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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…

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 …

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…

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…

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 …

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…

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…

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 …

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)…

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…

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…

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…

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…

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…

Surveillance of medical device-related hazards and adverse events in hospitalized patients. | PSNet

psnet.ahrq.gov/issue/surveillance-medical-device-related-hazards-and-adverse-events-hospitalized-patients

March 11, 2011 - Study Classic Surveillance of medical device-related hazards and adverse events in hospitalized patients. Citation Text: Samore MH, Evans S, Lassen A, et al. Surveillance of medical device-related hazards and adverse events in hospitalized patients. JAMA. 2004;2…

Frontline providers' and patients' perspectives on improving diagnostic safety in the emergency department: a qualitative study. | PSNet

psnet.ahrq.gov/issue/frontline-providers-and-patients-perspectives-improving-diagnostic-safety-emergency

May 15, 2024 - Study Frontline providers' and patients' perspectives on improving diagnostic safety in the emergency department: a qualitative study. Citation Text: Mangus CW, James TG, Parker SJ, et al. Frontline providers' and patients' perspectives on improving diagnostic safety in the emergency dep…

Hastened death due to disease burden and distress that has not received timely, quality palliative care is a medical error. | PSNet

psnet.ahrq.gov/issue/hastened-death-due-disease-burden-and-distress-has-not-received-timely-quality-palliative

October 31, 2023 - Commentary Hastened death due to disease burden and distress that has not received timely, quality palliative care is a medical error. Citation Text: Gallagher R, Passmore MJ, Baldwin C. Hastened death due to disease burden and distress that has not received timely, quality palliative ca…

Implementation strategies in the context of medication reconciliation: a qualitative study. | PSNet

psnet.ahrq.gov/issue/implementation-strategies-context-medication-reconciliation-qualitative-study

August 05, 2020 - Study Implementation strategies in the context of medication reconciliation: a qualitative study. Citation Text: Stolldorf DP, Ridner SH, Vogus TJ, et al. Implementation strategies in the context of medication reconciliation: a qualitative study. Implement Sci Commun. 2021;2(1):63. doi:1…

A systematic review of the prevalence and types of adverse events in interfacility critical care transfers by paramedics. | PSNet

psnet.ahrq.gov/issue/systematic-review-prevalence-and-types-adverse-events-interfacility-critical-care-transfers

November 25, 2020 - Review A systematic review of the prevalence and types of adverse events in interfacility critical care transfers by paramedics. Citation Text: Alabdali A, Fisher JD, Trivedy C, et al. A Systematic Review of the Prevalence and Types of Adverse Events in Interfacility Critical Care Transf…

Electronic health record-based triggers to detect adverse events after outpatient orthopaedic surgery. | PSNet

psnet.ahrq.gov/issue/electronic-health-record-based-triggers-detect-adverse-events-after-outpatient-orthopaedic

December 19, 2017 - Study Electronic health record-based triggers to detect adverse events after outpatient orthopaedic surgery. Citation Text: Menendez ME, Janssen SJ, Ring D. Electronic health record-based triggers to detect adverse events after outpatient orthopaedic surgery. BMJ Qual Saf. 2016;25(1):25-…

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