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psnet.ahrq.gov/node/44761/psn-pdf
January 06, 2016 - two-fatal-cases-accidental-intrathecal-vincristine-administration-learning-death-
events
Incorrectly administered vincristine can lead to serious adverse consequences … psnet.ahrq.gov/issue/preventing-vincristine-administration-errors
https://psnet.ahrq.gov/issue/fatal-consequences-simple-mistake-how-can-patient-be-saved-inadvertent-intrathecal
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psnet.ahrq.gov/node/45833/psn-pdf
January 30, 2018 - impact-electronic-medical-records-hospital-acquired-adverse-safety-events-
differential
Electronic health records enhance patient safety, but they also have unintended consequences … benefits-health-information-technology-review-recent-literature-shows-predominantly-positive
https://psnet.ahrq.gov/issue/some-unintended-consequences-information-technology-health-care-nature-patient-care
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psnet.ahrq.gov/node/47016/psn-pdf
June 25, 2018 - efforts to
proactively identify and address safety concerns may fall short and lead to unintended consequences … digital-health-and-patient-safety
https://psnet.ahrq.gov/issue/why-things-bite-back-technology-and-revenge-unintended-consequences
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psnet.ahrq.gov/node/47382/psn-pdf
August 29, 2018 - parenteral-opioid-shortage-treating-pain-during-opioid-overdose-epidemic
Well-intentioned system-level efforts to improve care can result in unintended consequences … parenteral-opioid-shortage-treating-pain-during-opioid-overdose-epidemic
https://psnet.ahrq.gov/issue/systematic-review-unintended-consequences-clinical-interventions-reduce-adverse-outcomes
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psnet.ahrq.gov/perspective/conversation-edward-tenner-phd
June 01, 2011 - in patient safety and is generally credited with introducing the concept of unintended consequences, … He is completing a new book on positive unintended consequences.
Dr. … Robert Wachter, Editor, AHRQ WebM&M : What do you mean by the term unintended consequences?
Dr. … Technology does have reverberations, including unintended consequences, or "revenge effects. … Why Things Bite Back: Technology and the Revenge of Unintended Consequences.
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psnet.ahrq.gov/node/33586/psn-pdf
September 07, 2019 - clinically-inconsequential-alerts-characteristics-opioid-drug-alerts-and-their-utility
https://psnet.ahrq.gov/issue/extent-and-importance-unintended-consequences-related-computerized-provider-order-entry … finding is intuitive, but also raises the important implication that without system redesign, the safety
consequences … Current context
Alert fatigue (and the unintended consequences of the computerization of health care … In order to mitigate these
consequences—including alert fatigue—The Joint Commission recommended improving … One limitation to addressing alert fatigue pertains to the legal consequences of removing alerts.
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psnet.ahrq.gov/node/845651/psn-pdf
November 17, 2016 - mri-centers-performing-lumbar-spine-mri-
examinations
Diagnostic errors and the resulting delays in care can have serious consequences … psnet.ahrq.gov/issue/undiagnosed-breast-cancer-mr-imaging-analysis-causes
https://psnet.ahrq.gov/web-mm/consequences-miscommunication-regarding-possible-artifact
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psnet.ahrq.gov/node/37346/psn-pdf
March 28, 2012 - While unintended consequences can result from adoption of CPOE systems, point-of-
care solutions have … medication-dispensing-errors-and-potential-adverse-drug-events-and-after-implementing-bar
https://psnet.ahrq.gov/issue/types-unintended-consequences-related-computerized-provider-order-entry
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psnet.ahrq.gov/node/41154/psn-pdf
November 26, 2014 - misses
increased significantly after CPOE implementation, highlighting the potential for unintended consequences … effects-two-commercial-electronic-prescribing-systems-prescribing-error-rates-hospital
https://psnet.ahrq.gov/issue/types-unintended-consequences-related-computerized-provider-order-entry
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psnet.ahrq.gov/node/37787/psn-pdf
May 28, 2008 - information technology (HIT) systems is driven by efforts to improve safety
and quality, but unintended consequences … systematic-review-impact-health-information-technology-quality-efficiency-and-costs-medical
https://psnet.ahrq.gov/issue/some-unintended-consequences-information-technology-health-care-nature-patient-care
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psnet.ahrq.gov/node/44379/psn-pdf
August 05, 2015 - decision support is considered to be integral to
patient safety, high implementation costs and unintended consequences … primer/computerized-provider-order-entry
https://psnet.ahrq.gov/issue/extent-and-importance-unintended-consequences-related-computerized-provider-order-entry
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psnet.ahrq.gov/node/38412/psn-pdf
September 01, 2016 - This phenomenon has been previously documented as one of
several types of unintended consequences of … https://psnet.ahrq.gov//#clinicaldecisionsupportsystem
https://psnet.ahrq.gov/issue/types-unintended-consequences-related-computerized-provider-order-entry
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psnet.ahrq.gov/node/37992/psn-pdf
August 20, 2008 - learning-different-lenses-reports-medical-errors-primary-care-clinicians-staff-and-patients
https://psnet.ahrq.gov/issue/testing-process-errors-and-their-harms-and-consequences-reported-family-medicine-practices … https://psnet.ahrq.gov/issue/testing-process-errors-and-their-harms-and-consequences-reported-family-medicine-practices
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psnet.ahrq.gov/issue/improving-departmental-psychological-safety-through-medical-school-wide-initiative
July 19, 2023 - Psychological safety is when team members feel comfortable speaking up without fear of negative consequences … View More
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Teaching nursing students the ethical and legal consequences
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psnet.ahrq.gov/issue/implementing-computerized-provider-order-entry-acute-care-hospitals-united-states-could
March 30, 2022 - decision support is considered to be integral to patient safety, high implementation costs and unintended consequences … September 1, 2016
Evaluation of medium-term consequences of implementing commercial computerized
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psnet.ahrq.gov/node/60238/psn-pdf
April 15, 2020 - addiction-disease-isolation-so-pandemic-puts-recovery-risk
https://psnet.ahrq.gov/issue/why-things-bite-back-technology-and-revenge-unintended-consequences
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psnet.ahrq.gov/issue/interorganizational-health-information-exchange-related-patient-safety-incidents-descriptive
November 10, 2021 - This study used four years of incident reports to identify the types, causes, and consequences of health … (e.g., deficiencies in content), and (2) causes related to the health professional or organization; consequences
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psnet.ahrq.gov/issue/medical-errors-and-quality-care-control-commitment
July 15, 2020 - The authors describe the assumptions and consequences of control-based management and compare it to commitment-based … Building on this background, they discuss the human resource practices and behavioral consequences of
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psnet.ahrq.gov/node/37362/psn-pdf
December 01, 2010 - A past AHRQ WebM&M commentary
discussed the unintended consequences of the public reporting of hospital … issue/national-patient-safety-goals
https://psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-consequences-public-reporting-hospital-quality
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psnet.ahrq.gov/node/37032/psn-pdf
May 27, 2011 - studies also provided only limited information
on implementation issues and potential unintended consequences … computerized-provider-order-entry
https://psnet.ahrq.gov//#adversedrugevent
https://psnet.ahrq.gov/issue/types-unintended-consequences-related-computerized-provider-order-entry