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  1. Failure mode and effects analysis to reduce risk of heparin use. | PSNet

    psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-reduce-risk-heparin-use
    July 19, 2023 - Study Failure mode and effects analysis to reduce risk of heparin use. Citation Text: Pino FA, Weidemann DK, Schroeder LL, et al. Failure mode and effects analysis to reduce risk of heparin use. Am J Health Syst Pharm. 2019;76(23):1972-1979. doi:10.1093/ajhp/zxz229. Copy Citation F…

  2. A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional change. | PSNet

    psnet.ahrq.gov/issue/case-transfusion-error-trauma-patient-subsequent-root-cause-analysis-leading-institutional
    March 30, 2022 - Commentary A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional change. Citation Text: Clifford SP, Mick PB, Derhake BM. A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional ch…

  3. Retrospective review for medication dose errors in pediatric emergency department medication orders that bypassed pharmacist review. | PSNet

    psnet.ahrq.gov/issue/retrospective-review-medication-dose-errors-pediatric-emergency-department-medication-orders
    January 12, 2022 - Study Retrospective review for medication dose errors in pediatric emergency department medication orders that bypassed pharmacist review. Citation Text: Todd SE, Thompson AJ, Russell WS. Retrospective review for medication dose errors in pediatric emergency department medication orders…

  4. Socio-technical issues and challenges in implementing safe patient handovers: insights from ethnographic case studies. | PSNet

    psnet.ahrq.gov/issue/socio-technical-issues-and-challenges-implementing-safe-patient-handovers-insights
    July 19, 2023 - Study Socio-technical issues and challenges in implementing safe patient handovers: insights from ethnographic case studies. Citation Text: Balka E, Tolar M, Coates S, et al. Socio-technical issues and challenges in implementing safe patient handovers: insights from ethnographic case st…

  5. A trigger tool to identify adverse events in the intensive care unit.  | PSNet

    psnet.ahrq.gov/issue/trigger-tool-identify-adverse-events-intensive-care-unit
    April 08, 2011 - Study A trigger tool to identify adverse events in the intensive care unit.  Citation Text: Resar RK, Rozich JD, Simmonds T, et al. A Trigger Tool to Identify Adverse Events in the Intensive Care Unit. The Joint Commission Journal on Quality and Patient Safety. 2016;32(10). doi:10.1016/s…

  6. Adopting high reliability organization principles to lead a large scale clinical transformation. | PSNet

    psnet.ahrq.gov/issue/adopting-high-reliability-organization-principles-lead-large-scale-clinical-transformation
    November 21, 2021 - Commentary Adopting high reliability organization principles to lead a large scale clinical transformation. Citation Text: Pozzobon LD, Lam J, Chimonides E, et al. Adopting high reliability organization principles to lead a large scale clinical transformation. Healthc Manage Forum. 2023;…

  7. Association between in-clinic opioid administration and discharge opioid prescription in urgent care: a retrospective cohort study. | PSNet

    psnet.ahrq.gov/issue/association-between-clinic-opioid-administration-and-discharge-opioid-prescription-urgent
    May 19, 2021 - Study Association between in-clinic opioid administration and discharge opioid prescription in urgent care: a retrospective cohort study. Citation Text: Calcaterra SL, Lou Y, Everhart RM, et al. Association between in-clinic opioid administration and discharge opioid prescription in urge…

  8. Determining current insulin pen use practices and errors in the inpatient setting. | PSNet

    psnet.ahrq.gov/issue/determining-current-insulin-pen-use-practices-and-errors-inpatient-setting
    June 29, 2016 - Study Determining current insulin pen use practices and errors in the inpatient setting. Citation Text: Brown KE, Hertig JB. Determining Current Insulin Pen Use Practices and Errors in the Inpatient Setting. Jt Comm J Qual Patient Saf. 2016;42(12):568-AP7. doi:10.1016/S1553-7250(16)30109…

  9. Human centered design workshops as a meta-solution to diagnostic disparities. | PSNet

    psnet.ahrq.gov/issue/human-centered-design-workshops-meta-solution-diagnostic-disparities
    July 31, 2024 - Study Human centered design workshops as a meta-solution to diagnostic disparities. Citation Text: Wiegand AA, Dukhanin V, Sheikh T, et al. Human centered design workshops as a meta-solution to diagnostic disparities. Diagnosis (Berl). 2022;9(4):458-467. doi:10.1515/dx-2022-0025. Copy …

  10. Does simulator-based clinical performance correlate with actual hospital behavior? The effect of extended work hours on patient care provided by medical interns. | PSNet

    psnet.ahrq.gov/issue/does-simulator-based-clinical-performance-correlate-actual-hospital-behavior-effect-extended
    February 17, 2011 - Study Does simulator-based clinical performance correlate with actual hospital behavior? The effect of extended work hours on patient care provided by medical interns. Citation Text: Gordon JA, Alexander EK, Lockley SW, et al. Does Simulator-Based Clinical Performance Correlate With Ac…

  11. Personal health records: a randomized trial of effects on elder medication safety. | PSNet

    psnet.ahrq.gov/issue/personal-health-records-randomized-trial-effects-elder-medication-safety
    November 16, 2022 - Study Personal health records: a randomized trial of effects on elder medication safety. Citation Text: Chrischilles EA, Hourcade JP, Doucette W, et al. Personal health records: a randomized trial of effects on elder medication safety. J Am Med Inform Assoc. 2014;21(4):679-86. doi:10.113…

  12. Reducing ambulatory central line-associated bloodstream infections: a family-centered approach. | PSNet

    psnet.ahrq.gov/issue/reducing-ambulatory-central-line-associated-bloodstream-infections-family-centered-approach
    February 15, 2023 - Study Reducing ambulatory central line-associated bloodstream infections: a family-centered approach. Citation Text: Wong CI, Ilowite M, Yan A, et al. Reducing ambulatory central line‐associated bloodstream infections: a family‐centered approach. Pediatr Blood Cancer. 2024;71(8):e31064. …

  13. Oncology pharmacist-led medication reconciliation among cancer patients initiating chemotherapy. | PSNet

    psnet.ahrq.gov/issue/oncology-pharmacist-led-medication-reconciliation-among-cancer-patients-initiating
    March 24, 2021 - Study Oncology pharmacist-led medication reconciliation among cancer patients initiating chemotherapy. Citation Text: Chun DS, Faso A, Muss HB, et al. Oncology pharmacist-led medication reconciliation among cancer patients initiating chemotherapy. J Oncol Pharm Pract. 2020;26(5):1156-116…

  14. The relationship between physician practice characteristics and physician adoption of electronic health records. | PSNet

    psnet.ahrq.gov/issue/relationship-between-physician-practice-characteristics-and-physician-adoption-electronic
    November 13, 2013 - Study The relationship between physician practice characteristics and physician adoption of electronic health records. Citation Text: Bramble JD, Galt KA, Siracuse M, et al. The relationship between physician practice characteristics and physician adoption of electronic health records.…

  15. Predicting computerized physician order entry system adoption in US hospitals: can the federal mandate be met? | PSNet

    psnet.ahrq.gov/issue/predicting-computerized-physician-order-entry-system-adoption-us-hospitals-can-federal
    October 06, 2011 - Study Predicting computerized physician order entry system adoption in US hospitals: can the federal mandate be met? Citation Text: Ford EW, McAlearney AS, Phillips MT, et al. Predicting computerized physician order entry system adoption in US hospitals: Can the federal mandate be met?…

  16. Assessing adverse events after chiropractic care at a chiropractic teaching clinic: an active-surveillance pilot study. | PSNet

    psnet.ahrq.gov/issue/assessing-adverse-events-after-chiropractic-care-chiropractic-teaching-clinic-active
    December 23, 2020 - Study Assessing adverse events after chiropractic care at a chiropractic teaching clinic: an active-surveillance pilot study. Citation Text: Pohlman KA, Funabashi M, Ndetan H, et al. Assessing adverse events after chiropractic care at a chiropractic teaching clinic: an active-surveillanc…

  17. Understanding and confronting our mistakes: the epidemiology of error in radiology and strategies for error reduction. | PSNet

    psnet.ahrq.gov/issue/understanding-and-confronting-our-mistakes-epidemiology-error-radiology-and-strategies-error
    February 02, 2022 - Commentary Understanding and confronting our mistakes: the epidemiology of error in radiology and strategies for error reduction. Citation Text: Bruno MA, Walker EA, Abujudeh H. Understanding and confronting our mistakes: the epidemiology of error in radiology and strategies for error re…

  18. Analysis of patient-physician concordance in the understanding of chemotherapy treatment plans among patients with cancer. | PSNet

    psnet.ahrq.gov/issue/analysis-patient-physician-concordance-understanding-chemotherapy-treatment-plans-among
    January 11, 2023 - Study Analysis of patient-physician concordance in the understanding of chemotherapy treatment plans among patients with cancer. Citation Text: Almalki H, Absi A, Alghamdi A, et al. Analysis of patient-physician concordance in the understanding of chemotherapy treatment plans among patie…

  19. Patient safety goals for the proposed Federal Health Information Technology Safety Center. | PSNet

    psnet.ahrq.gov/issue/patient-safety-goals-proposed-federal-health-information-technology-safety-center
    November 30, 2011 - Commentary Classic Patient safety goals for the proposed Federal Health Information Technology Safety Center. Citation Text: Sittig DF, Classen D, Singh H. Patient safety goals for the proposed Federal Health Information Technology Safety Center. J Am Med Inform…

  20. Medication errors by caregivers at home in neonates discharged from the neonatal intensive care unit. | PSNet

    psnet.ahrq.gov/issue/medication-errors-caregivers-home-neonates-discharged-neonatal-intensive-care-unit
    June 07, 2023 - Study Medication errors by caregivers at home in neonates discharged from the neonatal intensive care unit. Citation Text: Solanki R, Mondal N, Mahalakshmy T, et al. Medication errors by caregivers at home in neonates discharged from the neonatal intensive care unit. Arch Dis Child. 2017…
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