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  1. Opioids prescribed after low-risk surgical procedures in the United States, 2004–2012. | PSNet

    psnet.ahrq.gov/issue/opioids-prescribed-after-low-risk-surgical-procedures-united-states-2004-2012
    May 29, 2024 - Study Opioids prescribed after low-risk surgical procedures in the United States, 2004–2012. Citation Text: Wunsch H, Wijeysundera DN, Passarella MA, et al. Opioids Prescribed After Low-Risk Surgical Procedures in the United States, 2004-2012. JAMA. 2016;315(15):1654-7. doi:10.1001/jama.…

  2. Evaluation of near-miss wrong-patient events in radiology reports. | PSNet

    psnet.ahrq.gov/issue/evaluation-near-miss-wrong-patient-events-radiology-reports
    June 13, 2015 - Study Evaluation of near-miss wrong-patient events in radiology reports. Citation Text: Sadigh G, Loehfelm T, Applegate KE, et al. JOURNAL CLUB: Evaluation of Near-Miss Wrong-Patient Events in Radiology Reports. AJR Am J Roentgenol. 2015;205(2):337-43. doi:10.2214/AJR.14.13339. Copy Ci…

  3. Recognizing quality improvement and patient safety activities in academic promotion in departments of medicine: innovative language in promotion criteria. | PSNet

    psnet.ahrq.gov/issue/recognizing-quality-improvement-and-patient-safety-activities-academic-promotion-departments
    April 20, 2011 - Study Recognizing quality improvement and patient safety activities in academic promotion in departments of medicine: innovative language in promotion criteria. Citation Text: Staiger TO, Mills LM, Wong BM, et al. Recognizing Quality Improvement and Patient Safety Activities in Academic …

  4. The effect of electronic prescribing on medication errors and adverse drug events: a systematic review. | PSNet

    psnet.ahrq.gov/issue/effect-electronic-prescribing-medication-errors-and-adverse-drug-events-systematic-review
    October 30, 2013 - Review The effect of electronic prescribing on medication errors and adverse drug events: a systematic review. Citation Text: Ammenwerth E, Schnell-Inderst P, Machan C, et al. The effect of electronic prescribing on medication errors and adverse drug events: a systematic review. J Am M…

  5. A national patient safety curriculum in pediatric emergency medicine. | PSNet

    psnet.ahrq.gov/issue/national-patient-safety-curriculum-pediatric-emergency-medicine
    January 12, 2022 - Study A national patient safety curriculum in pediatric emergency medicine. Citation Text: Stankovic C, Wolff M, Chang TP, et al. A National Patient Safety Curriculum in Pediatric Emergency Medicine. Pediatr Emerg Care. 2019;35(8):519-521. doi:10.1097/PEC.0000000000001533. Copy Citatio…

  6. Risk-adjusted cumulative sum for early detection of hospitals with excess perioperative mortality. | PSNet

    psnet.ahrq.gov/issue/risk-adjusted-cumulative-sum-early-detection-hospitals-excess-perioperative-mortality
    August 14, 2019 - Study Risk-adjusted cumulative sum for early detection of hospitals with excess perioperative mortality. Citation Text: Chen VW, Chidi AP, Dong Y, et al. Risk-adjusted cumulative sum for early detection of hospitals with excess perioperative mortality. JAMA Surg. 2023;158(11):1176. doi:1…

  7. Medical errors and quality of care: from control to commitment. | PSNet

    psnet.ahrq.gov/issue/medical-errors-and-quality-care-control-commitment
    July 15, 2020 - Commentary Medical errors and quality of care: from control to commitment. Citation Text: Khatri N, Baveja A, Boren SA, et al. Medical Errors and Quality of Care: From Control to Commitment. California Manage Review. 2006;48(3):115-141. doi:10.2307/41166353. Copy Citation Format…

  8. Expressing concern and writing it down: an experimental study investigating transfer of information at nursing handover. | PSNet

    psnet.ahrq.gov/issue/expressing-concern-and-writing-it-down-experimental-study-investigating-transfer-information
    November 17, 2014 - Study Expressing concern and writing it down: an experimental study investigating transfer of information at nursing handover. Citation Text: Lee H, Cumin D, Devcich DA, et al. Expressing concern and writing it down: an experimental study investigating transfer of information at nursing …

  9. Identifying critically ill patients at risk for inappropriate antibiotic therapy: a pilot study of a point-of-care decision support alert. | PSNet

    psnet.ahrq.gov/issue/identifying-critically-ill-patients-risk-inappropriate-antibiotic-therapy-pilot-study-point
    August 02, 2011 - Study Identifying critically ill patients at risk for inappropriate antibiotic therapy: a pilot study of a point-of-care decision support alert. Citation Text: Micek ST, Heard KM, Gowan M, et al. Identifying critically ill patients at risk for inappropriate antibiotic therapy: a pilot st…

  10. The mental health trigger tool: development and testing of a specialized trigger tool for mental health settings. | PSNet

    psnet.ahrq.gov/issue/mental-health-trigger-tool-development-and-testing-specialized-trigger-tool-mental-health
    September 27, 2017 - Study The mental health trigger tool: development and testing of a specialized trigger tool for mental health settings. Citation Text: Sajith SG, Fung D, Chua HC. The Mental Health Trigger Tool: Development and Testing of a Specialized Trigger Tool for Mental Health Settings. J Patient S…

  11. The problems of detecting medication errors in hospitals. | PSNet

    psnet.ahrq.gov/issue/problems-detecting-medication-errors-hospitals
    February 01, 2012 - Study Classic The problems of detecting medication errors in hospitals. Citation Text: Barker KN, McConnell WE. The Problems of Detecting Medication Errors in Hospitals. Am J Health Syst Pharm. 1962;19(8):360-369. doi:10.1093/ajhp/19.8.360. Copy Citation …

  12. Organizational learning: health care leaders need to design structures and processes that enhance collective learning. | PSNet

    psnet.ahrq.gov/issue/organizational-learning-health-care-leaders-need-design-structures-and-processes-enhance
    November 18, 2020 - Commentary Organizational learning: health care leaders need to design structures and processes that enhance collective learning. Citation Text: Bohmer RM, Edmondson AC. Organizational learning in health care. Health Forum J. 2001;44(2):32-35. Copy Citation Format: Google…

  13. Defining the critical role of nurses in diagnostic error prevention: a conceptual framework and a call to action. | PSNet

    psnet.ahrq.gov/issue/defining-critical-role-nurses-diagnostic-error-prevention-conceptual-framework-and-call
    October 28, 2020 - Review Defining the critical role of nurses in diagnostic error prevention: a conceptual framework and a call to action. Citation Text: Gleason KT, Davidson PM, Tanner EK, et al. Defining the critical role of nurses in diagnostic error prevention: a conceptual framework and a call to act…

  14. Engaging the patient as observer to promote hand hygiene compliance in ambulatory care. | PSNet

    psnet.ahrq.gov/issue/engaging-patient-observer-promote-hand-hygiene-compliance-ambulatory-care
    September 02, 2020 - Study Engaging the patient as observer to promote hand hygiene compliance in ambulatory care. Citation Text: Bittle MJ, LaMarche S. Engaging the patient as observer to promote hand hygiene compliance in ambulatory care. Jt Comm J Qual Patient Saf. 2009;35(10):519-25. Copy Citation …

  15. Preventable hospital admissions related to medication (HARM): cost analysis of the HARM study. | PSNet

    psnet.ahrq.gov/issue/preventable-hospital-admissions-related-medication-harm-cost-analysis-harm-study
    April 27, 2022 - Study Preventable hospital admissions related to medication (HARM): cost analysis of the HARM study. Citation Text: Leendertse AJ, van den Bemt PMLA, Poolman JB, et al. Preventable hospital admissions related to medication (HARM): cost analysis of the HARM study. Value Health. 2011;14(1)…

  16. Safety climate associated with adverse events in nursing homes: a national VA study. | PSNet

    psnet.ahrq.gov/issue/safety-climate-associated-adverse-events-nursing-homes-national-va-study
    September 08, 2021 - Study Safety climate associated with adverse events in nursing homes: a national VA study. Citation Text: Quach ED, Kazis LE, Zhao S, et al. Safety climate associated with adverse events in nursing homes: a national VA study. J Am Med Dir Assoc. 2021;22(2):388-392. doi:10.1016/j.jamda.20…

  17. Do hospitals support second victims? Collective insights from patient safety leaders in Maryland. | PSNet

    psnet.ahrq.gov/issue/do-hospitals-support-second-victims-collective-insights-patient-safety-leaders-maryland
    May 11, 2016 - Study Do hospitals support second victims? Collective insights from patient safety leaders in Maryland. Citation Text: Edrees HH, Morlock L, Wu AW. Do Hospitals Support Second Victims? Collective Insights From Patient Safety Leaders in Maryland. Jt Comm J Qual Saf. 2017;43(9):471-483. do…

  18. Review of medication errors that are new or likely to occur more frequently with electronic medication management systems. | PSNet

    psnet.ahrq.gov/issue/review-medication-errors-are-new-or-likely-occur-more-frequently-electronic-medication
    August 18, 2021 - Study Review of medication errors that are new or likely to occur more frequently with electronic medication management systems. Citation Text: Van de Vreede M, McGrath A, de Clifford J. Review of medication errors that are new or likely to occur more frequently with electronic medicatio…

  19. Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions. | PSNet

    psnet.ahrq.gov/issue/enabling-learning-healthcare-system-automated-computer-protocols-produce-replicable-and
    September 23, 2020 - Commentary Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions. Citation Text: Morris AH, Stagg B, Lanspa M, et al. Enabling a learning healthcare system with automated computer protocols that produce replicab…

  20. Temporal clustering of critical illness events on medical wards. | PSNet

    psnet.ahrq.gov/issue/temporal-clustering-critical-illness-events-medical-wards
    January 31, 2024 - Study Temporal clustering of critical illness events on medical wards. Citation Text: Doshi S, Shin S, Lapointe-Shaw L, et al. Temporal clustering of critical illness events on medical wards. JAMA Intern Med. 2023;183(9):924-932. doi:10.1001/jamainternmed.2023.2629. Copy Citation F…
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