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An asset-based quality improvement tool for health care organizations: cultivating organization wide quality improvement and health care professional engagement. | PSNet

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September 16, 2020 - Commentary An asset-based quality improvement tool for health care organizations: cultivating organization wide quality improvement and health care professional engagement. Citation Text: Loving VA, Nolan C, Bessel M. An asset-based quality improvement tool for health care organizations:…

Factors that affect opioid quality improvement initiatives in primary care: insights from ten health systems. | PSNet

psnet.ahrq.gov/issue/factors-affect-opioid-quality-improvement-initiatives-primary-care-insights-ten-health

November 03, 2021 - Study Factors that affect opioid quality improvement initiatives in primary care: insights from ten health systems. Citation Text: Childs E, Tano CA, Mikosz CA, et al. Factors that affect opioid quality improvement initiatives in primary care: insights from ten health systems. Jt Comm J …

Patient mortality during unannounced accreditation surveys at US hospitals. | PSNet

psnet.ahrq.gov/issue/patient-mortality-during-unannounced-accreditation-surveys-us-hospitals

August 03, 2022 - Study Patient mortality during unannounced accreditation surveys at US hospitals. Citation Text: Barnett ML, Olenski AR, Jena AB. Patient Mortality During Unannounced Accreditation Surveys at US Hospitals. JAMA Intern Med. 2017;177(5):693-700. doi:10.1001/jamainternmed.2016.9685. Copy …

Changes in cancer detection and false-positive recall in mammography using artificial intelligence: a retrospective, multireader study. | PSNet

psnet.ahrq.gov/issue/changes-cancer-detection-and-false-positive-recall-mammography-using-artificial-intelligence

August 23, 2023 - Study Classic Changes in cancer detection and false-positive recall in mammography using artificial intelligence: a retrospective, multireader study. Citation Text: Kim H-E, Kim HH, Han B-K, et al. Changes in cancer detection and false-positive recall in mammogr…

Preventable adverse drug events causing hospitalisation: identifying root causes and developing a surveillance and learning system at an urban community hospital, a cross-sectional observational study. | PSNet

psnet.ahrq.gov/issue/preventable-adverse-drug-events-causing-hospitalisation-identifying-root-causes-and

March 05, 2008 - Study Preventable adverse drug events causing hospitalisation: identifying root causes and developing a surveillance and learning system at an urban community hospital, a cross-sectional observational study. Citation Text: de Lemos J, Loewen PS, Nagle C, et al. Preventable adverse drug e…

The burden of opioid-related adverse drug events on hospitalized previously opioid-free surgical patients. | PSNet

psnet.ahrq.gov/issue/burden-opioid-related-adverse-drug-events-hospitalized-previously-opioid-free-surgical

March 24, 2021 - Study Emerging Classic The burden of opioid-related adverse drug events on hospitalized previously opioid-free surgical patients. Citation Text: Urman RD, Seger DL, Fiskio JM, et al. The burden of opioid-related adverse drug events on hospitalized previously opi…

System hazards in managing laboratory test requests and results in primary care: medical protection database analysis and conceptual model. | PSNet

psnet.ahrq.gov/issue/system-hazards-managing-laboratory-test-requests-and-results-primary-care-medical-protection

November 08, 2017 - Study System hazards in managing laboratory test requests and results in primary care: medical protection database analysis and conceptual model. Citation Text: Bowie P, Price J, Hepworth N, et al. System hazards in managing laboratory test requests and results in primary care: medical p…

Incidence, duration and risk factors associated with delayed and missed diagnostic opportunities related to tuberculosis: a population-based longitudinal study. | PSNet

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May 19, 2021 - Study Incidence, duration and risk factors associated with delayed and missed diagnostic opportunities related to tuberculosis: a population-based longitudinal study. Citation Text: Miller AC, Arakkal AT, Koeneman S, et al. Incidence, duration and risk factors associated with delayed and…

Development of rapid response capabilities in a large COVID-19 alternate care site using Failure Modes and Effect Analysis with in situ simulation. | PSNet

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September 16, 2020 - Commentary Development of rapid response capabilities in a large COVID-19 alternate care site using Failure Modes and Effect Analysis with in situ simulation. Citation Text: Levy N, Zucco L, Ehrlichman RJ, et al. Development of rapid response capabilities in a large COVID-19 alternate ca…

COVID-19 pandemic preparation: using simulation for systems-based learning to prepare the largest healthcare workforce and system in Canada. | PSNet

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August 19, 2020 - Commentary Emerging Classic COVID-19 pandemic preparation: using simulation for systems-based learning to prepare the largest healthcare workforce and system in Canada. Citation Text: Dubé MM, Kaba A, Cronin T, et al. COVID-19 pandemic preparation: using simulat…

Identifying health information technology usability issues contributing to medication errors across medication process stages. | PSNet

psnet.ahrq.gov/issue/identifying-health-information-technology-usability-issues-contributing-medication-errors

November 03, 2021 - Study Identifying health information technology usability issues contributing to medication errors across medication process stages. Citation Text: Adams KT, Pruitt Z, Kazi S, et al. Identifying health information technology usability issues contributing to medication errors across medic…

Interorganizational health information exchange-related patient safety incidents: a descriptive register-based qualitative study. | PSNet

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November 10, 2021 - Study Interorganizational health information exchange-related patient safety incidents: a descriptive register-based qualitative study. Citation Text: Hyvämäki P, Sneck S, Meriläinen M, et al. Interorganizational health information exchange-related patient safety incidents: a descriptive…

Interprofessional/interdisciplinary teamwork during the early COVID-19 pandemic: experience from a children's hospital within an academic health center. | PSNet

psnet.ahrq.gov/issue/interprofessionalinterdisciplinary-teamwork-during-early-covid-19-pandemic-experience

September 23, 2020 - Commentary Interprofessional/interdisciplinary teamwork during the early COVID-19 pandemic: experience from a children's hospital within an academic health center. Citation Text: Natale JAE, Boehmer J, Blumberg DA, et al. Interprofessional/interdisciplinary teamwork during the early COVI…

Indication documentation and indication-based prescribing within electronic prescribing systems: a systematic review and narrative synthesis. | PSNet

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December 18, 2019 - Review Indication documentation and indication-based prescribing within electronic prescribing systems: a systematic review and narrative synthesis. Citation Text: Feather C, Appelbaum N, Darzi A, et al. Indication documentation and indication-based prescribing within electronic prescrib…

A scoping review of real-time automated clinical deterioration alerts and evidence of impacts on hospitalised patient outcomes. | PSNet

psnet.ahrq.gov/issue/scoping-review-real-time-automated-clinical-deterioration-alerts-and-evidence-impacts

February 16, 2022 - Review A scoping review of real-time automated clinical deterioration alerts and evidence of impacts on hospitalised patient outcomes. Citation Text: Blythe R, Parsons R, White NM, et al. A scoping review of real-time automated clinical deterioration alerts and evidence of impacts on hos…

Medication errors in anesthesiology: is it time to train by example? Vignettes can assess error awareness, assessment of harm, disclosure, and reporting practices. | PSNet

psnet.ahrq.gov/issue/medication-errors-anesthesiology-it-time-train-example-vignettes-can-assess-error-awareness

May 26, 2021 - Study Medication errors in anesthesiology: is it time to train by example? Vignettes can assess error awareness, assessment of harm, disclosure, and reporting practices. Citation Text: Duffy CC, Bass GA, Duncan JR, et al. Medication errors in anesthesiology: is it time to train by exampl…

Collaborative case review: a systems-based approach to patient safety event investigation and analysis. | PSNet

psnet.ahrq.gov/issue/collaborative-case-review-systems-based-approach-patient-safety-event-investigation-and

May 04, 2022 - Study Collaborative case review: a systems-based approach to patient safety event investigation and analysis. Citation Text: Lacson R, Khorasani R, Fiumara K, et al. Collaborative case review: a systems-based approach to patient safety event investigation and analysis. J Patient Saf. 202…

What do we really know about crew resource management in healthcare?: An umbrella review on crew resource management and its effectiveness. | PSNet

psnet.ahrq.gov/issue/what-do-we-really-know-about-crew-resource-management-healthcare-umbrella-review-crew

September 29, 2021 - Review What do we really know about crew resource management in healthcare?: An umbrella review on crew resource management and its effectiveness. Citation Text: Buljac-Samardzic M, Dekker-van Doorn CM, Maynard MT. What do we really know about crew resource management in healthcare?: An …

Unintentional therapeutic errors involving insulin in the ambulatory setting reported to poison centers. | PSNet

psnet.ahrq.gov/issue/unintentional-therapeutic-errors-involving-insulin-ambulatory-setting-reported-poison-centers

June 06, 2018 - Study Unintentional therapeutic errors involving insulin in the ambulatory setting reported to poison centers. Citation Text: Spiller HA, Borys DJ, Ryan ML, et al. Unintentional therapeutic errors involving insulin in the ambulatory setting reported to poison centers. Ann Pharmacother.…

The relationship of medical assistants' work engagement with their concerns of having made an important medical error: a cross-sectional study. | PSNet

psnet.ahrq.gov/issue/relationship-medical-assistants-work-engagement-their-concerns-having-made-important-medical

March 08, 2023 - Study The relationship of medical assistants' work engagement with their concerns of having made an important medical error: a cross-sectional study. Citation Text: Loerbroks A, Vu-Eickmann P, Dreher A, et al. The relationship of medical assistants' work engagement with their concerns of…

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