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psnet.ahrq.gov/node/865344/psn-pdf
March 27, 2024 - This systematic review of 17 studies examined the impact of
CPOE systems with CDS in preventing pediatric … Included studies evaluated CDS
tools providing dose range checks, dose calculators, and dosing frequency … The majority of studies
reported improvements in dose error prevention with use of CPOE-CDS systems, … with eight studies
reporting significant reductions in dosing errors.
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psnet.ahrq.gov/issue/leder-learning-lives-and-deaths
October 19, 2022 - Norah Frye Centre for Disability Studies; Bristol, England. … Linkedin
Copy URL
January 19, 2022
Norah Frye Centre for Disability Studies … Norah Frye Centre for Disability Studies; Bristol, England. … March 16, 2022
STARD 2015 guidelines for reporting diagnostic accuracy studies: explanation … Hospitalizations and deaths related to adverse drug events worldwide: systematic review of studies
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psnet.ahrq.gov/node/60299/psn-pdf
May 06, 2020 - This systematic review synthesized 24 studies examining the impact of either unit-based or hospital- … The majority of studies were uncontrolled pre-post study designs; only two
studies were controlled and … Given the limited number of studies evaluating hospital-wide
huddle programs, the authors conclude that
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psnet.ahrq.gov/issue/interventions-reliability-seeking-health-care-organizations-systematic-review-their-goals-and
October 19, 2022 - This systematic review identified 75 studies reporting on health systems’ interventions to improve reliability … The six goals of Crossing the Quality Chasm were used to categorize studies. … Most studies focused solely or in part on safety; only ten focused solely on one of the other five goals
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psnet.ahrq.gov/issue/malpractice-claims-related-diagnostic-errors-hospital
September 16, 2020 - Characterization of diagnostic error in the hospital setting has traditionally relied on data from autopsy studies … Consistent with other studies , a small proportion (9%) of physicians accounted for a large proportion … healthcare organisations struggling to improve quality: results from a systematic review of qualitative studies
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psnet.ahrq.gov/issue/does-root-cause-analysis-improve-patient-safety-systematic-review-department-veterans-affairs
March 24, 2021 - Of the ten retrospective studies included in the review, all reported improvements following RCA-recommended … interventions implementation, but the studies used different methodologies to assess effectiveness. … first-year resident physicians' extended duration work shifts: a pooled analysis of prospective cohort studies
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psnet.ahrq.gov/issue/effectiveness-double-checking-reduce-medication-administration-errors-systematic-review
August 26, 2020 - Investigators identified 13 studies (3 were considered high-quality) that demonstrated variable adherence … No studies demonstrated differences in patient harm with double-checking compared to usual medication … The authors call for higher-quality studies to determine whether the time-intensive practice of double-checking
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psnet.ahrq.gov/issue/how-satisfied-are-patients-and-surgeons-telemedicine-orthopaedic-care-during-covid-19
July 15, 2020 - orthopedic care delivery as compared to in-person visits.However, the authors note that the included studies … of health care strikes on patient mortality: a systematic review and meta-analysis of observational studies … patients with heart failure: a systematic review of randomized trials and non-randomized intervention studies
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psnet.ahrq.gov/issue/impact-providing-patients-access-electronic-health-records-quality-and-safety-care-systematic
July 27, 2022 - Meta-analysis found that sharing EHRs with patients is effective in reducing HbA1c levels; the included studies … However, the authors concluded that more methodologically robust studies are necessary to quantitatively … Hospitalizations and deaths related to adverse drug events worldwide: systematic review of studies
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psnet.ahrq.gov/issue/mixed-results-safety-performance-computerized-physician-order-entry
May 04, 2022 - Computerized provider order entry (CPOE) has provided significant safety benefits in research studies … However, CPOE's "real-world" performance has been mixed, with high-profile studies documenting a variety … Taken together, these studies imply that CPOE implementation may not result in large immediate effects
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psnet.ahrq.gov/issue/neglected-barrier-medication-use-systematic-review-difficulties-associated-opening-medication
February 16, 2022 - This review includes 12 studies where participants were observed opening a variety of medication packages … While all studies reported participant difficulty, no consistent contributory factors were identified … , and the methodological quality of all studies was typically low.
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psnet.ahrq.gov/issue/poking-skunk-ethical-and-medico-legal-concerns-research-about-patients-experiences-medical
May 05, 2021 - As with prior studies , researchers found that patients expressed a desire to be heard. … boards permit investigators to approach patients who have experienced adverse events to participate in studies … , rather than prohibit such studies due to fear of causing further psychological harm.
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psnet.ahrq.gov/issue/factors-influencing-medication-errors-prehospital-paramedic-environment-mixed-method
August 25, 2021 - While there are studies reporting a variety of prehospital adverse events (e.g., respiratory and airway … events , communication , etc.), there have been few studies of medication errors that occur in prehospital … This mixed methods systematic review of 56 studies and case reports identifies seven major themes such
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psnet.ahrq.gov/issue/association-between-nurse-staffing-and-quality-care-emergency-departments-systematic-review
June 16, 2021 - Sixteen studies on the effects of nurse staffing in emergency departments (EDs) were identified for this … Several, but not all, of the studies found that lower nurse staffing was associated with longer wait … Additional longitudinal studies are needed to further investigate nurse staffing in emergency departments
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psnet.ahrq.gov/sites/default/files/2025-03/PSNet%20Webinar%20Feb%202025_0.pdf
January 01, 2025 - , &
► restricting search to studies published in English & performed in the US … • MHS IV Methods
➢ Searched PubMed & Cochrane Library for systematic reviews & primary
studies ( … 2018-2023)
➢ 4 reviews, 19 primary studies
21
RRS versus no RRS: Mortality
22
Study Study Type … Systematic review Hospital mortality 7 of 13 studies showed
improvement
Adults
McGaughey et al. … ), early refill requests (3
studies) or patient satisfaction (2 studies)
45
Multicomponent Interventions
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psnet.ahrq.gov/node/33591/psn-pdf
March 15, 2025 - Current use of trigger tools
The Harvard Medical Practice Study and other classic studies used fairly … The GTT is practical for routine
improvement efforts and not just research studies, and it includes … Conceptually, though, the method resembles that of major adverse
event studies such as the Harvard Medical … This is
not inappropriate per se, but readers of such studies should be aware that inter-rater agreement … Although some studies have sought to develop trigger tools for ambulatory care, there is relatively little
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psnet.ahrq.gov/node/42067/psn-pdf
March 18, 2013 - However, this systematic review identifies an underlying flaw inherent in
studies of medication administration … For example, only 6 of 16 included studies considered
administration of a drug at the wrong time to … As delayed drug administration is relatively
common, studies that did not include such wrong-time errors … Prior studies have also raised concern that variations in the
definition of medication errors can affect … rates, and medication error measurement
standards have been developed for medication reconciliation studies
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psnet.ahrq.gov/node/72791/psn-pdf
March 03, 2021 - over
time: a systematic review and meta-analysis of
longitudinal retrospective patient record review studies … over time: a
systematic review and meta-analysis of longitudinal retrospective patient record review studies … The meta-analysis of included studies
estimated one adverse event prevented for every 59 hospital admissions … The authors note a need for
more research (particularly large-scale implementation studies) to establish
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psnet.ahrq.gov/innovation/johns-hopkins-venous-thromboembolism-vte-collaborative-studies-and-implements-methods
June 19, 2024 - The Johns Hopkins Venous Thromboembolism (VTE) Collaborative Studies and Implements Methods to Prevent … Venous Thromboembolism (VTE) Collaborative (the VTE Collaborative) is a multidisciplinary group that studies … practice that can reduce healthcare-associated VTE in high-risk patients by 30–65%. 4 Still, numerous studies
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psnet.ahrq.gov/node/45848/psn-pdf
November 19, 2018 - New Horizons in Patient Safety: Understanding
Communication: Case Studies for Physicians. … https://psnet.ahrq.gov/issue/new-horizons-patient-safety-understanding-communication-case-studies-
physicians … publication discusses factors that influence
communication in the medical care process and uses case studies … https://psnet.ahrq.gov/issue/new-horizons-patient-safety-understanding-communication-case-studies-physicians … https://psnet.ahrq.gov/issue/new-horizons-patient-safety-understanding-communication-case-studies-physicians