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Harnessing the power of medical malpractice data to improve patient care. | PSNet

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September 25, 2019 - Commentary Harnessing the power of medical malpractice data to improve patient care. Citation Text: Siegal D, Swift J, Forget J, et al. Harnessing the power of medical malpractice data to improve patient care. J Healthc Risk Manag. 2020;39(3):28-36. doi:10.1002/jhrm.21393. Copy Citatio…

Diagnostic delays in infectious diseases. | PSNet

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December 15, 2021 - Study Diagnostic delays in infectious diseases. Citation Text: Suneja M, Beekmann SE, Dhaliwal G, et al. Diagnostic delays in infectious diseases. Diagnosis (Berl). 2022;9(3):332-339. doi:10.1515/dx-2021-0092. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML E…

VHA's movement for change: implementing high-reliability principles and practices. | PSNet

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August 21, 2024 - Commentary VHA's movement for change: implementing high-reliability principles and practices. Citation Text: Cox GR, Starr LM. VHA's movement for change: implementing high-reliability principles and practices. J Healthc Manag. 2023;68(3):151-157. doi:10.1097/jhm-d-23-00056. Copy Citati…

Medication Safety in Nursing Homes: What's Wrong and How to Fix It | PSNet

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August 01, 2012 - Transitions between the nursing home, the emergency room, and the hospital are very common in this patient … Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions

In Conversation with... Christie Allen about Maternal Safety and Perinatal Mental Health | PSNet

psnet.ahrq.gov/perspective/conversation-christie-allen-about-maternal-safety-and-perinatal-mental-health

March 29, 2023 - The bundle is focused on best practices, including transitions of care, screening, and referral. … clinical challenges related to the onset, screening, and the challenges around coordination of care, transitions … healthcare, communication is a critical aspect of maintaining a safe environment to support care transitions

Graphical display of diagnostic test results in electronic health records: a comparison of 8 systems. | PSNet

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November 11, 2020 - Study Graphical display of diagnostic test results in electronic health records: a comparison of 8 systems. Citation Text: Sittig DF, Murphy DR, Smith MW, et al. Graphical display of diagnostic test results in electronic health records: a comparison of 8 systems. J Am Med Inform Assoc. 2…

Patterns of potential opioid misuse and subsequent adverse outcomes in Medicare, 2008 to 2012. | PSNet

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June 30, 2021 - Study Patterns of potential opioid misuse and subsequent adverse outcomes in Medicare, 2008 to 2012. Citation Text: Carey CM, Jena AB, Barnett ML. Patterns of Potential Opioid Misuse and Subsequent Adverse Outcomes in Medicare, 2008 to 2012. Ann Intern Med. 2018;168(12):837-845. doi:10.7…

Prevalence and characteristics of diagnostic error in pediatric critical care: a multicenter study. | PSNet

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December 11, 2024 - Study Prevalence and characteristics of diagnostic error in pediatric critical care: a multicenter study. Citation Text: Cifra CL, Custer JW, Smith CM, et al. Prevalence and characteristics of diagnostic error in pediatric critical care: a multicenter study. Crit Care Med. 2023;51(11):14…

Safer prescribing and care for the elderly (SPACE): cluster randomised controlled trial in general practice. | PSNet

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November 18, 2020 - Study Safer prescribing and care for the elderly (SPACE): cluster randomised controlled trial in general practice. Citation Text: Wallis KA, Elley CR, Moyes SA, et al. Safer prescribing and care for the elderly (SPACE): cluster randomised controlled trial in general practice. BJGP Open. …

Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive care unit. | PSNet

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July 14, 2010 - Study Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive care unit. Citation Text: Joy BF, Elliott E, Hardy C, et al. Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive care unit*. P…

Barriers to accessing nighttime supervisors: a national survey of internal medicine residents. | PSNet

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October 12, 2022 - Study Barriers to accessing nighttime supervisors: a national survey of internal medicine residents. Citation Text: Catalanotti JS, O’Connor AB, Kisielewski M, et al. Barriers to accessing nighttime supervisors: a national survey of internal medicine residents. J Gen Intern Med. 2021;36…

Patient participation in patient safety still missing: patient safety experts' views. | PSNet

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February 13, 2019 - Study Patient participation in patient safety still missing: patient safety experts' views. Citation Text: Sahlström M, Partanen P, Rathert C, et al. Patient participation in patient safety still missing: Patient safety experts' views. Int J Nurs Pract. 2016;22(5):461-469. doi:10.1111/ij…

The Ask Me to Explain campaign: a 90-day intervention to promote patient and family involvement in care in a pediatric emergency department. | PSNet

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November 16, 2022 - Study The Ask Me to Explain campaign: a 90-day intervention to promote patient and family involvement in care in a pediatric emergency department. Citation Text: Tothy AS, Limper HM, Driscoll J, et al. The Ask Me to Explain Campaign: A 90-Day Intervention to Promote Patient and Family In…

Medication errors involving oral chemotherapy. | PSNet

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January 06, 2017 - Study Medication errors involving oral chemotherapy. Citation Text: Weingart SN, Toro J, Spencer J, et al. Medication errors involving oral chemotherapy. Cancer. 2010;116(10):2455-2464. doi:10.1002/cncr.25027. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X…

Implementing patient and family involvement interventions for promoting patient safety: a systematic review and meta-analysis. | PSNet

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February 02, 2022 - Review Implementing patient and family involvement interventions for promoting patient safety: a systematic review and meta-analysis. Citation Text: Giap T-T-T, Park M. Implementing patient and family involvement interventions for promoting patient safety. J Patient Saf. 2021;17(2):131-1…

The Rural VA Multi-Center Medication Reconciliation Quality Improvement Study (R-VA-MARQUIS). | PSNet

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September 30, 2020 - Study The Rural VA Multi-Center Medication Reconciliation Quality Improvement Study (R-VA-MARQUIS). Citation Text: Presley CA, Wooldridge KT, Byerly SH, et al. The Rural VA Multi-Center Medication Reconciliation Quality Improvement Study (R-VA-MARQUIS). Am J Health Syst Pharm. 2020;77(2)…

One fourth of unplanned transfers to a higher level of care are associated with a highly preventable adverse event: a patient record review in six Belgian hospitals. | PSNet

psnet.ahrq.gov/issue/one-fourth-unplanned-transfers-higher-level-care-are-associated-highly-preventable-adverse

May 16, 2018 - Study One fourth of unplanned transfers to a higher level of care are associated with a highly preventable adverse event: a patient record review in six Belgian hospitals. Citation Text: Marquet K, Claes N, De Troy E, et al. One fourth of unplanned transfers to a higher level of care are…

Humanizing harm: using a restorative approach to heal and learn from adverse events. | PSNet

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November 30, 2022 - Commentary Humanizing harm: using a restorative approach to heal and learn from adverse events. Citation Text: Wailling J, Kooijman A, Hughes J, et al. Humanizing harm: Using a restorative approach to heal and learn from adverse events. Health Expect. 2022;25(4):1192-1199. doi:10.1111/he…

Older patients' understanding of emergency department discharge information and its relationship with adverse outcomes. | PSNet

psnet.ahrq.gov/issue/older-patients-understanding-emergency-department-discharge-information-and-its-relationship

October 10, 2012 - Study Older patients' understanding of emergency department discharge information and its relationship with adverse outcomes. Citation Text: Hastings SN, Barrett A, Weinberger M, et al. Older Patients' Understanding of Emergency Department Discharge Information and Its Relationship Wit…

Decisions about critical events in device-related scenarios as a function of expertise. | PSNet

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January 02, 2017 - Study Decisions about critical events in device-related scenarios as a function of expertise. Citation Text: Laxmisan A, Malhotra S, Keselman A, et al. Decisions about critical events in device-related scenarios as a function of expertise. J Biomed Inform. 2005;38(3):200-12. Copy Citat…

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