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  1. A medication error prevention survey: five years of results. | PSNet

    psnet.ahrq.gov/issue/medication-error-prevention-survey-five-years-results
    March 26, 2015 - Study A medication error prevention survey: five years of results. Citation Text: Cusano FL, Chambers C, Summach L. A medication error prevention survey: five years of results. J Oncol Pharm Pract. 2009;15(2):87-93. doi:10.1177/1078155208099284. Copy Citation Format: DOI …

  2. The relationship between computerized physician order entry and pediatric adverse drug events: a nested matched case-control study. | PSNet

    psnet.ahrq.gov/issue/relationship-between-computerized-physician-order-entry-and-pediatric-adverse-drug-events
    July 13, 2009 - Study The relationship between computerized physician order entry and pediatric adverse drug events: a nested matched case-control study. Citation Text: Yu F, Salas M, Kim Y-I, et al. The relationship between computerized physician order entry and pediatric adverse drug events: a nested…

  3. Identifying, understanding, and minimizing unconscious cognitive biases in perioperative crisis management: a narrative review. | PSNet

    psnet.ahrq.gov/issue/identifying-understanding-and-minimizing-unconscious-cognitive-biases-perioperative-crisis
    June 19, 2019 - Review Identifying, understanding, and minimizing unconscious cognitive biases in perioperative crisis management: a narrative review. Citation Text: Yan L, Karamchandani K, Gaiser RR, et al. Identifying, understanding, and minimizing unconscious cognitive biases in perioperative crisis …

  4. Outcomes of a quality improvement project for educating nurses on medication administration and errors in nursing homes. | PSNet

    psnet.ahrq.gov/issue/outcomes-quality-improvement-project-educating-nurses-medication-administration-and-errors
    April 24, 2018 - Study Outcomes of a quality improvement project for educating nurses on medication administration and errors in nursing homes. Citation Text: Tenhunen ML, Tanner EK, Dahlen R. Outcomes of a quality improvement project for educating nurses on medication administration and errors in nursin…

  5. Influences of physical layout and space on patient safety and communication in ambulatory oncology practices: a multisite, mixed method investigation. | PSNet

    psnet.ahrq.gov/issue/influences-physical-layout-and-space-patient-safety-and-communication-ambulatory-oncology
    August 25, 2021 - Study Influences of physical layout and space on patient safety and communication in ambulatory oncology practices: a multisite, mixed method investigation. Citation Text: Fauer AJ. Influences of physical layout and space on patient safety and communication in ambulatory oncology practic…

  6. The additional cost of perioperative medication errors | PSNet

    psnet.ahrq.gov/issue/additional-cost-perioperative-medication-errors
    July 24, 2024 - Study The additional cost of perioperative medication errors Citation Text: Langlieb ME, Sharma P, Hocevar M, et al. The additional cost of perioperative medication errors. J Patient Saf. 2023;19(6):375-378. doi:10.1097/pts.0000000000001136. Copy Citation Format: DOI Google…

  7. Accuracy of laboratory data communication on ICU daily rounds using an electronic health record. | PSNet

    psnet.ahrq.gov/issue/accuracy-laboratory-data-communication-icu-daily-rounds-using-electronic-health-record
    July 27, 2016 - Study Accuracy of laboratory data communication on ICU daily rounds using an electronic health record. Citation Text: Artis KA, Dyer E, Mohan V, et al. Accuracy of Laboratory Data Communication on ICU Daily Rounds Using an Electronic Health Record. Crit Care Med. 2017;45(2):179-186. doi:…

  8. Frequency of passive EHR alerts in the ICU: another form of alert fatigue? | PSNet

    psnet.ahrq.gov/issue/frequency-passive-ehr-alerts-icu-another-form-alert-fatigue
    January 23, 2017 - Study Frequency of passive EHR alerts in the ICU: another form of alert fatigue? Citation Text: Kizzier-Carnahan V, Artis KA, Mohan V, et al. Frequency of Passive EHR Alerts in the ICU: Another Form of Alert Fatigue? J Patient Saf. 2019;15(3):246-250. doi:10.1097/PTS.0000000000000270. …

  9. Implementation of crew resource management: a qualitative study in 3 intensive care units. | PSNet

    psnet.ahrq.gov/issue/implementation-crew-resource-management-qualitative-study-3-intensive-care-units
    July 10, 2013 - Study Implementation of crew resource management: a qualitative study in 3 intensive care units. Citation Text: Kemper PF, van Dyck C, Wagner C, et al. Implementation of Crew Resource Management: A Qualitative Study in 3 Intensive Care Units. J Patient Saf. 2017;13(4):223-231. doi:10.109…

  10. Variation in safety culture dimensions within and between US and Swiss Hospital units: an exploratory study. | PSNet

    psnet.ahrq.gov/issue/variation-safety-culture-dimensions-within-and-between-us-and-swiss-hospital-units
    October 08, 2013 - Study Variation in safety culture dimensions within and between US and Swiss Hospital units: an exploratory study. Citation Text: Schwendimann R, Zimmermann N, Küng K, et al. Variation in safety culture dimensions within and between US and Swiss Hospital Units: an exploratory study. BM…

  11. Effectiveness and cost of a transitional care program for heart failure: a prospective study with concurrent controls. | PSNet

    psnet.ahrq.gov/issue/effectiveness-and-cost-transitional-care-program-heart-failure-prospective-study-concurrent
    April 24, 2019 - Study Effectiveness and cost of a transitional care program for heart failure: a prospective study with concurrent controls. Citation Text: Stauffer BD, Fullerton C, Fleming N, et al. Effectiveness and cost of a transitional care program for heart failure: a prospective study with conc…

  12. A review of healthcare failure mode and effects analysis (HFMEA) in radiotherapy. | PSNet

    psnet.ahrq.gov/issue/review-healthcare-failure-mode-and-effects-analysis-hfmea-radiotherapy
    June 13, 2011 - Review A review of healthcare failure mode and effects analysis (HFMEA) in radiotherapy. Citation Text: Giardina M, Cantone MC, Tomarchio E, et al. A Review of Healthcare Failure Mode and Effects Analysis (HFMEA) in Radiotherapy. Health Phys. 2016;111(4):317-26. doi:10.1097/HP.0000000000…

  13. TRIAD XII: are patients aware of and agree with DNR or POLST orders in their medical records. | PSNet

    psnet.ahrq.gov/issue/triad-xii-are-patients-aware-and-agree-dnr-or-polst-orders-their-medical-records
    September 15, 2021 - Study TRIAD XII: are patients aware of and agree with DNR or POLST orders in their medical records. Citation Text: Mirarchi FL, Juhasz K, Cooney TE, et al. TRIAD XII: Are Patients Aware of and Agree With DNR or POLST Orders in Their Medical Records. J Patient Saf. 2019;15(3):230-237. doi…

  14. Association of hospital public quality reporting with electronic health record medication safety performance. | PSNet

    psnet.ahrq.gov/issue/association-hospital-public-quality-reporting-electronic-health-record-medication-safety
    October 21, 2020 - Study Association of hospital public quality reporting with electronic health record medication safety performance. Citation Text: Holmgren AJ, Bates DW. Association of hospital public quality reporting with electronic health record medication safety performance. JAMA Netw Open. 2021;4(9…

  15. Clinical oversight: conceptualizing the relationship between supervision and safety. | PSNet

    psnet.ahrq.gov/issue/clinical-oversight-conceptualizing-relationship-between-supervision-and-safety
    June 23, 2010 - Study Clinical oversight: conceptualizing the relationship between supervision and safety. Citation Text: Kennedy TJT, Lingard LA, Baker R, et al. Clinical oversight: conceptualizing the relationship between supervision and safety. J Gen Intern Med. 2007;22(8):1080-5. Copy Citation …

  16. IT-CARES: an interactive tool for case-crossover analyses of electronic medical records for patient safety. | PSNet

    psnet.ahrq.gov/issue/it-cares-interactive-tool-case-crossover-analyses-electronic-medical-records-patient-safety
    October 30, 2013 - Study IT-CARES: an interactive tool for case-crossover analyses of electronic medical records for patient safety. Citation Text: Caron A, Chazard E, Muller J, et al. IT-CARES: an interactive tool for case-crossover analyses of electronic medical records for patient safety. J Am Med Infor…

  17. Unintended discontinuation of medication following hospitalisation: a retrospective cohort study. | PSNet

    psnet.ahrq.gov/issue/unintended-discontinuation-medication-following-hospitalisation-retrospective-cohort-study
    September 05, 2018 - Study Unintended discontinuation of medication following hospitalisation: a retrospective cohort study. Citation Text: Redmond P, McDowell R, Grimes TC, et al. Unintended discontinuation of medication following hospitalisation: a retrospective cohort study. BMJ Open. 2019;9(6):e024747. d…

  18. How common are cognitive errors in cases presented at emergency medicine resident morbidity and mortality conferences? | PSNet

    psnet.ahrq.gov/issue/how-common-are-cognitive-errors-cases-presented-emergency-medicine-resident-morbidity-and
    May 08, 2019 - Study How common are cognitive errors in cases presented at emergency medicine resident morbidity and mortality conferences? Citation Text: Chu D, Xiao J, Shah P, et al. How common are cognitive errors in cases presented at emergency medicine resident morbidity and mortality conferences?…

  19. Video capture of clinical care to enhance patient safety. | PSNet

    psnet.ahrq.gov/issue/video-capture-clinical-care-enhance-patient-safety
    March 28, 2012 - Study Classic Video capture of clinical care to enhance patient safety. Citation Text: Weinger MB, Gonzales DC, Slagle J, et al. Video capture of clinical care to enhance patient safety. Qual Saf Health Care. 2004;13(2):136-44. Copy Citation Format: …

  20. Discrepancies in written versus calculated durations in opioid prescriptions: pre-post study. | PSNet

    psnet.ahrq.gov/issue/discrepancies-written-versus-calculated-durations-opioid-prescriptions-pre-post-study
    October 19, 2022 - Study Discrepancies in written versus calculated durations in opioid prescriptions: pre-post study. Citation Text: Slovis BH, Kairys J, Babula B, et al. Discrepancies in written versus calculated durations in opioid prescriptions: pre-post study. JMIR Med Inform. 2020;8(3). doi:10.2196/1…
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