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psnet.ahrq.gov/issue/accuracy-medication-documentation-hospital-discharge-summaries-retrospective-analysis
March 23, 2012 - Study
Accuracy of medication documentation in hospital discharge summaries: a retrospective analysis of medication transcription errors in manual and electronic discharge summaries.
Citation Text:
Callen J, McIntosh J, Li J. Accuracy of medication documentation in hospital discharge su…
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psnet.ahrq.gov/node/42014/psn-pdf
February 06, 2013 - Diagnostic errors in orthopedic surgery: evaluation of
resident documentation of neurovascular examinations
for orthopedic trauma patients.
February 6, 2013
Tan EW, Ting BL, Jia X, et al. Diagnostic errors in orthopedic surgery: evaluation of resident documentation
of neurovascular examinations for orthopedic trau…
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psnet.ahrq.gov/node/836749/psn-pdf
March 16, 2022 - Comparison of a focused family cancer history
questionnaire to family history documentation in the
electronic medical record.
March 16, 2022
Clift K, Macklin-Mantia S, Barnhorst M, et al. Comparison of a focused family cancer history questionnaire
to family history documentation in the electronic medical record. J…
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psnet.ahrq.gov/node/48178/psn-pdf
January 01, 2020 - ACR guidance document on MR safe practices: updates
and critical information 2019.
August 14, 2019
ACR Committee on MR Safety, Greenberg TD, Hoff MN, Gilk TB, et al. J Magn Reson Imaging.
2020;51(2):331-338.
https://psnet.ahrq.gov/issue/acr-guidance-document-mr-safe-practices-updates-and-critical-inform…
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psnet.ahrq.gov/node/60616/psn-pdf
June 24, 2020 - Nurse-reported bullying and documented adverse patient
events: an exploratory study in a US Hospital.
June 24, 2020
Arnetz JE, Neufcourt L, Sudan S, et al. Nurse-reported bullying and documented adverse patient events:
an exploratory study in a US Hospital. J Nurs Care Qual. 2020;35(3):206-212.
doi:10.1097/ncq.000…
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psnet.ahrq.gov/node/41423/psn-pdf
January 03, 2017 - Improving documentation of a beta-blocker quality
measure through an anesthesia information management
system and real-time notification of documentation
errors.
January 3, 2017
Nair BG, Peterson GN, Newman S-F, et al. Improving documentation of a beta-blocker quality measure
through an anesthesia information man…
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psnet.ahrq.gov/node/73509/psn-pdf
July 21, 2021 - NHS ‘Learning from Deaths’ reports: a qualitative and
quantitative document analysis of the first year of a
countrywide patient safety programme.
July 21, 2021
Brummell Z, Vindrola-Padros C, Braun D, et al. NHS ‘Learning from Deaths’ reports: a qualitative and
quantitative document analysis of the first year of a …
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psnet.ahrq.gov/node/837429/psn-pdf
January 01, 2022 - Improving allergy documentation: a retrospective
electronic health record system-wide patient safety
initiative.
January 1, 2022
Li L, Foer D, Hallisey RK, et al. Improving allergy documentation: a retrospective electronic health record
system-wide patient safety initiative. J Patient Saf. 2022;18(1):e108-e114.
d…
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psnet.ahrq.gov/node/854259/psn-pdf
January 01, 2024 - The power of written word: reflection reduces errors of
omission.
October 4, 2023
Rao A, Heidemann LA, Hartley S, et al. The power of written word: reflection reduces errors of omission.
Clin Teach. 2024;21(1):e13630. doi:10.1111/tct.13630.
https://psnet.ahrq.gov/issue/power-written-word-reflection-reduces-errors-…
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psnet.ahrq.gov/node/46847/psn-pdf
March 28, 2018 - Advance care planning documentation practices and
accessibility in the electronic health record: implications
for patient safety.
March 28, 2018
Walker E, McMahan R, Barnes D, et al. Advance Care Planning Documentation Practices and Accessibility
in the Electronic Health Record: Implications for Patient Safety. J …
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psnet.ahrq.gov/node/38091/psn-pdf
February 18, 2011 - Questionable hospital chart documentation practices by
physicians.
February 18, 2011
Sharma R, Kostis WJ, Wilson AC, et al. Questionable hospital chart documentation practices by
physicians. J Gen Intern Med. 2008;23(11):1865-70. doi:10.1007/s11606-008-0750-6.
https://psnet.ahrq.gov/issue/questionable-hospital-cha…
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psnet.ahrq.gov/node/33886/psn-pdf
August 01, 2019 - Medical Scribes and Patient Safety
August 1, 2019
Woodcock D, Bergstrom R. Medical Scribes and Patient Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/medical-scribes-and-patient-safety
Perspective
Scribes have supported physicians for thousands of years.(1) However, little is known about how to…
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psnet.ahrq.gov/issue/documenting-diagnosis-exploring-impact-electronic-health-records-diagnostic-safety
August 16, 2023 - Book/Report
Documenting Diagnosis: Exploring the Impact of Electronic Health Records on Diagnostic Safety.
Citation Text:
Miller K, Ratwani R, Hose B-Z, et al. Documenting Diagnosis: Exploring The Impact Of Electronic Health Records On Diagnostic Safety. Rockville, MD: Agency for Healthc…
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psnet.ahrq.gov/web-mm/over-not-so-easy
April 01, 2005 - If a physician documents a food allergy in the CPOE system, the food services information system receives
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psnet.ahrq.gov/node/61060/psn-pdf
October 28, 2020 - Finding the right balance: an evidence-informed guidance
document to support the re-opening of Canadian nursing
homes to family caregivers and visitors during the
coronavirus disease 2019 pandemic.
October 28, 2020
Stall NM, Johnstone J, McGeer AJ, et al. Finding the right balance: an evidence-informed guidance
d…
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psnet.ahrq.gov/node/38178/psn-pdf
October 29, 2008 - Documentation of clinical review and vital signs after
major surgery.
October 29, 2008
McGain F, Cretikos MA, Jones D, et al. Documentation of clinical review and vital signs after major surgery.
Med J Aust. 2008;189(7):380-3.
https://psnet.ahrq.gov/issue/documentation-clinical-review-and-vital-signs-after-major-s…
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psnet.ahrq.gov/issue/surgical-ward-round-checklist-improving-patient-safety-and-clinical-documentation
March 17, 2021 - Study
The surgical ward round checklist: improving patient safety and clinical documentation.
Citation Text:
Krishnamohan N, Maitra I, Shetty VD. The surgical ward round checklist: improving patient safety and clinical documentation. J Multidiscip Healthc. 2019;12:789-794. doi:10.2147/JM…
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psnet.ahrq.gov/web-mm/inside-time-out
March 01, 2004 - but, given the requirements to ensure it occurs, best practices must also address the issue of who documents
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psnet.ahrq.gov/issue/care-post-roe-documenting-cases-poor-quality-care-dobbs-decision
December 09, 2020 - Book/Report
Care Post-Roe: Documenting Cases of Poor-quality Care Since the Dobbs Decision.
Citation Text:
Care Post-Roe: Documenting Cases of Poor-quality Care Since the Dobbs Decision. Grossman D, Joffe C, Kaller S, et al. Advancing New Standards in Reproductive Health, University of C…
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psnet.ahrq.gov/issue/intraoperative-handoffs-among-anesthesia-providers-increase-incidence-documentation-errors
April 12, 2019 - Study
Intraoperative handoffs among anesthesia providers increase the incidence of documentation errors for controlled drugs.
Citation Text:
Epstein RH, Dexter F, Gratch DM, et al. Intraoperative Handoffs Among Anesthesia Providers Increase the Incidence of Documentation Errors for Contr…