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August 30, 2017 - Inpatients notes: sensemaking—fostering a shared
understanding in clinical teams.
August 30, 2017
Leykum LK, O'Leary KJ. Web Exclusives. Annals for Hospitalists Inpatient Notes - Sensemaking-Fostering
a Shared Understanding in Clinical Teams. Ann Intern Med. 2017;167(4):HO2-HO3. doi:10.7326/M17-
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March 13, 2019 - Medicare trims payments to 800 hospitals, citing patient
safety incidents.
March 13, 2019
Rau J. Kaiser Health News. March 1, 2019.
https://psnet.ahrq.gov/issue/medicare-trims-payments-800-hospitals-citing-patient-safety-incidents
Financial incentives may encourage adoption of practice improvements that enhance sa…
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November 21, 2016 - Insensible losses: when the medical community forgets
the family.
November 21, 2016
Elias P. Insensible losses: when the medical community forgets the family. Health Aff (Millwood).
2015;34(4):707-710. doi:10.1377/hlthaff.2014.0536.
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February 18, 2019 - Structured handover in general surgery: an audit of
current practice.
February 18, 2019
Jones HG, Watt B, Lewis L, et al. Structured Handover in General Surgery: An Audit of Current Practice. J
Patient Saf. 2019;15(1):7-10. doi:10.1097/PTS.0000000000000201.
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April 23, 2014 - Disclosing harmful medical errors to patients: a time for
professional action.
April 23, 2014
Gallagher TH, Levinson W. Disclosing Harmful Medical Errors to Patients. Arch Intern Med. 2005;165(16).
doi:10.1001/archinte.165.16.1819.
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May 03, 2017 - Secret data on hospital inspections may soon become
public.
May 3, 2017
Ornstein C. Health Shots. National Public Radio and ProPublica. April 18, 2017.
https://psnet.ahrq.gov/issue/secret-data-hospital-inspections-may-soon-become-public
Summary data about serious errors in hospitals are available, but often detail…
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January 01, 2021 - The effects of bar-coding technology on medication
errors: a systematic literature review.
April 19, 2017
Hutton K, Ding Q, Wellman G. The Effects of Bar-coding Technology on Medication Errors: A Systematic
Literature Review. J Patient Saf. 2021;17(3):e192-e206. doi:10.1097/PTS.0000000000000366.
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September 22, 2021 - Bringing the clinical laboratory into the strategy to
advance diagnostic excellence.
September 22, 2021
Lubin IM, Astles J R, Shahangian S, et al. Bringing the clinical laboratory into the strategy to advance
diagnostic excellence. Diagnosis (Berl). 2021;8(3):281-294. doi:10.1515/dx-2020-0119.
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July 11, 2017 - Automatic errors: a case series on the errors inherent in
electronic prescribing.
July 11, 2017
Lourenco LM, Bursua A, Groo VL. Automatic Errors: A Case Series on the Errors Inherent in Electronic
Prescribing. J Gen Intern Med. 2016;31(7):808-811. doi:10.1007/s11606-016-3606-5.
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May 27, 2011 - Evaluation of outpatient computerized physician
medication order entry systems: a systematic review.
May 27, 2011
Eslami S, Abu-Hanna A, de Keizer NF. Evaluation of outpatient computerized physician medication order
entry systems: a systematic review. J Am Med Inform Assoc. 2007;14(4):400-6.
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May 21, 2009 - The state of the evidence for computerized provider order
entry: a systematic review and analysis of the quality of
the literature.
May 21, 2009
Weir C, Staggers N, Phansalkar S. The state of the evidence for computerized provider order entry: a
systematic review and analysis of the quality of the literature. Int …
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October 23, 2019 - Automation of the I-PASS tool to improve transitions of
care.
October 23, 2019
Skaret MM, Weaver TD, Humes RJ, et al. Automation of the I-PASS Tool to Improve Transitions of Care. J
Healthc Qual. 2019;41(5):274-280. doi:10.1097/JHQ.0000000000000174.
https://psnet.ahrq.gov/issue/automation-i-pass-tool-improve-trans…
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May 15, 2024 - Addressing electronic health record contributions to
diagnostic error.
May 15, 2024
Ratwani RM, Bates DW, Gold J. Health Affairs Forefront. April 25, 2024.
https://psnet.ahrq.gov/issue/addressing-electronic-health-record-contributions-diagnostic-error
Design and user issues are persistent detractors from the relia…
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August 10, 2016 - Where are my instruments? Hazards in delivery of
surgical instruments.
August 10, 2016
Guédon ACP, Wauben LSGL, van der Eijk AC, et al. Where are my instruments? Hazards in delivery of
surgical instruments. Surg Endosc. 2016;30(7):2728-35. doi:10.1007/s00464-015-4537-7.
https://psnet.ahrq.gov/issue/where-are-my-in…
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March 25, 2020 - A protocol for the safe use of hazardous drugs in the OR.
March 25, 2020
Hemingway MW, Meleis L, Oliver J, et al. A protocol for the safe use of hazardous drugs in the OR. AORN
J. 2020;111(3). doi:10.1002/aorn.12960.
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Perioperative personnel often ca…
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April 01, 2020 - Effective Reporting Could Improve Safe Use of Electronic
Health Records.
April 1, 2020
Philadelphia, PA: Pew Charitable Trusts; March 2020.
https://psnet.ahrq.gov/issue/effective-reporting-could-improve-safe-use-electronic-health-records
Electronic health records both enhance and challenge the safety of care proce…
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August 02, 2015 - Reducing inappropriate polypharmacy: the process of
deprescribing.
August 2, 2015
Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing.
JAMA Intern Med. 2015;175(5):827-34. doi:10.1001/jamainternmed.2015.0324.
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January 10, 2018 - Leveraging the electronic health record to improve quality
and safety in rheumatology.
January 10, 2018
Schmajuk G, Yazdany J. Leveraging the electronic health record to improve quality and safety in
rheumatology. Rheumatol Int. 2017;37(10):1603-1610. doi:10.1007/s00296-017-3804-4.
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June 10, 2018 - Fatal PCA adverse events continue to happen...better
patient monitoring is essential to prevent harm.
June 10, 2018
ISMP Medication Safety Alert! Acute Care Edition. May 30, 2013;18:1-3.
https://psnet.ahrq.gov/issue/fatal-pca-adverse-events-continue-happenbetter-patient-monitoring-essential-
prevent-harm
Describi…
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June 15, 2017 - The global burden of diagnostic errors in primary care.
June 15, 2017
Singh H, Schiff G, Graber ML, et al. The global burden of diagnostic errors in primary care. BMJ Qual Saf.
2017;26(6):484-494. doi:10.1136/bmjqs-2016-005401.
https://psnet.ahrq.gov/issue/global-burden-diagnostic-errors-primary-care
The need to i…