, 2014 - What is known about adverse events in older medical
hospital inpatients? A systematic review of the literature.
December 29, 2014
Long SJ, Brown KF, Ames D, et al. What is known about adverse events in older medical hospital
inpatients? A systematic review of the literature. Int J Health Care Qual. 2013;25(5):542-5…
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psnet.ahrq.gov/node/44635/psn-pdf
June 21, 2016 - Evaluation of perioperative medication errors and adverse
drug events.
June 21, 2016
Nanji KC, Patel A, Shaikh S, et al. Evaluation of Perioperative Medication Errors and Adverse Drug Events.
Anesthesiology. 2016;124(1):25-34. doi:10.1097/ALN.0000000000000904.
https://psnet.ahrq.gov/issue/evaluation-perioperative-…
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psnet.ahrq.gov/node/41568/psn-pdf
April 05, 2013 - Preventable deaths due to problems in care in English
acute hospitals: a retrospective case record review study.
April 5, 2013
Hogan H, Healey F, Neale G, et al. Preventable deaths due to problems in care in English acute hospitals:
a retrospective case record review study. BMJ Qual Saf. 2012;21(9):737-745. doi:10.…
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psnet.ahrq.gov/node/46923/psn-pdf
August 17, 2018 - What can patients tell us about the quality and safety of
hospital care? Findings from a UK multicentre survey
study.
August 17, 2018
O'Hara JK, Reynolds C, Moore S, et al. What can patients tell us about the quality and safety of hospital
care? Findings from a UK multicentre survey study. BMJ Qual Saf. 2018;27(9)…
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psnet.ahrq.gov/node/45541/psn-pdf
September 28, 2016 - Is there evidence for a better health care for cancer
patients after a second opinion? A systematic review.
September 28, 2016
Ruetters D, Keinki C, Schroth S, et al. Is there evidence for a better health care for cancer patients after a
second opinion? A systematic review. J Cancer Res Clin Oncol. 2016;142(7):1521…
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psnet.ahrq.gov/node/73252/psn-pdf
January 01, 2022 - Why test results are still getting "lost" to follow-up: a
qualitative study of implementation gaps.
May 12, 2021
Zimolzak AJ, Shahid U, Giardina TD, et al. Why test results are still getting "lost" to follow-up: a qualitative
study of implementation gaps. J Gen Intern Med. 2022;37(1):137-144. doi:10.1007/s11606-021…
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psnet.ahrq.gov/node/865531/psn-pdf
April 10, 2024 - Implicit bias and patient care: mitigating bias, preventing
harm.
April 10, 2024
Barber Doucet H, Wilson T, Vrablik L, et al. Implicit bias and patient care: mitigating bias, preventing harm.
MedEdPORTAL. 2023;19:11343. doi:10.15766/mep_2374-8265.11343.
https://psnet.ahrq.gov/innovation/implicit-bias-and-patient-c…
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psnet.ahrq.gov/perspective/conversation-didier-pittet-md-ms
May 01, 2014 - identification devices use ZigBee technology (wireless communication protocol based on IEEE 802.15.3 standards
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psnet.ahrq.gov/node/837658/psn-pdf
July 08, 2022 - documented and shared is at their individual discretion, which may be impacted further by lack of
standardization
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psnet.ahrq.gov/web-mm/dangerous-detour
November 28, 2018 - Continuous observation procedures for psychiatric wards lack standardization and use inconsistent terminology
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psnet.ahrq.gov/node/33754/psn-pdf
September 01, 2013 - prompted me to do that was the question of what do you do with people who
don't follow reasonable safety standards
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psnet.ahrq.gov/node/865532/psn-pdf
April 10, 2024 - Let us to the TWISST; Plan, Simulate, Study and Act.
April 10, 2024
Colman N, Hebbar KB. Let us to the TWISST; Plan, Simulate, Study and Act. Pediatr Qual Saf.
2023;8(4):e664. doi:10.1097/pq9.0000000000000664.
https://psnet.ahrq.gov/innovation/let-us-twisst-plan-simulate-study-and-act
In situ simulation can identi…
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psnet.ahrq.gov/node/42628/psn-pdf
January 07, 2015 - Engaging patients in medication reconciliation via a
patient portal following hospital discharge.
January 7, 2015
Heyworth L, Paquin AM, Clark J, et al. Engaging patients in medication reconciliation via a patient portal
following hospital discharge. J Am Med Inform Assoc. 2014;21(e1):e157-62. doi:10.1136/amiajnl-2…