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psnet.ahrq.gov/node/50824/psn-pdf
January 22, 2020 - Failure to rescue and 30-day in-hospital mortality in
hospitals with and without crew-resource-management
safety training.
January 22, 2020
Bacon CT, McCoy TP, Henshaw DS. Failure to rescue and 30?day in?hospital mortality in hospitals with
and without crew?resource?management safety training. Res Nurs Health. 201…
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psnet.ahrq.gov/node/50704/psn-pdf
December 04, 2019 - Hospital-Acquired Condition Reduction Program is not
associated with additional patient safety improvement.
December 4, 2019
Sheetz KH, Dimick JB, Englesbe MJ, et al. Hospital-Acquired Condition Reduction Program Is Not
Associated With Additional Patient Safety Improvement. Health Aff (Millwood). 2019;38(11):1858-1…
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psnet.ahrq.gov/node/44698/psn-pdf
April 08, 2016 - Relationship between patient safety climate and standard
precaution adherence: a systematic review of the
literature.
April 8, 2016
Hessels AJ, Larson EL. Relationship between patient safety climate and standard precaution adherence: a
systematic review of the literature. J Hosp Infect. 2016;92(4):349-62. doi:10.1…
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psnet.ahrq.gov/node/46240/psn-pdf
June 21, 2017 - Implementation of a modified bedside handoff for a
postpartum unit.
June 21, 2017
Wollenhaup CA, Stevenson EL, Thompson J, et al. Implementation of a Modified Bedside Handoff for a
Postpartum Unit. J Nurs Admin. 2017;47(6):320-326. doi:10.1097/NNA.0000000000000487.
https://psnet.ahrq.gov/issue/implementation-modif…
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psnet.ahrq.gov/node/47299/psn-pdf
March 20, 2019 - Unintentionally retained guidewires: a descriptive study
of 73 sentinel events.
March 20, 2019
Steelman VM, Thenuwara K, Shaw C, et al. Unintentionally Retained Guidewires: A Descriptive Study of 73
Sentinel Events. Jt Comm J Qual Saf. 2019;45(2):81-90. doi:10.1016/j.jcjq.2018.08.003.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/40270/psn-pdf
March 09, 2011 - Harvey Cushing's open and thorough documentation of
surgical mishaps at the dawn of neurologic surgery.
March 9, 2011
Latimer K, Pendleton C, Olivi A, et al. Harvey Cushing's open and thorough documentation of surgical
mishaps at the dawn of neurologic surgery. Arch Surg. 2011;146(2):226-32.
doi:10.1001/archsurg.2…
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psnet.ahrq.gov/node/845640/psn-pdf
March 08, 2023 - Effect of Patient and Family Centered I-PASS on adverse
event rates in hospitalized children with complex chronic
conditions.
March 8, 2023
Kuzma N, Khan A, Rickey L, et al. Effect of Patient and Family Centered I?PASS on adverse event rates in
hospitalized children with complex chronic conditions. J Hosp Med. 202…
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psnet.ahrq.gov/node/35154/psn-pdf
January 02, 2017 - Ambulatory care visits for treating adverse drug effects in
the United States, 1995-2001.
January 2, 2017
Zhan C, Arispe IE, Kelley E, et al. Ambulatory Care Visits for Treating Adverse Drug Effects in the United
States, 1995–2001. The Joint Commission Journal on Quality and Patient Safety. 2016;31(7).
doi:10.1016…
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psnet.ahrq.gov/node/45771/psn-pdf
January 11, 2017 - Closing the loop: a process evaluation of inpatient care
team communication.
January 11, 2017
Broman KK, Kensinger C, Hart H, et al. Closing the loop: a process evaluation of inpatient care team
communication. BMJ Qual Saf. 2017;26(1):30-32. doi:10.1136/bmjqs-2015-004580.
https://psnet.ahrq.gov/issue/closing-loop-…
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psnet.ahrq.gov/node/37699/psn-pdf
February 22, 2011 - The effect of computerized physician order entry with
clinical decision support on the rates of adverse drug
events: a systematic review.
February 22, 2011
Wolfstadt JI, Gurwitz JH, Field T, et al. The effect of computerized physician order entry with clinical
decision support on the rates of adverse drug events: …
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psnet.ahrq.gov/node/33706/psn-pdf
February 01, 2011 - RW: You were looking at care delivery from a business, a process, and a statistical perspective. … And you come at this from a data
background and a statistical background.
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psnet.ahrq.gov/node/33785/psn-pdf
May 01, 2015 - When our statistical analyst walked into my office with the very first
analysis of the relationship
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psnet.ahrq.gov/node/46319/psn-pdf
August 09, 2017 - Opioids in Medicare Part D: Concerns About Extreme Use
and Questionable Prescribing.
August 9, 2017
Office of the Inspector General. Washington, DC: US Department of Health and Human Services; July
2017. Report No. OEI-02-17-00250.
https://psnet.ahrq.gov/issue/opioids-medicare-part-d-concerns-about-extreme-use-and…
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psnet.ahrq.gov/node/37178/psn-pdf
October 06, 2011 - Randomized trial to improve prescribing safety in
ambulatory elderly patients.
October 6, 2011
Raebel MA, Charles J, Dugan J, et al. Randomized trial to improve prescribing safety in ambulatory elderly
patients. J Am Geriatr Soc. 2007;55(7):977-85.
https://psnet.ahrq.gov/issue/randomized-trial-improve-prescribing-…
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psnet.ahrq.gov/node/844801/psn-pdf
January 01, 2021 - A mixed-methods study of challenges experienced by
clinical teams in measuring improvement.
September 11, 2019
Woodcock T, Liberati EG, Dixon-Woods M. A mixed-methods study of challenges experienced by clinical
teams in measuring improvement. BMJ Qual Saf. 2021;30(2):106-115. doi:10.1136/bmjqs-2018-009048.
https:/…
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psnet.ahrq.gov/node/38940/psn-pdf
November 25, 2009 - The role of advice in medication administration errors in
the pediatric ambulatory setting.
November 25, 2009
Lemer C, Bates DW, Yoon CS, et al. The role of advice in medication administration errors in the pediatric
ambulatory setting. J Patient Saf. 2009;5(3):168-75. doi:10.1097/PTS.0b013e3181b3a9b0.
https://psn…
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psnet.ahrq.gov/node/40338/psn-pdf
March 23, 2011 - Nurse staffing and inpatient hospital mortality.
March 23, 2011
Needleman J, Buerhaus P, Pankratz S, et al. Nurse staffing and inpatient hospital mortality. New Engl J
Med. 2011;364(11):1037-1045. doi:10.1056/NEJMsa1001025.
https://psnet.ahrq.gov/issue/nurse-staffing-and-inpatient-hospital-mortality
Several studie…
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psnet.ahrq.gov/node/45296/psn-pdf
September 21, 2016 - Comparison of medication safety systems in critical
access hospitals: combined analysis of two studies.
September 21, 2016
Cochran GL, Barrett RS, Horn SD. Comparison of medication safety systems in critical access hospitals:
Combined analysis of two studies. Am J Health Syst Pharm. 2016;73(15):1167-73.
doi:10.214…
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psnet.ahrq.gov/web-mm/its-all-syringe
February 01, 2013 - Statistical Abstract of the United States: 2006. Washington, DC: US Census Bureau; 2006.
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psnet.ahrq.gov/perspective/conversation-david-m-gaba-md
March 01, 2013 - So when we get on an airliner nowadays, we have every reason to the n th statistical degree to expect … patient-related outcomes (behaviors and direct patient effects) the benefits approached but did not reach statistical … patient effects) revealed benefits of similar direction and magnitude that approached but did not reach statistical