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  1. Diagnostic discordance, health information exchange, and inter-hospital transfer outcomes: a population study. | PSNet

    psnet.ahrq.gov/issue/diagnostic-discordance-health-information-exchange-and-inter-hospital-transfer-outcomes
    May 19, 2021 - Study Diagnostic discordance, health information exchange, and inter-hospital transfer outcomes: a population study. Citation Text: Usher M, Sahni N, Herrigel D, et al. Diagnostic discordance, health information exchange, and inter-hospital transfer outcomes: a population study. J Gen In…

  2. Exploring new avenues to assess the sharp end of patient safety: an analysis of nationally aggregated peer review data. | PSNet

    psnet.ahrq.gov/issue/exploring-new-avenues-assess-sharp-end-patient-safety-analysis-nationally-aggregated-peer
    December 21, 2014 - Study Exploring new avenues to assess the sharp end of patient safety: an analysis of nationally aggregated peer review data. Citation Text: Meeks DW, Meyer AND, Rose B, et al. Exploring new avenues to assess the sharp end of patient safety: an analysis of nationally aggregated peer revi…

  3. Case Study: Collaborating to Improve the Quality of Care: Lessons Learned from the Alabama Medicaid Agency (pdf file)

    digital.ahrq.gov/sites/default/files/docs/medicaid/AL_case_study.pdf
    March 01, 2010 - Case Study: Collaborating to Improve the Quality of Care: Lessons Learned from the Alabama Medicaid Agency Case Study: Collaborating to Improve the Quality of Care: Lessons Learned from the Alabama Medicaid Agency Prepared for: Agency for Healthcare Research and Quality U.S. Department of Health and Human…

  4. The impact of automated notification on follow-up of actionable tests pending at discharge: a cluster-randomized controlled trial. | PSNet

    psnet.ahrq.gov/issue/impact-automated-notification-follow-actionable-tests-pending-discharge-cluster-randomized
    March 04, 2015 - Study Classic The impact of automated notification on follow-up of actionable tests pending at discharge: a cluster-randomized controlled trial. Citation Text: Dalal A, Schaffer A, Gershanik EF, et al. The Impact of Automated Notification on Follow-up of Actiona…

  5. Clinical decision support alert malfunctions: analysis and empirically derived taxonomy. | PSNet

    psnet.ahrq.gov/issue/clinical-decision-support-alert-malfunctions-analysis-and-empirically-derived-taxonomy
    December 04, 2016 - Study Clinical decision support alert malfunctions: analysis and empirically derived taxonomy. Citation Text: Wright A, Ai A, Ash JS, et al. Clinical decision support alert malfunctions: analysis and empirically derived taxonomy. J Am Med Inform Assoc. 2018;25(5):496-506. doi:10.1093/jam…

  6. Some unintended consequences of information technology in health care: the nature of patient care information system-related errors. | PSNet

    psnet.ahrq.gov/issue/some-unintended-consequences-information-technology-health-care-nature-patient-care
    November 18, 2020 - Study Classic Some unintended consequences of information technology in health care: the nature of patient care information system-related errors. Citation Text: Ash JS, Berg M, Coiera E. Some unintended consequences of information technology in health care: t…

  7. Clinicians' use of health information exchange technologies for medication reconciliation in the U.S. Department of Veterans Affairs: a qualitative analysis. | PSNet

    psnet.ahrq.gov/issue/clinicians-use-health-information-exchange-technologies-medication-reconciliation-us
    August 04, 2021 - Study Clinicians' use of health information exchange technologies for medication reconciliation in the U.S. Department of Veterans Affairs: a qualitative analysis. Citation Text: Snyder ME, Nguyen KA, Patel H, et al. Clinicians' use of health information exchange technologies for medicat…

  8. The Medication Metronome Project - 2011 | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/medication-metronome-project/annual-summary/2011
    January 01, 2011 - The Medication Metronome Project - 2011 Project Name The Medication Metronome Project Principal Investigator Atlas, Steven J. Organization Massachusetts General Hospital Funding Mechanism PAR: HS08-270: Utilizing Health Information Technology to Improve Health Care …

  9. Varying rates of patient identity verification when using computerized provider order entry. | PSNet

    psnet.ahrq.gov/issue/varying-rates-patient-identity-verification-when-using-computerized-provider-order-entry
    July 07, 2021 - Study Varying rates of patient identity verification when using computerized provider order entry. Citation Text: Fortman E, Hettinger AZ, Howe JL, et al. Varying rates of patient identity verification when using computerized provider order entry. J Am Med Info Assoc. 2020;27(6):924-928…

  10. Case Study: Collaborating to Improve the Quality of Care: Lessons Learned from the Alabama Medicaid Agency (pdf file)

    digital.ahrq.gov/sites/default/files/docs/page/AL_case_study_0.pdf
    March 01, 2010 - Case Study: Collaborating to Improve the Quality of Care: Lessons Learned from the Alabama Medicaid Agency Case Study: Collaborating to Improve the Quality of Care: Lessons Learned from the Alabama Medicaid Agency Prepared for: Agency for Healthcare Research and Quality U.S. Department of Health and Human…

  11. Routine multidisciplinary review of severe maternal morbidity is associated with a reduction in preventable cases of severe maternal morbidity. | PSNet

    psnet.ahrq.gov/issue/routine-multidisciplinary-review-severe-maternal-morbidity-associated-reduction-preventable
    September 02, 2020 - Study Routine multidisciplinary review of severe maternal morbidity is associated with a reduction in preventable cases of severe maternal morbidity. Citation Text: Ozimek JA, Greene N, Geller AI, et al. Routine multidisciplinary review of severe maternal morbidity is associated with a r…

  12. Patient safety culture, health information technology implementation, and medical office problems that could lead to diagnostic error. | PSNet

    psnet.ahrq.gov/issue/patient-safety-culture-health-information-technology-implementation-and-medical-office
    December 15, 2010 - Study Patient safety culture, health information technology implementation, and medical office problems that could lead to diagnostic error. Citation Text: Campione JR, Mardon RE, McDonald KM. Patient Safety Culture, Health Information Technology Implementation, and Medical Office Proble…

  13. Factors contributing to an increase in duplicate medication order errors after CPOE implementation. | PSNet

    psnet.ahrq.gov/issue/factors-contributing-increase-duplicate-medication-order-errors-after-cpoe-implementation
    December 31, 2014 - Study Factors contributing to an increase in duplicate medication order errors after CPOE implementation. Citation Text: Wetterneck TB, Walker JM, Blosky MA, et al. Factors contributing to an increase in duplicate medication order errors after CPOE implementation. J Am Med Inform Assoc. …

  14. Room for resilience: a qualitative study about accountability mechanisms in the relation between work-as-done (WAD) and work-as-imagined (WAI) in hospitals. | PSNet

    psnet.ahrq.gov/issue/room-resilience-qualitative-study-about-accountability-mechanisms-relation-between-work-done
    August 31, 2022 - Study Room for resilience: a qualitative study about accountability mechanisms in the relation between work-as-done (WAD) and work-as-imagined (WAI) in hospitals. Citation Text: Weenink J-W, Tresfon J, van de Voort I, et al. Room for resilience: a qualitative study about accountability m…

  15. Surgical checklists: a systematic review of impacts and implementation. | PSNet

    psnet.ahrq.gov/issue/surgical-checklists-systematic-review-impacts-and-implementation
    January 06, 2018 - Review Surgical checklists: a systematic review of impacts and implementation. Citation Text: Treadwell JR, Lucas S, Tsou AY. Surgical checklists: a systematic review of impacts and implementation. BMJ Qual Saf. 2014;23(4):299-318. doi:10.1136/bmjqs-2012-001797. Copy Citation F…

  16. Teamwork- Part 1: Divided We Fall; Part 2: Cursed By Knowledge: Building a Culture of Psychological Safety; and Part 3: The Not-My-Problem Problem. | PSNet

    psnet.ahrq.gov/issue/teamwork-part-1-divided-we-fall-part-2-cursed-knowledge-building-culture-psychological-safety
    August 02, 2015 - Commentary Emerging Classic Teamwork- Part 1: Divided We Fall; Part 2: Cursed By Knowledge: Building a Culture of Psychological Safety; and Part 3: The Not-My-Problem Problem. Citation Text: Rosenbaum L. Divided We Fall. N Engl J Med. 2019;380(7):684-688. doi:10…

  17. Medication safety amid technological change: usability evaluation to inform inpatient nurses' electronic health record system transition. | PSNet

    psnet.ahrq.gov/issue/medication-safety-amid-technological-change-usability-evaluation-inform-inpatient-nurses
    March 22, 2023 - Study Medication safety amid technological change: usability evaluation to inform inpatient nurses' electronic health record system transition. Citation Text: Reale C, Ariosto DA, Weinger MB, et al. Medication safety amid technological change: usability evaluation to inform inpatient nur…

  18. Impact of extended-duration shifts on medical errors, adverse events, and attentional failures. | PSNet

    psnet.ahrq.gov/issue/impact-extended-duration-shifts-medical-errors-adverse-events-and-attentional-failures
    February 02, 2011 - Study Impact of extended-duration shifts on medical errors, adverse events, and attentional failures. Citation Text: Barger LK, Ayas N, Cade BE, et al. Impact of extended-duration shifts on medical errors, adverse events, and attentional failures. PLoS Med. 2006;3(12):e487. Copy Cita…

  19. Qualitative perspectives of emergency nurses on electronic health record behavioral flags to promote workplace safety. | PSNet

    psnet.ahrq.gov/issue/qualitative-perspectives-emergency-nurses-electronic-health-record-behavioral-flags-promote
    January 25, 2023 - Study Qualitative perspectives of emergency nurses on electronic health record behavioral flags to promote workplace safety. Citation Text: Seeburger EF, Gonzales R, South EC, et al. Qualitative perspectives of emergency nurses on electronic health record behavioral flags to promote work…

  20. Systems analysis of adverse drug events. | PSNet

    psnet.ahrq.gov/issue/systems-analysis-adverse-drug-events
    February 10, 2011 - Study Classic Systems analysis of adverse drug events. Citation Text: Leape L, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA. 1995;274(1):35-43. Copy Citation Format: Google Scholar PubMed B…
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