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  1. Anatomy of a failure: a sociotechnical evaluation of a laboratory physician order entry system implementation. | PSNet

    psnet.ahrq.gov/issue/anatomy-failure-sociotechnical-evaluation-laboratory-physician-order-entry-system
    April 13, 2022 - Study Anatomy of a failure: a sociotechnical evaluation of a laboratory physician order entry system implementation. Citation Text: Peute LW, Aarts J, Bakker PJM, et al. Anatomy of a failure: a sociotechnical evaluation of a laboratory physician order entry system implementation. Int J…

  2. Debunking the myth that the majority of medical errors are attributed to communication. | PSNet

    psnet.ahrq.gov/issue/debunking-myth-majority-medical-errors-are-attributed-communication
    February 14, 2024 - Journal Article Debunking the myth that the majority of medical errors are attributed to communication. Citation Text: Clapper TC, Ching K. Debunking the myth that the majority of medical errors are attributed to communication. Med Educ. 2020;54(1):74-81. doi:10.1111/medu.13821. Copy C…

  3. Approaches for improving continuity of care in medication management: a systematic review. | PSNet

    psnet.ahrq.gov/issue/approaches-improving-continuity-care-medication-management-systematic-review
    April 13, 2022 - Review Approaches for improving continuity of care in medication management: a systematic review. Citation Text: Spinewine A, Claeys C, Foulon V, et al. Approaches for improving continuity of care in medication management: a systematic review. Int J Qual Health Care. 2013;25(4):403-17. d…

  4. Anesthesia Risk Alert program: a proactive safety initiative. | PSNet

    psnet.ahrq.gov/issue/anesthesia-risk-alert-program-proactive-safety-initiative
    September 02, 2015 - Study Anesthesia Risk Alert program: a proactive safety initiative. Citation Text: Lee B, Marhalik-Helms J, Penzi L. Anesthesia Risk Alert program: a proactive safety initiative. Jt Comm J Qual Patient Saf. 2023;49(9):441-449. doi:10.1016/j.jcjq.2023.06.005. Copy Citation Format: …

  5. Use of colour-coded labels for intravenous high-risk medications and lines to improve patient safety. | PSNet

    psnet.ahrq.gov/issue/use-colour-coded-labels-intravenous-high-risk-medications-and-lines-improve-patient-safety
    December 29, 2014 - Study Use of colour-coded labels for intravenous high-risk medications and lines to improve patient safety. Citation Text: Porat N, Bitan Y, Shefi D, et al. Use of colour-coded labels for intravenous high-risk medications and lines to improve patient safety. Qual Saf Health Care. 2009;…

  6. Survey of the national drug shortage effect on anesthesia and patient safety: a patient perspective. | PSNet

    psnet.ahrq.gov/issue/survey-national-drug-shortage-effect-anesthesia-and-patient-safety-patient-perspective
    May 23, 2018 - Study Survey of the national drug shortage effect on anesthesia and patient safety: a patient perspective. Citation Text: Hsia IK-H, Dexter F, Logvinov I, et al. Survey of the National Drug Shortage Effect on Anesthesia and Patient Safety: A Patient Perspective. Anesth Analg. 2015;121(2)…

  7. Organizational ambidexterity and the hybrid middle manager: the case of patient safety in UK hospitals. | PSNet

    psnet.ahrq.gov/issue/organizational-ambidexterity-and-hybrid-middle-manager-case-patient-safety-uk-hospitals
    January 29, 2014 - Study Organizational ambidexterity and the hybrid middle manager: the case of patient safety in UK hospitals. Citation Text: Burgess N, Strauss K, Currie G, et al. Organizational Ambidexterity and the Hybrid Middle Manager: The Case of Patient Safety in UK Hospitals. Hum Resour Manage. 2…

  8. Interventions to improve safe sleep among hospitalized infants at eight children's hospitals. | PSNet

    psnet.ahrq.gov/issue/interventions-improve-safe-sleep-among-hospitalized-infants-eight-childrens-hospitals
    April 24, 2018 - Study Interventions to improve safe sleep among hospitalized infants at eight children's hospitals. Citation Text: Kuhlmann S, Ahlers-Schmidt CR, Lukasiewicz G, et al. Interventions to Improve Safe Sleep Among Hospitalized Infants at Eight Children's Hospitals. Hosp Pediatr. 2016;6(2):88…

  9. Designing a critical care nurse–led rapid response team using only available resources: 6 years later. | PSNet

    psnet.ahrq.gov/issue/designing-critical-care-nurse-led-rapid-response-team-using-only-available-resources-6-years
    December 21, 2014 - Study Designing a critical care nurse–led rapid response team using only available resources: 6 years later. Citation Text: Mitchell A, Schatz M, Francis H. Designing a critical care nurse-led rapid response team using only available resources: 6 years later. Crit Care Nurse. 2014;34(3):…

  10. Role of communicating diagnostic uncertainty in the safety-netting process: insights from a vignette study. | PSNet

    psnet.ahrq.gov/issue/role-communicating-diagnostic-uncertainty-safety-netting-process-insights-vignette-study
    February 20, 2019 - Study Role of communicating diagnostic uncertainty in the safety-netting process: insights from a vignette study. Citation Text: Cox C, Hatfield T, Fritz Z. Role of communicating diagnostic uncertainty in the safety-netting process: insights from a vignette study. BMJ Qual Saf. 2024;33(1…

  11. Making patients safer: nurses' responses to patient safety alerts. | PSNet

    psnet.ahrq.gov/issue/making-patients-safer-nurses-responses-patient-safety-alerts
    April 13, 2011 - Study Making patients safer: nurses' responses to patient safety alerts. Citation Text: Lankshear A, Lowson K, Harden J, et al. Making patients safer: nurses’ responses to patient safety alerts. J Adv Nurs. 2008;63(6). doi:10.1111/j.1365-2648.2008.04741.x. Copy Citation Format: …

  12. Liability reform should make patients safer: "Avoidable classes of events" are a key improvement. | PSNet

    psnet.ahrq.gov/issue/liability-reform-should-make-patients-safer-avoidable-classes-events-are-key-improvement
    July 26, 2023 - Commentary Liability reform should make patients safer: "Avoidable classes of events" are a key improvement. Citation Text: Bovbjerg RR, Tancredi LR. Liability reform should make patients safer: "avoidable classes of events" are a key improvement. J Law Med Ethics. 2005;33(3):478-500. …

  13. The role of quality improvement and patient safety in academic promotion: results of a survey of chairs of departments of internal medicine in North America. | PSNet

    psnet.ahrq.gov/issue/role-quality-improvement-and-patient-safety-academic-promotion-results-survey-chairs
    July 13, 2016 - Study The role of quality improvement and patient safety in academic promotion: results of a survey of chairs of departments of internal medicine in North America. Citation Text: Staiger TO, Wong EY, Schleyer AM, et al. The role of quality improvement and patient safety in academic prom…

  14. Communication of vital signs at emergency department handoff: opportunities for improvement. | PSNet

    psnet.ahrq.gov/issue/communication-vital-signs-emergency-department-handoff-opportunities-improvement
    May 16, 2012 - Study Communication of vital signs at emergency department handoff: opportunities for improvement. Citation Text: Venkatesh AK, Curley D, Chang Y, et al. Communication of Vital Signs at Emergency Department Handoff: Opportunities for Improvement. Ann Emerg Med. 2015;66(2):125-30. doi:10.…

  15. Utilization of a role-based head covering system to decrease misidentification in the operating room. | PSNet

    psnet.ahrq.gov/issue/utilization-role-based-head-covering-system-decrease-misidentification-operating-room
    September 23, 2020 - Study Utilization of a role-based head covering system to decrease misidentification in the operating room. Citation Text: Rosen DA, Criser AL, Petrone AB, et al. Utilization of a Role-Based Head Covering System to Decrease Misidentification in the Operating Room. J Patient Saf. 2019;15(…

  16. Patient safety perception within hospitals: an examination of job type, handoffs and information exchange, and hospital management support. | PSNet

    psnet.ahrq.gov/issue/patient-safety-perception-within-hospitals-examination-job-type-handoffs-and-information
    December 18, 2014 - Study Patient safety perception within hospitals: an examination of job type, handoffs and information exchange, and hospital management support. Citation Text: Ming Y, Meehan R. Patient safety perception within hospitals: an examination of job type, handoffs and information exchange, an…

  17. Hospital inpatient falls across clinical departments. | PSNet

    psnet.ahrq.gov/issue/hospital-inpatient-falls-across-clinical-departments
    September 15, 2021 - Study Hospital inpatient falls across clinical departments. Citation Text: Mikos M, Banas T, Czerw A, et al. Hospital inpatient falls across clinical departments. Int J Environ Res Public Health. 2021;18(15):8167. doi:10.3390/ijerph18158167. Copy Citation Format: DOI Google…

  18. The problems of detecting medication errors in hospitals. | PSNet

    psnet.ahrq.gov/issue/problems-detecting-medication-errors-hospitals
    February 01, 2012 - Study Classic The problems of detecting medication errors in hospitals. Citation Text: Barker KN, McConnell WE. The Problems of Detecting Medication Errors in Hospitals. Am J Health Syst Pharm. 1962;19(8):360-369. doi:10.1093/ajhp/19.8.360. Copy Citation …

  19. CPOE in Iran—a viable prospect? Physicians' opinions on using CPOE in an Iranian teaching hospital. | PSNet

    psnet.ahrq.gov/issue/cpoe-iran-viable-prospect-physicians-opinions-using-cpoe-iranian-teaching-hospital
    June 30, 2011 - Study CPOE in Iran—a viable prospect? Physicians' opinions on using CPOE in an Iranian teaching hospital. Citation Text: Kazemi A, Ellenius J, Tofighi S, et al. CPOE in Iran--a viable prospect? Physicians' opinions on using CPOE in an Iranian teaching hospital. Int J Med Inform. 2009;7…

  20. Measuring perceptions of safety climate in primary care: a cross-sectional study. | PSNet

    psnet.ahrq.gov/issue/measuring-perceptions-safety-climate-primary-care-cross-sectional-study
    January 19, 2011 - Study Measuring perceptions of safety climate in primary care: a cross-sectional study. Citation Text: de Wet C, Johnson P, Mash R, et al. Measuring perceptions of safety climate in primary care: a cross-sectional study. J Eval Clin Pract. 2010;18(1). doi:10.1111/j.1365-2753.2010.01537…
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