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  1. Harnessing in situ simulation to identify human errors and latent safety threats in adult tracheostomy care. | PSNet

    psnet.ahrq.gov/issue/harnessing-situ-simulation-identify-human-errors-and-latent-safety-threats-adult-tracheostomy
    September 23, 2020 - Study Harnessing in situ simulation to identify human errors and latent safety threats in adult tracheostomy care. Citation Text: Hassan B, Tawfik M-M, Schiff E, et al. Harnessing in situ simulation to identify human errors and latent safety threats in adult tracheostomy care. Jt Comm J …

  2. An electronic trigger based on care escalation to identify preventable adverse events in hospitalised patients. | PSNet

    psnet.ahrq.gov/issue/electronic-trigger-based-care-escalation-identify-preventable-adverse-events-hospitalised
    September 28, 2016 - Study Classic An electronic trigger based on care escalation to identify preventable adverse events in hospitalised patients. Citation Text: Bhise V, Sittig DF, Vaghani V, et al. An electronic trigger based on care escalation to identify preventable adverse even…

  3. ICU attending handoff practices: results from a national survey of academic intensivists. | PSNet

    psnet.ahrq.gov/issue/icu-attending-handoff-practices-results-national-survey-academic-intensivists
    February 06, 2019 - Study ICU attending handoff practices: results from a national survey of academic intensivists. Citation Text: Lane-Fall MB, Collard ML, Turnbull AE, et al. ICU Attending Handoff Practices: Results From a National Survey of Academic Intensivists. Crit Care Med. 2016;44(4):690-8. doi:10.1…

  4. Observing sources of system resilience using in situ alarm simulations. | PSNet

    psnet.ahrq.gov/issue/observing-sources-system-resilience-using-situ-alarm-simulations
    August 30, 2023 - Study Observing sources of system resilience using in situ alarm simulations. Citation Text: McLoone M, McNamara M, Jennings MA, et al. Observing sources of system resilience using in situ alarm simulations. J Hosp Med. 2023;18(11):994-998. doi:10.1002/jhm.13217. Copy Citation Form…

  5. Does nurse use of a standardized flowsheet to document communication with advanced providers provide a mechanism to detect pulse oximetry failures? A retrospective study of electronic health record data. | PSNet

    psnet.ahrq.gov/issue/does-nurse-use-standardized-flowsheet-document-communication-advanced-providers-provide
    June 22, 2022 - Study Does nurse use of a standardized flowsheet to document communication with advanced providers provide a mechanism to detect pulse oximetry failures? A retrospective study of electronic health record data. Citation Text: Gleason KT, Tran A, Fawzy A, et al. Does nurse use of a standar…

  6. How safe are outpatient electronic health records? An evaluation of medication-related decision support using the Ambulatory Electronic Health Record Evaluation Tool. | PSNet

    psnet.ahrq.gov/issue/how-safe-are-outpatient-electronic-health-records-evaluation-medication-related-decision
    March 17, 2021 - Study How safe are outpatient electronic health records? An evaluation of medication-related decision support using the Ambulatory Electronic Health Record Evaluation Tool. Citation Text: Co Z, Classen DC, Cole JM, et al. How safe are outpatient electronic health records? An evaluation o…

  7. Effect of digital tools to promote hospital quality and safety on adverse events after discharge. | PSNet

    psnet.ahrq.gov/issue/effect-digital-tools-promote-hospital-quality-and-safety-adverse-events-after-discharge
    October 16, 2024 - Study Effect of digital tools to promote hospital quality and safety on adverse events after discharge. Citation Text: Vasudevan A, Plombon S, Piniella N, et al. Effect of digital tools to promote hospital quality and safety on adverse events after discharge. J Am Med Inform Assoc. 2024;…

  8. The effect of two different electronic health record user interfaces on intensive care provider task load, errors of cognition, and performance. | PSNet

    psnet.ahrq.gov/issue/effect-two-different-electronic-health-record-user-interfaces-intensive-care-provider-task
    March 16, 2022 - Study The effect of two different electronic health record user interfaces on intensive care provider task load, errors of cognition, and performance. Citation Text: Ahmed A, Chandra S, Herasevich V, et al. The effect of two different electronic health record user interfaces on intensi…

  9. Optimization of drug–drug interaction alert rules in a pediatric hospital's electronic health record system using a visual analytics dashboard. | PSNet

    psnet.ahrq.gov/issue/optimization-drug-drug-interaction-alert-rules-pediatric-hospitals-electronic-health-record
    May 20, 2019 - Study Optimization of drug–drug interaction alert rules in a pediatric hospital's electronic health record system using a visual analytics dashboard. Citation Text: Simpao AF, Ahumada LM, Desai BR, et al. Optimization of drug-drug interaction alert rules in a pediatric hospital's electro…

  10. When illegitimate tasks threaten patient safety culture: a cross-sectional survey in a tertiary hospital. | PSNet

    psnet.ahrq.gov/issue/when-illegitimate-tasks-threaten-patient-safety-culture-cross-sectional-survey-tertiary
    February 19, 2020 - Study When illegitimate tasks threaten patient safety culture: a cross-sectional survey in a tertiary hospital. Citation Text: Cullati S, Semmer NK, Tschan F, et al. When illegitimate tasks threaten patient safety culture: a cross-sectional survey in a tertiary hospital. Int J Public Hea…

  11. Peers without fears? Barriers to effective communication among primary care physicians and oncologists about diagnostic delays in cancer. | PSNet

    psnet.ahrq.gov/issue/peers-without-fears-barriers-effective-communication-among-primary-care-physicians-and
    October 27, 2021 - Study Peers without fears? Barriers to effective communication among primary care physicians and oncologists about diagnostic delays in cancer. Citation Text: Lipitz-Snyderman A, Kale M, Robbins L, et al. Peers without fears? Barriers to effective communication among primary care physici…

  12. Identifying and classifying diagnostic errors in acute care across hospitals: early lessons from the Utility of Predictive Systems in Diagnostic Errors (UPSIDE) study. | PSNet

    psnet.ahrq.gov/issue/identifying-and-classifying-diagnostic-errors-acute-care-across-hospitals-early-lessons
    April 12, 2023 - Study Identifying and classifying diagnostic errors in acute care across hospitals: early lessons from the Utility of Predictive Systems in Diagnostic Errors (UPSIDE) study. Citation Text: Dalal AK, Schnipper JL, Raffel K, et al. Identifying and classifying diagnostic errors in acute car…

  13. Safer prescribing for hospitalized older adults with an electronic health records‐based prescribing context. | PSNet

    psnet.ahrq.gov/issue/safer-prescribing-hospitalized-older-adults-electronic-health-records-based-prescribing
    March 09, 2022 - Study Safer prescribing for hospitalized older adults with an electronic health records‐based prescribing context. Citation Text: Drago K, Sharpe J, De Lima B, et al. Safer prescribing for hospitalized older adults with an electronic health records‐based prescribing context. J Am Geriatr…

  14. Impact of smart pump-electronic health record interoperability on patient safety and finances at a community hospital | PSNet

    psnet.ahrq.gov/issue/impact-smart-pump-electronic-health-record-interoperability-patient-safety-and-finances
    September 23, 2020 - Study Impact of smart pump-electronic health record interoperability on patient safety and finances at a community hospital Citation Text: Wei W, Coffey W, Adeola M, et al. Impact of smart pump-electronic health record interoperability on patient safety and finances at a community hospit…

  15. Effect of a real-time pediatric ICU safety bundle dashboard on quality improvement measures. | PSNet

    psnet.ahrq.gov/issue/effect-real-time-pediatric-icu-safety-bundle-dashboard-quality-improvement-measures
    June 21, 2015 - Study Effect of a real-time pediatric ICU safety bundle dashboard on quality improvement measures. Citation Text: Shaw SJ, Jacobs B, Stockwell DC, et al. Effect of a Real-Time Pediatric ICU Safety Bundle Dashboard on Quality Improvement Measures. Jt Comm J Qual Patient Saf. 2015;41(9):41…

  16. Using the Global Trigger Tool in surgical and neurosurgical patients: a feasibility study. | PSNet

    psnet.ahrq.gov/issue/using-global-trigger-tool-surgical-and-neurosurgical-patients-feasibility-study
    June 09, 2021 - Study Using the Global Trigger Tool in surgical and neurosurgical patients: a feasibility study. Citation Text: Brösterhaus M, Hammer A, Gruber R, et al. Using the Global Trigger Tool in surgical and neurosurgical patients: a feasibility study. PLoS ONE. 2022;17(8):e0272853. doi:10.1371/…

  17. Examination of the relationship between management and clinician perception of patient safety climate and patient satisfaction. | PSNet

    psnet.ahrq.gov/issue/examination-relationship-between-management-and-clinician-perception-patient-safety-climate
    November 07, 2018 - Study Classic Examination of the relationship between management and clinician perception of patient safety climate and patient satisfaction. Citation Text: Mazurenko O, Richter J, Kazley AS, et al. Examination of the relationship between management and clinicia…

  18. Electronic health records, communication, and data sharing: challenges and opportunities for improving the diagnostic process. | PSNet

    psnet.ahrq.gov/issue/electronic-health-records-communication-and-data-sharing-challenges-and-opportunities
    October 13, 2018 - Study Electronic health records, communication, and data sharing: challenges and opportunities for improving the diagnostic process. Citation Text: Quinn M, Forman J, Harrod M, et al. Electronic health records, communication, and data sharing: challenges and opportunities for improving t…

  19. Breast cancer screening in Denmark: a cohort study of tumor size and overdiagnosis. | PSNet

    psnet.ahrq.gov/issue/breast-cancer-screening-denmark-cohort-study-tumor-size-and-overdiagnosis
    July 10, 2018 - Study Classic Breast cancer screening in Denmark: a cohort study of tumor size and overdiagnosis. Citation Text: Jørgensen KJ, Gøtzsche PC, Kalager M, et al. Breast Cancer Screening in Denmark: A Cohort Study of Tumor Size and Overdiagnosis. Ann Intern Med. 2017…

  20. Wrong-patient blood transfusion error: leveraging technology to overcome human error in intraoperative blood component administration. | PSNet

    psnet.ahrq.gov/issue/wrong-patient-blood-transfusion-error-leveraging-technology-overcome-human-error
    December 09, 2020 - Study Wrong-patient blood transfusion error: leveraging technology to overcome human error in intraoperative blood component administration. Citation Text: Hensley NB, Koch CG, Pronovost P, et al. Wrong-Patient Blood Transfusion Error: Leveraging Technology to Overcome Human Error in Int…
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