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  1. Periodic Issue | PSNet

    psnet.ahrq.gov/periodic-issue/periodic-issue-343
    May 16, 2022 - Safety Board, installation of a single national body for incident reporting, and implementation of electronic … health record learning systems that flag potential risks.

  2. Preventable Transfer to the Hospital | PSNet

    psnet.ahrq.gov/web-mm/preventable-transfer-hospital
    March 31, 2022 - high-risk discordant care and avoidable readmissions. 11 Although hospitals and SNFs may both use electronic … health records (EHRs), what is documented and shared is at their individual discretion, which may be

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33638/psn-pdf
    August 01, 2006 - Getting Into Patient Safety: A Personal Story August 1, 2006 Cooper JB. Getting Into Patient Safety: A Personal Story. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/getting-patient-safety-personal-story Perspective My journey into patient safety began in 1972. It was born of serendipity enabled by the…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49644/psn-pdf
    December 01, 2011 - Missing the Point—Eye Injury December 1, 2011 Sharma R, Brunette DD. Missing the Point—Eye Injury. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/missing-point-eye-injury The Case A 31-year-old woman presented to the emergency department (ED) after suffering multiple lacerations during an assault. The pati…

  5. Cups of Error | PSNet

    psnet.ahrq.gov/web-mm/cups-error
    January 12, 2011 - Cups of Error Citation Text: Blegen MA, Pepper GA. Cups of Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS…

  6. The nature of surgical error: a cautionary tale and a call to reason. | PSNet

    psnet.ahrq.gov/issue/nature-surgical-error-cautionary-tale-and-call-reason
    September 12, 2007 - Development of a proactive process to harmonize policy, infusion pump library, and electronic … health record entries for continuous infusions at an academic medical center.

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49853/psn-pdf
    February 01, 2019 - Adverse Event During Intrahospital Transport February 1, 2019 Bergman L, Chaboyer W. Adverse Event During Intrahospital Transport. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/adverse-event-during-intrahospital-transport The Case A 4-year-old boy underwent surgery under general anesthesia for correction o…

  8. The Forgotten Radiographic Read | PSNet

    psnet.ahrq.gov/web-mm/forgotten-radiographic-read
    June 07, 2016 - Timely follow-up of abnormal diagnostic imaging test results in an outpatient setting: are electronic … medical records achieving their potential?

  9. Rss

    psnet.ahrq.gov/weekly-resource/rss.xml
    January 01, 2024 - support systems to reduce medication errors can result in alert fatigue and excessive time spent in the electronic … health record).

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49413/psn-pdf
    September 01, 2003 - Did We Forget Something? September 1, 2003 Gibbs VC. Did We Forget Something? PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/did-we-forget-something The Case A 76-year-old-man underwent right aorto-iliac aneurysm repair. He developed postoperative fever, initially attributed to ventilator-associated pneumo…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49712/psn-pdf
    June 01, 2014 - taken out of the physician's hands, with default instructions selected at the time of order.(25,26) Electronic … health record (EHR) tools exist to standardize prescribing, structure counseling, and prompt patients

  12. Mobility Lost in the ICU | PSNet

    psnet.ahrq.gov/web-mm/mobility-lost-icu
    August 01, 2018 - With growing reliance on electronic health records and CPOE, systems that potentially prompt or guide

  13. Patient Safety Innovations Exchange | PSNet

    psnet.ahrq.gov/innovations-exchange
    May 01, 2021 - Approaches (2) Teamwork (2) Telemedicine (2) Clinical Information Systems (1) Electronic … Health Records (1) Clinical Pharmacist Involvement (1) Communication Improvement

  14. Misgivings. | PSNet

    psnet.ahrq.gov/issue/misgivings
    March 17, 2021 - September 23, 2020 The development and piloting of the Ambulatory Electronic Health Record

  15. Duplicate Insulin Order | PSNet

    psnet.ahrq.gov/web-mm/duplicate-insulin-order
    May 04, 2012 - Although computerized provider order entry (CPOE) systems and electronic health records (EHRs) have reduced

  16. Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists | PSNet

    psnet.ahrq.gov/web-mm/sepsis-resulting-delays-treatment-and-miscommunication-among-specialists
    February 26, 2025 - November 18, 2020 Electronic health records and malpractice claims in office practice

  17. Pharmacist Role in Patient Safety | PSNet

    psnet.ahrq.gov/perspective/pharmacist-role-patient-safety
    June 29, 2020 - With the growth of electronic health records, pharmacist review can be done remotely, minimizing burden

  18. Medication Mix-Up: From Bad to Worse | PSNet

    psnet.ahrq.gov/web-mm/medication-mix-bad-worse
    March 01, 2018 - antihypertensive medications was minoxidil, and his outpatient dose of 7.5 mg per day was ordered via the electronic … health record.

  19. Empty Handoff | PSNet

    psnet.ahrq.gov/web-mm/empty-handoff
    August 01, 2017 - The electronic health record (EHR) did not reflect the glucose levels because the bedside glucose-monitoring

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865419/psn-pdf
    March 27, 2024 - sophisticated approach, if available, involves incorporating age-specific pediatric vital sign ranges into the electronic … health record (EHR) and generating automated alerts for patients with abnormal vital signs. … decision support tools for detection of sepsis such as alerts and predictive risk scores integrated into electronic … health record systems can aid clinicians in interpreting age-specific pediatric vital sign ranges and
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