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  1. An acetaminophen icon helps reduce medication decision errors in an experimental setting. | PSNet

    psnet.ahrq.gov/issue/acetaminophen-icon-helps-reduce-medication-decision-errors-experimental-setting
    January 12, 2022 - Study An acetaminophen icon helps reduce medication decision errors in an experimental setting. Citation Text: Shiffman S, Cotton H, Jessurun C, et al. An acetaminophen icon helps reduce medication decision errors in an experimental setting. J Am Pharm Assoc (2003). 2016;56(5):495-503.e4…

  2. Healthcare Inspection: Evaluation of the Veterans Health Administration's National Consult Delay Review and Associated Fact Sheet. | PSNet

    psnet.ahrq.gov/issue/healthcare-inspection-evaluation-veterans-health-administrations-national-consult-delay
    September 10, 2014 - Book/Report Healthcare Inspection: Evaluation of the Veterans Health Administration's National Consult Delay Review and Associated Fact Sheet. Citation Text: Healthcare Inspection: Evaluation of the Veterans Health Administration's National Consult Delay Review and Associated Fact Sheet.…

  3. Debunking the myth that the majority of medical errors are attributed to communication. | PSNet

    psnet.ahrq.gov/issue/debunking-myth-majority-medical-errors-are-attributed-communication
    February 14, 2024 - Journal Article Debunking the myth that the majority of medical errors are attributed to communication. Citation Text: Clapper TC, Ching K. Debunking the myth that the majority of medical errors are attributed to communication. Med Educ. 2020;54(1):74-81. doi:10.1111/medu.13821. Copy C…

  4. The landscape of inappropriate laboratory testing: a 15-year meta-analysis. | PSNet

    psnet.ahrq.gov/issue/landscape-inappropriate-laboratory-testing-15-year-meta-analysis
    February 12, 2020 - Study The landscape of inappropriate laboratory testing: a 15-year meta-analysis. Citation Text: Zhi M, Ding EL, Theisen-Toupal J, et al. The landscape of inappropriate laboratory testing: a 15-year meta-analysis. PLoS One. 2013;8(11):e78962. doi:10.1371/journal.pone.0078962. Copy Cit…

  5. The global burden of unsafe medical care: analytic modelling of observational studies. | PSNet

    psnet.ahrq.gov/issue/global-burden-unsafe-medical-care-analytic-modelling-observational-studies
    September 29, 2017 - Study Classic The global burden of unsafe medical care: analytic modelling of observational studies. Citation Text: Jha AK, Larizgoitia I, Audera-Lopez C, et al. The global burden of unsafe medical care: analytic modelling of observational studies. BMJ Qual Saf.…

  6. An analysis of adverse events in the rehabilitation department: using the Veterans Affairs root cause analysis system. | PSNet

    psnet.ahrq.gov/issue/analysis-adverse-events-rehabilitation-department-using-veterans-affairs-root-cause-analysis
    June 21, 2017 - Study An analysis of adverse events in the rehabilitation department: using the Veterans Affairs root cause analysis system. Citation Text: Hagley GW, Mills PD, Shiner B, et al. An Analysis of Adverse Events in the Rehabilitation Department: Using the Veterans Affairs Root Cause Analysis…

  7. Characteristics of morbidity and mortality conferences associated with the implementation of patient safety improvement initiatives, an observational study. | PSNet

    psnet.ahrq.gov/issue/characteristics-morbidity-and-mortality-conferences-associated-implementation-patient-safety
    March 18, 2020 - Study Characteristics of morbidity and mortality conferences associated with the implementation of patient safety improvement initiatives, an observational study. Citation Text: François P, Prate F, Vidal-Trecan G, et al. Characteristics of morbidity and mortality conferences associated …

  8. Safety first! Using a checklist for intrafacility transport of adult intensive care patients. | PSNet

    psnet.ahrq.gov/issue/safety-first-using-checklist-intrafacility-transport-adult-intensive-care-patients
    October 09, 2024 - Commentary Safety first! Using a checklist for intrafacility transport of adult intensive care patients. Citation Text: Comeau OY, Armendariz-Batiste J, Woodby SA. Safety First! Using a Checklist for Intrafacility Transport of Adult Intensive Care Patients. Crit Care Nurse. 2015;35(5):16…

  9. Competition and health plan performance: evidence from health maintenance organization insurance markets. | PSNet

    psnet.ahrq.gov/issue/competition-and-health-plan-performance-evidence-health-maintenance-organization-insurance
    July 14, 2009 - Study Competition and health plan performance: evidence from health maintenance organization insurance markets. Citation Text: Scanlon D, Swaminathan S, Chernew M, et al. Competition and health plan performance: evidence from health maintenance organization insurance markets. Med Care.…

  10. Incidence of adverse events related to health care in Spain: results of the Spanish National Study of Adverse Events. | PSNet

    psnet.ahrq.gov/issue/incidence-adverse-events-related-health-care-spain-results-spanish-national-study-adverse
    December 01, 2011 - Study Incidence of adverse events related to health care in Spain: results of the Spanish National Study of Adverse Events. Citation Text: Aranaz-Andrés JM, Aibar-Remón C, Vitaller-Murillo J, et al. Incidence of adverse events related to health care in Spain: results of the Spanish Nat…

  11. Day of discharge does not impact hospital readmission after major cardiac surgery. | PSNet

    psnet.ahrq.gov/issue/day-discharge-does-not-impact-hospital-readmission-after-major-cardiac-surgery
    October 16, 2019 - Study Day of discharge does not impact hospital readmission after major cardiac surgery. Citation Text: Sanaiha Y, Ou R, Ramos G, et al. Day of Discharge Does Not Impact Hospital Readmission After Major Cardiac Surgery. Ann Thorac Surg. 2018;106(6):1767-1773. doi:10.1016/j.athoracsur.201…

  12. Systematic review of morbidity and mortality meeting standardization: does it lead to improved professional development, system improvements, clinician engagement, and enhanced patient safety culture? | PSNet

    psnet.ahrq.gov/issue/systematic-review-morbidity-and-mortality-meeting-standardization-does-it-lead-improved
    October 23, 2024 - Review Systematic review of morbidity and mortality meeting standardization: does it lead to improved professional development, system improvements, clinician engagement, and enhanced patient safety culture? Citation Text: Steel EJ, Janda M, Jamali S, et al. Systematic review of morbidit…

  13. Simulation safety first: an imperative. | PSNet

    psnet.ahrq.gov/issue/simulation-safety-first-imperative
    February 13, 2014 - Commentary Simulation safety first: an imperative. Citation Text: Raemer D, Hannenberg A, Mullen A. Simulation Safety First: An Imperative. Simul Healthc. 2018;13(6):373-375. doi:10.1097/SIH.0000000000000341. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3…

  14. 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…

  15. Department of anesthesiology skilled peer support program outcomes: second victim perceptions. | PSNet

    psnet.ahrq.gov/issue/department-anesthesiology-skilled-peer-support-program-outcomes-second-victim-perceptions
    April 12, 2011 - Study Department of anesthesiology skilled peer support program outcomes: second victim perceptions. Citation Text: Bursch B, Ziv K, Marchese S, et al. Department of anesthesiology skilled peer support program outcomes: second victim perceptions. Jt Comm J Qual Patient Saf. 2024;50(6):44…

  16. U.S. Preventive Services Task Force Issues Final Recommendation on Screening for Syphilis Infection (pdf file)

    www.uspreventiveservicestaskforce.org/uspstf/sites/default/files/file/supporting_documents/syphilis-nonpregnant-adults-adolescents-screening-final-rec-bulletin.pdf
    September 27, 2022 - U.S. Preventive Services Task Force Issues Final Recommendation on Screening for Syphilis Infection http://www.uspreventiveservicestaskforce.org 1 U.S. Preventive Services Task Force Issues Final Recommendation on Screening for Syphilis Infection Task Force recommends screening people at increased risk fo…

  17. "Mr Smith's been our problem child today...": anticipatory management communication (AMC) in VA end-of-shift medicine and nursing handoffs. | PSNet

    psnet.ahrq.gov/issue/mr-smiths-been-our-problem-child-today-anticipatory-management-communication-amc-va-end-shift
    January 22, 2016 - Study "Mr Smith's been our problem child today...": anticipatory management communication (AMC) in VA end-of-shift medicine and nursing handoffs. Citation Text: Bergman AA, Flanagan ME, Ebright PR, et al. "Mr Smith's been our problem child today…": anticipatory management communication (…

  18. Estimating the hospital costs of inpatient harms. | PSNet

    psnet.ahrq.gov/issue/estimating-hospital-costs-inpatient-harms
    February 07, 2024 - Study Estimating the hospital costs of inpatient harms. Citation Text: Anand P, Kranker K, Chen AY. Estimating the hospital costs of inpatient harms. Health Serv Res. 2019;54(1):86-96. doi:10.1111/1475-6773.13066. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNo…

  19. Race differences in reported harmful patient safety events in healthcare system high reliability organizations. | PSNet

    psnet.ahrq.gov/issue/race-differences-reported-harmful-patient-safety-events-healthcare-system-high-reliability
    March 01, 2023 - Study Race differences in reported harmful patient safety events in healthcare system high reliability organizations. Citation Text: Thomas AD, Pandit C, Krevat SA. Race Differences in Reported Harmful Patient Safety Events in Healthcare System High Reliability Organizations. J Patient S…

  20. Using the patient safety indicators to detect potential safety events among US veterans with psychotic disorders: clinical and research implications. | PSNet

    psnet.ahrq.gov/issue/using-patient-safety-indicators-detect-potential-safety-events-among-us-veterans-psychotic
    November 16, 2022 - Study Using the patient safety indicators to detect potential safety events among US veterans with psychotic disorders: clinical and research implications. Citation Text: Smith EG, Zhao S, Rosen AK. Using the patient safety indicators to detect potential safety events among US veterans w…
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