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psnet.ahrq.gov/issue/consequences-whistle-blowing-integrative-review
November 16, 2022 - Review
The consequences of whistle-blowing: an integrative review.
Citation Text:
Lim CR, Zhang MWB, Hussain SF, et al. The Consequences of Whistle-blowing: An Integrative Review. J Patient Saf. 2021;17(6):e497-e502. doi:10.1097/PTS.0000000000000396.
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psnet.ahrq.gov/issue/lessons-learned-implementing-principled-approach-resolution-following-patient-harm
February 12, 2020 - Commentary
Lessons learned from implementing a principled approach to resolution following patient harm.
Citation Text:
Smith KM, Smith LL, (Jack) Gentry JC, et al. Lessons learned from implementing a principled approach to resolution following patient harm. J Patient Saf Risk Manag. 201…
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psnet.ahrq.gov/issue/development-instrument-measure-unintended-consequences-ehrs
June 22, 2011 - Commentary
Development of an instrument to measure the unintended consequences of EHRs.
Citation Text:
Carrington JM, Gephart SM, Verran JA, et al. Development of an Instrument to Measure the Unintended Consequences of EHRs. West J Nurs Res. 2015;37(7):842-58. doi:10.1177/019394591557608…
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psnet.ahrq.gov/issue/beyond-clinical-team-evaluating-human-factors-oriented-training-non-clinical-professionals
March 12, 2025 - Study
Beyond the clinical team: evaluating the human factors-oriented training of non-clinical professionals working in healthcare contexts.
Citation Text:
Lavelle M, Reedy GB, Attoe C, et al. Beyond the clinical team: evaluating the human factors-oriented training of non-clinical profes…
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psnet.ahrq.gov/issue/covid-19-pandemic-and-tension-between-need-act-and-need-know
July 28, 2021 - Commentary
COVID-19 pandemic and the tension between the need to act and the need to know.
Citation Text:
Scott IA. COVID-19 pandemic and the tension between the need to act and the need to know. Intern Med J. 2020;50(8):904-909. doi:10.1111/imj.14929.
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psnet.ahrq.gov/issue/cognitive-error-most-frequent-contributory-factor-cases-medical-injury-study-verdicts
September 25, 2013 - Study
Cognitive error as the most frequent contributory factor in cases of medical injury: a study on verdict's judgment among closed claims in Japan.
Citation Text:
Tokuda Y, Kishida N, Konishi R, et al. Cognitive error as the most frequent contributory factor in cases of medical inju…
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www.ahrq.gov/news/newsroom/case-studies/201512.html
May 01, 2015 - AHRQ’s RED Toolkit Helps VA Hospitals in California and Texas Lower Readmissions, Improve Discharge Process
Search All Impact Case Studies
May 2015
Thirty-day all-cause hospital readmissions at the Department of Veterans Affairs (VA) Palo Alto (CA) Health Care System dropped 30 percent after administrators …
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psnet.ahrq.gov/issue/significant-and-sustained-reduction-chemotherapy-errors-through-improvement-science
October 19, 2022 - Study
Significant and sustained reduction in chemotherapy errors through improvement science.
Citation Text:
Weiss BD, Scott M, Demmel K, et al. Significant and sustained reduction in chemotherapy errors through improvement science. J Oncol Pract. 2017;13(4):e329-e336. doi:10.1200/JOP.20…
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psnet.ahrq.gov/issue/ethnography-parents-perceptions-patient-safety-neonatal-intensive-care-unit
September 01, 2018 - Study
An ethnography of parents' perceptions of patient safety in the neonatal intensive care unit.
Citation Text:
Ottosen MJ, Engebretson J, Etchegaray J, et al. An Ethnography of Parents' Perceptions of Patient Safety in the Neonatal Intensive Care Unit. Adv Neonatal Care. 2019;19(6):5…
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psnet.ahrq.gov/issue/potassium-and-phosphorus-repletion-hospitalized-patients-implications-clinical-practice-and
May 09, 2014 - Study
Potassium and phosphorus repletion in hospitalized patients: implications for clinical practice and the potential use of healthcare information technology to improve prescribing and patient safety.
Citation Text:
Hemstreet BA, Stolpman N, Badesch DB, et al. Potassium and phosphor…
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psnet.ahrq.gov/issue/overriding-drug-safety-alerts-computerized-physician-order-entry
March 04, 2011 - Review
Overriding of drug safety alerts in computerized physician order entry.
Citation Text:
van der Sijs H, Aarts J, Vulto A, et al. Overriding of drug safety alerts in computerized physician order entry. J Am Med Inform Assoc. 2006;13(2):138-47.
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psnet.ahrq.gov/issue/ins-and-outs-change-shift-handoffs-between-nurses-communication-challenge
October 19, 2022 - Study
The ins and outs of change of shift handoffs between nurses: a communication challenge.
Citation Text:
Carroll JS, Williams M, Gallivan TM. The ins and outs of change of shift handoffs between nurses: a communication challenge. BMJ Qual Saf. 2012;21(7):586-93. doi:10.1136/bmjqs-2…
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psnet.ahrq.gov/issue/applying-aviation-factors-oral-and-maxillofacial-surgery-human-element
September 23, 2020 - Commentary
Applying aviation factors to oral and maxillofacial surgery—the human element.
Citation Text:
Seager L, Smith DW, Patel A, et al. Applying aviation factors to oral and maxillofacial surgery--the human element. Br J Oral Maxillofac Surg. 2013;51(1):8-13. doi:10.1016/j.bjoms.2…
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psnet.ahrq.gov/issue/restricting-resident-work-hours-good-bad-and-ugly
December 02, 2020 - Review
Restricting resident work hours: the good, the bad, and the ugly.
Citation Text:
Peets A, Ayas N. Restricting resident work hours: the good, the bad, and the ugly. Crit Care Med. 2012;40(3):960-6. doi:10.1097/CCM.0b013e3182413bc5.
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psnet.ahrq.gov/issue/how-house-officers-cope-their-mistakes
June 26, 2015 - Study
Classic
How house officers cope with their mistakes.
Citation Text:
Wu AW, Folkman S, McPhee SJ, et al. How house officers cope with their mistakes. West J Med. 1993;159(5):565-569.
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psnet.ahrq.gov/issue/role-anesthesia-surgical-mortality
July 19, 2023 - Study
Classic
The role of anesthesia in surgical mortality.
Citation Text:
DRIPPS RD, LAMONT A, ECKENHOFF JE. The role of anesthesia in surgical mortality. JAMA. 1961;178:261-6.
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psnet.ahrq.gov/issue/impact-computerized-physician-order-entry-system
October 19, 2022 - Study
Impact of a computerized physician order-entry system.
Citation Text:
Stone WM, Smith BE, Shaft JD, et al. Impact of a computerized physician order-entry system. J Am Coll Surg. 2009;208(5):960-7; discussion 967-9. doi:10.1016/j.jamcollsurg.2009.01.042.
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psnet.ahrq.gov/issue/womens-safety-alerts-maternity-care-speaking-enough
July 08, 2015 - Study
Women's safety alerts in maternity care: is speaking up enough?
Citation Text:
Rance S, McCourt C, Rayment J, et al. Women's safety alerts in maternity care: is speaking up enough? BMJ Qual Saf. 2013;22(4):348-55. doi:10.1136/bmjqs-2012-001295.
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psnet.ahrq.gov/issue/trends-opioid-use-commercially-insured-and-medicare-advantage-populations-2007-16
March 13, 2018 - Study
Trends in opioid use in commercially insured and Medicare Advantage populations in 2007–16: retrospective cohort study.
Citation Text:
Jeffery MM, Hooten M, Henk HJ, et al. Trends in opioid use in commercially insured and Medicare Advantage populations in 2007-16: retrospective coh…
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psnet.ahrq.gov/issue/prescribing-decision-making-medical-residents-night-shifts-qualitative-study
April 14, 2021 - Study
Prescribing decision making by medical residents on night shifts: a qualitative study.
Citation Text:
Lauffenburger JC, Coll MD, Kim E, et al. Prescribing decision making by medical residents on night shifts: a qualitative study. Med Educ. 2022;56(10):1032-1041. doi:10.1111/medu.14…