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psnet.ahrq.gov/node/37758/psn-pdf
March 10, 2011 - Informatics opportunities: the intersection of patient
safety and clinical informatics.
March 10, 2011
Kilbridge PM, Classen D. The informatics opportunities at the intersection of patient safety and clinical
informatics. J Am Med Inform Assoc. 2008;15(4):397-407. doi:10.1197/jamia.M2735.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/41525/psn-pdf
July 18, 2012 - Effect of clinical decision-support systems: a systematic
review.
July 18, 2012
Bright TJ, Wong A, Dhurjati R, et al. Effect of clinical decision-support systems: a systematic review. Ann
Intern Med. 2012;157(1):29-43. doi:10.7326/0003-4819-157-1-201207030-00450.
https://psnet.ahrq.gov/issue/effect-clinical-decisi…
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psnet.ahrq.gov/node/34782/psn-pdf
November 01, 2016 - When systems fail.
November 1, 2016
Roberts KH, Bea RG. When systems fail. Organ Dyn. 2002;29(3):179-191. doi:10.1016/s0090-
2616(01)00025-0.
https://psnet.ahrq.gov/issue/when-systems-fail
This review provides a detailed account of managerial causes of failure and managerial failure prevention
strategies. The aut…
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psnet.ahrq.gov/node/37872/psn-pdf
January 11, 2017 - The effectiveness of root cause analysis: what does the
literature tell us?
January 11, 2017
Percarpio KB, Watts V, Weeks WB. The effectiveness of root cause analysis: what does the literature tell
us? Jt Comm J Qual Patient Saf. 2008;34(7):391-8.
https://psnet.ahrq.gov/issue/effectiveness-root-cause-analysis-what…
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psnet.ahrq.gov/node/34082/psn-pdf
July 21, 2009 - Microsystems in health care: Part 2. Creating a rich
information environment.
July 21, 2009
Nelson EC, Batalden PB, Homa K, et al. Microsystems in health care: Part 2. Creating a rich information
environment. Jt Comm J Qual Patient Saf. 2003;29(1):5-15.
https://psnet.ahrq.gov/issue/microsystems-health-care-part-2-…
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psnet.ahrq.gov/node/74102/psn-pdf
January 01, 2022 - Workforce planning and safe workload in sterile
compounding hospital pharmacy services.
November 24, 2021
Chaker A, Omair I, Mohamed WH, et al. Workforce planning and safe workload in sterile compounding
hospital pharmacy services. Am J Health Syst Pharm. 2022;79(3):187–192. doi:10.1093/ajhp/zxab379.
https://psnet…
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psnet.ahrq.gov/node/50675/psn-pdf
November 20, 2019 - A systematic review of natural language processing for
classification tasks in the field of incident reporting and
adverse event analysis.
November 20, 2019
Young IJB, Luz S, Lone N. A systematic review of natural language processing for classification tasks in
the field of incident reporting and adverse event ana…
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psnet.ahrq.gov/node/60557/psn-pdf
January 01, 2021 - Implementing receiver-driven handoffs to the emergency
department to reduce miscommunication.
June 3, 2020
Huth K, Stack AM, Hatoun J, et al. Implementing receiver-driven handoffs to the emergency department to
reduce miscommunication. BMJ Qual Saf. 2021;30(3):208-215. doi:10.1136/bmjqs-2019-010540.
https://psnet.…
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psnet.ahrq.gov/node/72703/psn-pdf
February 03, 2021 - Acting between guidelines and reality- an interview study
exploring the strategies of first line managers in patient
safety work.
February 3, 2021
Hedsköld M, Sachs MA, Rosander T, et al. Acting between guidelines and reality- an interview study
exploring the strategies of first line managers in patient safety wor…
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psnet.ahrq.gov/node/60621/psn-pdf
June 24, 2020 - Design and implementation of the infection prevention
program into risk management: managing high level
disinfection and sterilization in the outpatient setting.
June 24, 2020
Sweet W, Snyder D, Raymond M. Design and implementation of the infection prevention program into risk
management: Managing high level disin…
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psnet.ahrq.gov/node/40599/psn-pdf
November 23, 2011 - Organizational climate determinants of resident safety
culture in nursing homes.
November 23, 2011
Arnetz JE, Zhdanova LS, Elsouhag D, et al. Organizational climate determinants of resident safety culture
in nursing homes. Gerontologist. 2011;51(6):739-49. doi:10.1093/geront/gnr053.
https://psnet.ahrq.gov/issue/or…
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psnet.ahrq.gov/node/39439/psn-pdf
May 10, 2010 - Improving insulin distribution and administration safety
using Lean Six Sigma methodologies.
May 10, 2010
Yamamoto J, Abraham D, Malatestinic B. Improving Insulin Distribution and Administration Safety Using
Lean Six Sigma Methodologies. Hosp Pharm. 2010;45(3). doi:10.1310/hpj4503-212.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/43844/psn-pdf
January 21, 2015 - Unintended side effects: arbitration and the deterrence of
medical error.
January 21, 2015
Shieh D. N Y Univ Law Rev. 2014;89:1806-1835.
https://psnet.ahrq.gov/issue/unintended-side-effects-arbitration-and-deterrence-medical-error
This commentary explores the role of medical malpractice arbitration as a deterrent …
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psnet.ahrq.gov/node/42974/psn-pdf
September 07, 2016 - Chemotherapy drug shortages in pediatric oncology: a
consensus statement.
September 7, 2016
Decamp M, Joffe S, Fernandez C, et al. Chemotherapy drug shortages in pediatric oncology: a consensus
statement. Pediatrics. 2014;133(3):e716-24. doi:10.1542/peds.2013-2946.
https://psnet.ahrq.gov/issue/chemotherapy-drug-sh…
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psnet.ahrq.gov/node/38352/psn-pdf
June 14, 2011 - Developing a tool for assessing competency in root cause
analysis.
June 14, 2011
Gupta P, Varkey P. Developing a tool for assessing competency in root cause analysis. Jt Comm J Qual
Patient Saf. 2009;35(1):36-42.
https://psnet.ahrq.gov/issue/developing-tool-assessing-competency-root-cause-analysis
Root cause anal…
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psnet.ahrq.gov/node/38613/psn-pdf
May 20, 2009 - Improved operating room teamwork via SAFETY prep: a
rural community hospital's experience.
May 20, 2009
Paige JT, Aaron DL, Yang T, et al. Improved operating room teamwork via SAFETY prep: a rural
community hospital's experience. World J Surg. 2009;33(6):1181-7. doi:10.1007/s00268-009-9952-2.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/37477/psn-pdf
January 16, 2008 - Enhancing healthcare process design with human factors
engineering and reliability science, part 1: setting the
context.
January 16, 2008
Boston-Fleischhauer C. Enhancing healthcare process design with human factors engineering and
reliability science, part 1: setting the context. J Nurs Adm. 2008;38(1):27-32.
do…
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psnet.ahrq.gov/node/37857/psn-pdf
May 26, 2011 - The impact of computerized physician medication order
entry in hospitalized patients—a systematic review.
May 26, 2011
Eslami S, de Keizer NF, Abu-Hanna A. The impact of computerized physician medication order entry in
hospitalized patients--a systematic review. Int J Med Inform. 2008;77(6):365-76.
https://psnet.a…
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psnet.ahrq.gov/node/37416/psn-pdf
March 28, 2012 - The story behind the story: physician skepticism about
relying on clinical information technologies to reduce
medical errors.
March 28, 2012
McAlearney AS, Chisolm DJ, Schweikhart S, et al. The story behind the story: physician skepticism about
relying on clinical information technologies to reduce medical errors.…
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psnet.ahrq.gov/node/40113/psn-pdf
December 21, 2014 - Working with a fixed operating room team on consecutive
similar cases and the effect on case duration and
turnover time.
December 21, 2014
Stepaniak PS, Vrijland WW, de Quelerij M, et al. Working with a fixed operating room team on consecutive
similar cases and the effect on case duration and turnover time. Arch S…