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  1. The Theory of Distributed Cognition | Agency for Healthcare Research and Quality

    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/distributed-cognition-er-nurses2.html
    August 01, 2022 - Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department The Theory of Distributed Cognition Previous Page Next Page Table of Contents Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department Introduction The Theory of Dis…

  2. Real-time clinical alerting: effect of an automated paging system on response time to critical laboratory values—a randomised controlled trial. | PSNet

    psnet.ahrq.gov/issue/real-time-clinical-alerting-effect-automated-paging-system-response-time-critical-laboratory
    October 31, 2011 - Study Real-time clinical alerting: effect of an automated paging system on response time to critical laboratory values—a randomised controlled trial. Citation Text: Etchells E, Adhikari NKJ, Cheung C, et al. Real-time clinical alerting: effect of an automated paging system on response …

  3. Enhancing patient safety during pediatric sedation: the impact of simulation-based training of nonanesthesiologists. | PSNet

    psnet.ahrq.gov/issue/enhancing-patient-safety-during-pediatric-sedation-impact-simulation-based-training
    January 17, 2012 - Study Enhancing patient safety during pediatric sedation: the impact of simulation-based training of nonanesthesiologists. Citation Text: Shavit I, Keidan I, Hoffmann Y, et al. Enhancing patient safety during pediatric sedation: the impact of simulation-based training of nonanesthesiol…

  4. Are pathologists self-aware of their diagnostic accuracy? Metacognition and the diagnostic process in pathology. | PSNet

    psnet.ahrq.gov/issue/are-pathologists-self-aware-their-diagnostic-accuracy-metacognition-and-diagnostic-process
    May 18, 2022 - Study Are pathologists self-aware of their diagnostic accuracy? Metacognition and the diagnostic process in pathology. Citation Text: Clayton DA, Eguchi MM, Kerr KF, et al. Are pathologists self-aware of their diagnostic accuracy? Metacognition and the diagnostic process in pathology. Me…

  5. A review of incidents related to health information technology in Swedish healthcare to characterise system issues as a basis for improvement in clinical practice. | PSNet

    psnet.ahrq.gov/issue/review-incidents-related-health-information-technology-swedish-healthcare-characterise-system
    December 20, 2023 - Study A review of incidents related to health information technology in Swedish healthcare to characterise system issues as a basis for improvement in clinical practice. Citation Text: Pan D, Nilsson E, Rahman Jabin MS. A review of incidents related to health information technology in Sw…

  6. Drug-related morbidity and mortality and the economic impact of pharmaceutical care. | PSNet

    psnet.ahrq.gov/issue/drug-related-morbidity-and-mortality-and-economic-impact-pharmaceutical-care
    December 23, 2008 - Study Drug-related morbidity and mortality and the economic impact of pharmaceutical care. Citation Text: Johnson JA, Bootman JL. Drug-related morbidity and mortality and the economic impact of pharmaceutical care. Am J Health Syst Pharm. 1997;54(5):554-8. Copy Citation Format: …

  7. Leveraging patient safety research: efforts made fifteen years since To Err Is Human. | PSNet

    psnet.ahrq.gov/issue/leveraging-patient-safety-research-efforts-made-fifteen-years-err-human
    March 24, 2019 - Study Leveraging patient safety research: efforts made fifteen years since To Err Is Human. Citation Text: Liang C, Miao Q, Kang H, et al. Leveraging Patient Safety Research: Efforts Made Fifteen Years Since To Err Is Human. Stud Health Technol Inform. 2019;264:983-987. doi:10.3233/SHTI1…

  8. Errors in laboratory medicine: practical lessons to improve patient safety. | PSNet

    psnet.ahrq.gov/issue/errors-laboratory-medicine-practical-lessons-improve-patient-safety
    February 14, 2024 - Commentary Classic Errors in laboratory medicine: practical lessons to improve patient safety. Citation Text: Howanitz PJ. Errors in laboratory medicine: practical lessons to improve patient safety. Arch Pathol Lab Med. 2005;129(10):1252-1261. Copy Citation …

  9. Assessing resident safety culture in nursing homes: using the nursing home survey on resident safety. | PSNet

    psnet.ahrq.gov/issue/assessing-resident-safety-culture-nursing-homes-using-nursing-home-survey-resident-safety
    April 06, 2011 - Study Assessing resident safety culture in nursing homes: using the nursing home survey on resident safety. Citation Text: Castle NG, Wagner LM, Perera S, et al. Assessing Resident Safety Culture in Nursing Homes. J Patient Saf. 2010;64(2):59-67. doi:10.1097/pts.0b013e3181bc05fc. Cop…

  10. ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing—2013. | PSNet

    psnet.ahrq.gov/issue/ashp-national-survey-pharmacy-practice-hospital-settings-prescribing-and-transcribing-2013
    September 30, 2020 - Study ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing—2013. Citation Text: Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: Prescribing and transcribing-2013. Am J Health Syst Pharm. 2…

  11. Overlapping surgery in orthopaedics: a review of efficacy, surgical costs, surgical outcomes, and patient safety. | PSNet

    psnet.ahrq.gov/issue/overlapping-surgery-orthopaedics-review-efficacy-surgical-costs-surgical-outcomes-and-patient
    November 03, 2021 - Review Overlapping surgery in orthopaedics: a review of efficacy, surgical costs, surgical outcomes, and patient safety. Citation Text: Ahmed M, Suhrawardy A, Olszewski A, et al. Overlapping surgery in orthopaedics: a review of efficacy, surgical costs, surgical outcomes, and patient saf…

  12. Exploring the causes of COPD misdiagnosis in primary care: a mixed methods study. | PSNet

    psnet.ahrq.gov/issue/exploring-causes-copd-misdiagnosis-primary-care-mixed-methods-study
    September 23, 2020 - Study Exploring the causes of COPD misdiagnosis in primary care: a mixed methods study. Citation Text: Patel K, Smith DJ, Huntley CC, et al. Exploring the causes of COPD misdiagnosis in primary care: a mixed methods study. PLoS ONE. 2024;19(3):e0298432. doi:10.1371/journal.pone.0298432. …

  13. Improving the Safety of Medication Use in the Long-term Care Setting: Potential Impact of Computerized Clinical Decision Support (pdf file)

    digital.ahrq.gov/sites/default/files/docs/page/2006FieldJudgeDeFlorio_051211comp.pdf
    January 01, 2006 - Improving the Safety of Medication Use in the Long-term Care Setting: Potential Impact of Computerized Clinical Decision Support Improving the Safety of Medication Use in the Long-term Care Setting: Potential Impact of Computerized Clinical Decision Support Terry Field, James Judg…

  14. Crisis checklists in emergency medicine: another step forward for cognitive aids. | PSNet

    psnet.ahrq.gov/issue/crisis-checklists-emergency-medicine-another-step-forward-cognitive-aids
    April 21, 2021 - Commentary Crisis checklists in emergency medicine: another step forward for cognitive aids. Citation Text: Chen Y-YK, Arriaga AF. Crisis checklists in emergency medicine: another step forward for cognitive aids. BMJ Qual Saf. 2021;30(9):689-693. doi:10.1136/bmjqs-2021-013203. Copy Cit…

  15. Case Studies | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/cusp/clabsi-hpwpreport/clabsi-hpwp2.html
    August 01, 2015 - High-Performance Work Practices in CLABSI Prevention Interventions Case Studies Previous Page Next Page Table of Contents High-Performance Work Practices in CLABSI Prevention Interventions Case Studies Key Findings Conclusions References Table 1. Case Study Sites Table 2. Summary of Ke…

  16. What defines a high-performing health system: a systematic review. | PSNet

    psnet.ahrq.gov/issue/what-defines-high-performing-health-system-systematic-review
    August 17, 2022 - Review What defines a high-performing health system: a systematic review. Citation Text: Ahluwalia SC, Damberg CL, Silverman M, et al. What Defines a High-Performing Health Care Delivery System: A Systematic Review. Jt Comm J Qual Patient Saf. 2017;43(9):450-459. doi:10.1016/j.jcjq.2017.…

  17. 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…

  18. ASPEN survey of parenteral nutrition access issues: how the system fails the patients. | PSNet

    psnet.ahrq.gov/issue/aspen-survey-parenteral-nutrition-access-issues-how-system-fails-patients
    October 02, 2013 - Study ASPEN survey of parenteral nutrition access issues: how the system fails the patients. Citation Text: Mirtallo JM, Allen P, Book WM, et al. ASPEN survey of parenteral nutrition access issues: how the system fails the patient. Nutr Clin Pract. 2024;39(5):1164-1181. doi:10.1002/ncp.1…

  19. Alternative medications for medications in the Use of High-Risk Medications in the Elderly and Potentially Harmful Drug–Disease Interactions in the Elderly quality measures. | PSNet

    psnet.ahrq.gov/issue/alternative-medications-medications-use-high-risk-medications-elderly-and-potentially-harmful
    April 27, 2011 - Review Alternative medications for medications in the Use of High-Risk Medications in the Elderly and Potentially Harmful Drug–Disease Interactions in the Elderly quality measures. Citation Text: Hanlon JT, Semla TP, Schmader KE. Alternative Medications for Medications in the Use of High…

  20. Drug calculation ability of qualified paramedics: a pilot study. | PSNet

    psnet.ahrq.gov/issue/drug-calculation-ability-qualified-paramedics-pilot-study
    June 25, 2018 - Study Drug calculation ability of qualified paramedics: a pilot study. Citation Text: Boyle MJ, Eastwood K. Drug calculation ability of qualified paramedics: A pilot study. World J Emerg Med. 2018;9(1):41-45. doi:10.5847/wjem.j.1920-8642.2018.01.006. Copy Citation Format: D…
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