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psnet.ahrq.gov/issue/effect-documenting-patient-weight-kilograms-pediatric-medication-dosing-errors-emergency
October 19, 2022 - Weight-based calculation errors and lack of weight documentation can lead to medication errors in … medical services (EMS) data including children who received a weight-based medication found that weight documentation
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psnet.ahrq.gov/issue/register-based-research-adverse-events-revealing-incomplete-records-threatening-patient
October 06, 2021 - the 82,353 incidents occurring between 2007 and 2016 result from inadequate, missing, or incorrect documentation … , underscoring the need for standardized documentation platforms and care processes.
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psnet.ahrq.gov/node/43513/psn-pdf
September 10, 2014 - provides an overview of patient safety issues in audiology such as diagnostic error and
incomplete documentation … ://psnet.ahrq.gov/primer/diagnostic-errors
https://psnet.ahrq.gov/issue/questionable-hospital-chart-documentation-practices-physicians
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psnet.ahrq.gov/issue/patient-identification-diagnostic-safety-blindspots-and-participation-good-catches-through
October 27, 2021 - When doctors share visit notes with patients: a study of patient and doctor perceptions of documentation … Charting diagnostic safety: exploring patient-provider discordance in medical record documentation … 2022
Comparison of a focused family cancer history questionnaire to family history documentation
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psnet.ahrq.gov/node/35715/psn-pdf
February 15, 2006 - generation-intensive
The investigators studied the effect of an intensive care unit information system on documentation … They found that the system decreased time spent on documentation and increased the amount of time
nurses
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psnet.ahrq.gov/node/46977/psn-pdf
April 04, 2018 - Tracking staff awareness of latex allergies,
purchasing latex-safe alternatives, and improving handoff documentation … A WebM&M commentary discussed allergy documentation in patient health
records.
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psnet.ahrq.gov/issue/triad-xii-are-patients-aware-and-agree-dnr-or-polst-orders-their-medical-records
September 15, 2021 - A prior study argued that inaccurate documentation of patient's wishes for end-of-life care should … November 23, 2016
Hospital discharge documentation and risk of rehospitalisation.
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psnet.ahrq.gov/issue/how-do-stakeholders-experience-adoption-electronic-prescribing-systems-hospitals-systematic
December 16, 2020 - Benefits of electronic prescribing included improved quality, safety , documentation, and enhanced reputation … May 14, 2008
View More
Related Resources
Indication documentation
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psnet.ahrq.gov/issue/does-nurse-use-standardized-flowsheet-document-communication-advanced-providers-provide
June 22, 2022 - This study assessed the potential of using frequency of nursing documentation of provider notification … Patients with both evident and occult hypoxemia had increased nurse documentation in the four hours before
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psnet.ahrq.gov/node/46936/psn-pdf
April 11, 2018 - this newspaper article describes problems associated
with lack of standards for advance care planning documentation … failure-engage-hospitalized-elderly-patients-and-their-families-advance-care-planning
https://psnet.ahrq.gov/issue/advance-care-planning-documentation-practices-and-accessibility-electronic-health-record
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psnet.ahrq.gov/node/60745/psn-pdf
October 01, 2020 - and recording of medications administered or wasted.11
Lack of proper documentation can lead to several … additional errors beyond the lack of documentation. … These same principles apply to the proper timing
and documentation of medication waste. … Lack of documentation and failure to follow appropriate procedure
when it comes to wasting medications … Experts
recommend the best practice for documentation of medication waste in the surgical setting is
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psnet.ahrq.gov/issue/latex-lingering-and-lurking-safety-risk
October 03, 2018 - Tracking staff awareness of latex allergies, purchasing latex-safe alternatives, and improving handoff documentation … A WebM&M commentary discussed allergy documentation in patient health records.
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psnet.ahrq.gov/node/36734/psn-pdf
March 10, 2011 - document any adverse events, in one of 16 predefined categories, as part of their routine clinical
documentation … suffer from low
physician reporting rates, integration of incident reporting into routine electronic documentation
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psnet.ahrq.gov/node/45507/psn-pdf
November 02, 2016 - This retrospective study of transfers from outside hospitals to intensive care units found that documentation … was often incomplete and lack of documentation was associated with higher in-hospital mortality.
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psnet.ahrq.gov/node/45811/psn-pdf
May 08, 2017 - Improving Health IT Safety
Through the Use of Natural Language Processing to
Improve Accuracy of EHR Documentation … This webinar discussed voice-generated
electronic records as a strategy to augment clinical documentation
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psnet.ahrq.gov/issue/changes-intensive-care-unit-nurse-task-activity-after-installation-third-generation-intensive
October 14, 2015 - The investigators studied the effect of an intensive care unit information system on documentation time … They found that the system decreased time spent on documentation and increased the amount of time nurses
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psnet.ahrq.gov/node/37438/psn-pdf
June 16, 2010 - Documentation could be found in the paper chart or
electronic medical record, by means of a color-coded … The
authors call for development of national standards for DNR documentation.
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psnet.ahrq.gov/issue/between-flags-implementing-rapid-response-system-scale
June 08, 2011 - The intervention standardized documentation of patients' vital signs to create visual triggers for timely … 2014
Developing a medical emergency team running sheet to improve clinical handoff and documentation
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psnet.ahrq.gov/node/43124/psn-pdf
August 02, 2015 - occupational needle-stick
exposures, and the vast majority routinely copied and pasted information from prior documentation … extended-work-duration-and-risk-self-reported-percutaneous-injuries-interns
https://psnet.ahrq.gov/issue/questionable-hospital-chart-documentation-practices-physicians
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psnet.ahrq.gov/issue/allergy-safety-events-healthcare-development-and-application-classification-schema-based
December 09, 2020 - Classification categories include: (1) incomplete or inaccurate EHR documentation, (2) human factors, … December 9, 2020
Improving allergy documentation: a retrospective electronic health record