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Horsham, PA: Institute for Safe Medication Practices; August 24, 2017.
Drug shortages can contribute to treatment delays and complications that lead to patient harm. This survey seeks insights from hospital directors of pharmacy regarding their experiences with drug shortages over the past 6 months.
Investigating the association of alerts from a national mortality surveillance system with subsequent hospital mortality in England: an interrupted time series analysis.
Cecil E, Bottle A, Esmail A, Wilkinson S, Vincent C, Aylin PP. BMJ Qual Saf. 2018 May 4; [Epub ahead of print].
Senior staff safety rounds: a commitment to ensure safety is the top priority.
O'Connell RT, Ivy ME. NEJM Catalyst. May 1, 2018.
Time out—charting a path for improving performance measurement.
MacLean CH, Kerr EA, Qaseem A. N Engl J Med. 2018 Apr 18; [Epub ahead of print].
Realist synthesis of intentional rounding in hospital wards: exploring the evidence of what works, for whom, in what circumstances and why.
Sims S, Leamy M, Davies N, et al. BMJ Qual Saf. 2018 Mar 14; [Epub ahead of print].
Adverse events in patients in home healthcare: a retrospective record review using trigger tool methodology.
Schildmeijer KGI, Unbeck M, Ekstedt M, Lindblad M, Nilsson L. BMJ Open. 2018;8:e019267.
Development of a trigger tool to identify adverse events and no-harm incidents that affect patients admitted to home healthcare.
Lindblad M, Schildmeijer K, Nilsson L, Ekstedt M, Unbeck M. BMJ Qual Saf. 2017 Sep 29; [Epub ahead of print].
Providing feedback following Leadership WalkRounds is associated with better patient safety culture, higher employee engagement and lower burnout.
Sexton JB, Adair KC, Leonard MW, et al. BMJ Qual Saf. 2018;27:261-270.
Performance of a trigger tool for identifying adverse events in oncology.
Lipitz-Snyderman A, Classen D, Pfister D, et al. J Oncol Pract. 2017;13:e223-e230.
Development of a trigger tool to identify adverse drug events in elderly patients with multimorbidity.
Toscano Guzmán MD, Galván Banqueri M, Otero MJ, Alfaro Lara ER, Casajus Lagranja P, Santos Ramos B. J Patient Saf. 2017 Jun 14; [Epub ahead of print].
A systematic review of measurement tools for the proactive assessment of patient safety in general practice.
Lydon S, Cupples ME, Murphy AW, Hart N, O'Connor P. J Patient Saf. 2017 Apr 4; [Epub ahead of print].
Design and reliability of a specific instrument to evaluate patient safety for patients with acute myocardial infarction treated in a predefined care track: a retrospective patient record review study in a single tertiary hospital in the Netherlands.
Eindhoven DC, Borleffs CJW, Dietz MF, Schalij MJ, Brouwers C, de Bruijne MC. BMJ Open. 2017;7:e014360.
'If no-one stops me, I'll make the mistake again': changing prescribing behaviours through feedback; a Perceptual Control Theory perspective.
Ferguson J, Keyworth C, Tully MP. Res Social Adm Pharm. 2018;14:241-247.
Pediatric prehospital medication dosing errors: a national survey of paramedics.
Hoyle JD Jr, Crowe RP, Bentley MA, Beltran G, Fales W. Prehosp Emerg Care. 2017;21:185-191.
Development of a trigger tool to identify adverse events and harm in emergency medical services.
Howard IL, Bowen JM, Al Shaikh LAH, Mate KS, Owen RC, Williams DM. Emerg Med J. 2017;34:391-397.
Impact of the Opioid Safety Initiative on opioid-related prescribing in veterans.
Lin LA, Bohnert AS, Kerns RD, Clay MA, Ganoczy D, Ilgen MA. Pain. 2017;158:833-839.
Understanding interrater reliability and validity of risk assessment tools used to predict adverse clinical events.
Siedlecki SL, Albert NM. Clin Nurse Spec. 2017;31:23-29.
Adverse event and error of unexpected life-threatening events within 24h of emergency department admission.
Zhang E, Hung SC, Wu CH, Chen LL, Tsai MT, Lee WH. Am J Emerg Med. 2017;35:479-483.
Development and preliminary testing of the Coordination Process Error Reporting Tool (CPERT), a prospective clinical surveillance mechanism for teamwork errors in the pediatric cardiac ICU.
Bates KE, Shea JA, Bird GL, et al. Jt Comm J Qual Patient Saf. 2016;42:562-571.
Improving health care quality and patient safety through peer-to-peer assessment: demonstration project in two academic medical centers.
Mort E, Bruckel J, Donelan K, et al; Peer-to-Peer Study Team. Am J Med Qual. 2017;32:472-479.
Peer feedback, learning, and improvement: answering the call of the Institute of Medicine report on diagnostic error.
Larson DB, Donnelly LF, Podberesky DJ, Merrow AC, Sharpe RE Jr, Kruskal JB. Radiology. 2017;283:231-241.
Operating room–to-ICU patient handovers: a multidisciplinary human-centered design approach.
Segall N, Bonifacio AS, Barbeito A, et al. Jt Comm J Qual Patient Saf. 2016;42:400-414.
Vital signs are still vital: instability on discharge and the risk of post-discharge adverse outcomes.
Nguyen OK, Makam AN, Clark C, et al. J Gen Intern Med. 2017;32:42-48.
How to monitor patient safety in primary care? Healthcare professionals' views.
Samra R, Car J, Majeed A, Vincent C, Aylin P. JRSM Open. 2016;7:2054270416648045.
Potentially preventable 30-day hospital readmissions at a children's hospital.
Toomey SL, Peltz A, Loren S, et al. Pediatrics. 2016;138:e20154182.
Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; July 2016. Report No. OEI-06-14-00110.
PSNET: Patient Safety Network
PSNet is produced for the Agency for Healthcare Research and Quality by a team of editors at the University of California, San Francisco with guidance from a prominent Technical Expert/Advisory Panel. The AHRQ PSNet site was designed and implemented by Silverchair.
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