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Encouraging employees to speak up to prevent infections: opportunities to leverage quality improvement and care management processes. | PSNet

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January 23, 2017 - Study Encouraging employees to speak up to prevent infections: opportunities to leverage quality improvement and care management processes. Citation Text: Robbins J, McAlearney AS. Encouraging employees to speak up to prevent infections: Opportunities to leverage quality improvement and …

When do supervising physicians decide to entrust residents with unsupervised tasks? | PSNet

psnet.ahrq.gov/issue/when-do-supervising-physicians-decide-entrust-residents-unsupervised-tasks

October 03, 2012 - Study When do supervising physicians decide to entrust residents with unsupervised tasks? Citation Text: Sterkenburg A, Barach P, Kalkman CJ, et al. When do supervising physicians decide to entrust residents with unsupervised tasks? Acad Med. 2010;85(9):1408-1417. doi:10.1097/ACM.0b013…

Differential perceptions of what constitutes a medical error associated with electronic medical records. | PSNet

psnet.ahrq.gov/issue/differential-perceptions-what-constitutes-medical-error-associated-electronic-medical-records

August 09, 2023 - Commentary Differential perceptions of what constitutes a medical error associated with electronic medical records. Citation Text: Koppel R, Kuziemsky C, Elkin PL, et al. Differential perceptions of what constitutes a medical error associated with electronic medical records. Stud Health …

Variability in the measurement of hospital-wide mortality rates. | PSNet

psnet.ahrq.gov/issue/variability-measurement-hospital-wide-mortality-rates

July 01, 2016 - Study Classic Variability in the measurement of hospital-wide mortality rates. Citation Text: Shahian DM, Wolf RE, Iezzoni LI, et al. Variability in the measurement of hospital-wide mortality rates. N Engl J Med. 2010;363(26):2530-9. doi:10.1056/NEJMsa1006396. …

Do calculation errors by nurses cause medication errors in clinical practice? A literature review. | PSNet

psnet.ahrq.gov/issue/do-calculation-errors-nurses-cause-medication-errors-clinical-practice-literature-review

December 14, 2016 - Review Do calculation errors by nurses cause medication errors in clinical practice? A literature review. Citation Text: Wright K. Do calculation errors by nurses cause medication errors in clinical practice? A literature review. Nurse Educ Today. 2010;30(1):85-97. doi:10.1016/j.nedt.2…

Understanding the roles of three academic communities in a prospective learning health ecosystem for diagnostic excellence. | PSNet

psnet.ahrq.gov/issue/understanding-roles-three-academic-communities-prospective-learning-health-ecosystem

October 19, 2022 - Study Understanding the roles of three academic communities in a prospective learning health ecosystem for diagnostic excellence. Citation Text: Satterfield K, Rubin JC, Yang D, et al. Understanding the roles of three academic communities in a prospective learning health ecosystem for di…

Using Lean to improve medication administration safety: in search of the "perfect dose." | PSNet

psnet.ahrq.gov/issue/using-lean-improve-medication-administration-safety-search-perfect-dose

September 16, 2015 - Study Using Lean to improve medication administration safety: in search of the "perfect dose." Citation Text: Ching JM, Long C, Williams BL, et al. Using lean to improve medication administration safety: in search of the "perfect dose". Jt Comm J Qual Patient Saf. 2013;39(5):195-204. C…

A usability and safety analysis of electronic health records: a multi-center study. | PSNet

psnet.ahrq.gov/issue/usability-and-safety-analysis-electronic-health-records-multi-center-study

October 13, 2018 - Study Emerging Classic A usability and safety analysis of electronic health records: a multi-center study. Citation Text: Ratwani RM, Savage E, Will A, et al. A usability and safety analysis of electronic health records: a multi-center study. J Am Med Inform Ass…

Implementation of a high-reliability organization framework in a large integrated health care system: a pre-post quasi-experimental quality improvement project. | PSNet

psnet.ahrq.gov/issue/implementation-high-reliability-organization-framework-large-integrated-health-care-system

July 14, 2018 - Study Implementation of a high-reliability organization framework in a large integrated health care system: a pre-post quasi-experimental quality improvement project. Citation Text: Sawyer AM, Thiyarajan S, Essen KE, et al. Implementation of a high-reliability organization framework in a…

Targeted implementation of the Comprehensive Unit-Based Safety Program through an assessment of safety culture to minimize central line-associated bloodstream infections. | PSNet

psnet.ahrq.gov/issue/targeted-implementation-comprehensive-unit-based-safety-program-through-assessment-safety

November 20, 2015 - Study Targeted implementation of the Comprehensive Unit-Based Safety Program through an assessment of safety culture to minimize central line-associated bloodstream infections. Citation Text: Richter J, McAlearney AS. Targeted implementation of the Comprehensive Unit-Based Safety Program…

Adverse-event-reporting practices by US hospitals: results of a national survey. | PSNet

psnet.ahrq.gov/issue/adverse-event-reporting-practices-us-hospitals-results-national-survey

December 30, 2014 - Study Adverse-event-reporting practices by US hospitals: results of a national survey. Citation Text: Farley DO, Haviland A, Champagne S, et al. Adverse-event-reporting practices by US hospitals: results of a national survey. Qual Saf Health Care. 2008;17(6):416-23. doi:10.1136/qshc.20…

A visual medication schedule to improve anticoagulation control: a randomized, controlled trial. | PSNet

psnet.ahrq.gov/issue/visual-medication-schedule-improve-anticoagulation-control-randomized-controlled-trial

October 21, 2010 - Study A visual medication schedule to improve anticoagulation control: a randomized, controlled trial. Citation Text: Machtinger EL, Wang F, Chen L-L, et al. A visual medication schedule to improve anticoagulation control: a randomized, controlled trial. Jt Comm J Qual Patient Saf. 2007;…

"I wish I had seen this test result earlier!": dissatisfaction with test result management systems in primary care. | PSNet

psnet.ahrq.gov/issue/i-wish-i-had-seen-test-result-earlier-dissatisfaction-test-result-management-systems-primary

February 15, 2011 - Study "I wish I had seen this test result earlier!": dissatisfaction with test result management systems in primary care. Citation Text: Poon EG, Gandhi TK, Sequist TD, et al. "I wish I had seen this test result earlier!": Dissatisfaction with test result management systems in primary ca…

Perceptions of risk to patient safety in the pediatric ICU, a study of American pediatric intensivists. | PSNet

psnet.ahrq.gov/issue/perceptions-risk-patient-safety-pediatric-icu-study-american-pediatric-intensivists

August 28, 2017 - Study Perceptions of risk to patient safety in the pediatric ICU, a study of American pediatric intensivists. Citation Text: Bauer P, Hoffmann RG, Bragg D, et al. Perceptions of risk to patient safety in the pediatric ICU, a study of American pediatric intensivists. Saf Sci. 2012;53. d…

Advance care planning documentation practices and accessibility in the electronic health record: implications for patient safety. | PSNet

psnet.ahrq.gov/issue/advance-care-planning-documentation-practices-and-accessibility-electronic-health-record

December 05, 2012 - Study Emerging Classic Advance care planning documentation practices and accessibility in the electronic health record: implications for patient safety. Citation Text: Walker E, McMahan R, Barnes D, et al. Advance Care Planning Documentation Practices and Access…

Fatigue risk management: the impact of anesthesiology residents' work schedules on job performance and a review of potential countermeasures. | PSNet

psnet.ahrq.gov/issue/fatigue-risk-management-impact-anesthesiology-residents-work-schedules-job-performance-and

November 03, 2010 - Commentary Fatigue risk management: the impact of anesthesiology residents' work schedules on job performance and a review of potential countermeasures. Citation Text: Wong LR, Flynn-Evans E, Ruskin KJ. Fatigue Risk Management: The Impact of Anesthesiology Residents' Work Schedules on Jo…

Hospital at night: an organizational design that provides safer care at night. | PSNet

psnet.ahrq.gov/issue/hospital-night-organizational-design-provides-safer-care-night

November 16, 2022 - Study Hospital at night: an organizational design that provides safer care at night. Citation Text: Hamilton-Fairley D, Coakley J, Moss F. Hospital at night: an organizational design that provides safer care at night. BMC Med Edu. 2014;14(Suppl 1):S17. doi:10.1186/1472-6920-14-S1-S17. …

Adverse events involving telehealth in the Veterans Health Administration. | PSNet

psnet.ahrq.gov/issue/adverse-events-involving-telehealth-veterans-health-administration

October 26, 2022 - Review Adverse events involving telehealth in the Veterans Health Administration. Citation Text: Mills PD, Tomolo A, Yackel EE. Adverse events involving telehealth in the Veterans Health Administration. Jt Comm J Qual Patient Saf. 2024;Epub Dec 20. doi:10.1016/j.jcjq.2024.12.002. Copy …

Inappropriate dosing of direct oral anticoagulants in patients with atrial fibrillation. | PSNet

psnet.ahrq.gov/issue/inappropriate-dosing-direct-oral-anticoagulants-patients-atrial-fibrillation

August 04, 2021 - Study Emerging Classic Inappropriate dosing of direct oral anticoagulants in patients with atrial fibrillation. Citation Text: Sugrue A, Sanborn D, Amin M, et al. Inappropriate dosing of direct oral anticoagulants in patients with atrial fibrillation. Am J Cardi…

Patient safety issues from information overload in electronic medical records. | PSNet

psnet.ahrq.gov/issue/patient-safety-issues-information-overload-electronic-medical-records

May 04, 2022 - Review Patient safety issues from information overload in electronic medical records. Citation Text: Nijor S, Rallis G, Lad N, et al. Patient safety issues from information overload in electronic medical records. J Patient Saf. 2022;18(6):e999-e1003. doi:10.1097/pts.0000000000001002. C…

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