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Using computerized prescriber order entry to limit overrides from automated dispensing cabinets. | PSNet

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May 18, 2022 - Commentary Using computerized prescriber order entry to limit overrides from automated dispensing cabinets. Citation Text: Drake E, Srinivas P, Trujillo T. Using computerized prescriber order entry to limit overrides from automated dispensing cabinets. Am J Health-Syst Pharm. 2016;73(14)…

Teaching nursing students the ethical and legal consequences of medical errors: insights from the RaDonda Vaught case using the jigsaw technique. | PSNet

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July 05, 2017 - Study Teaching nursing students the ethical and legal consequences of medical errors: insights from the RaDonda Vaught case using the jigsaw technique. Citation Text: Geiselman EL, Opsahl A, Townsend C. Teaching nursing students the ethical and legal consequences of medical errors: insig…

Implicit bias in healthcare professionals: a systematic review. | PSNet

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September 28, 2022 - Review Implicit bias in healthcare professionals: a systematic review. Citation Text: FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics. 2017;18(1):19. doi:10.1186/s12910-017-0179-8. Copy Citation Format: DOI Google Schola…

Problems with health information technology and their effects on care delivery and patient outcomes: a systematic review. | PSNet

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February 14, 2024 - Review Problems with health information technology and their effects on care delivery and patient outcomes: a systematic review. Citation Text: Kim MO, Coiera E, Magrabi F. Problems with health information technology and their effects on care delivery and patient outcomes: a systematic r…

Implementation of a mock root cause analysis to provide simulated patient safety training. | PSNet

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January 12, 2022 - Commentary Implementation of a mock root cause analysis to provide simulated patient safety training. Citation Text: Murphy M, Duff J, Whitney J, et al. Implementation of a mock root cause analysis to provide simulated patient safety training. BMJ Open Qual. 2017;6(2). doi:10.1136/bmjoq-…

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May 23, 2025 - Privacy Policy Thank you for visiting AHRQ PSNet. The site is produced by an editorial team at the University of California, Davis under a contract from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. We collect no personal information about you when you visit …

The error of omission: a simple checklist approach for improving operating room safety. | PSNet

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August 03, 2022 - Commentary The error of omission: a simple checklist approach for improving operating room safety. Citation Text: Rosenfield LK, Chang DS. The error of omission: a simple checklist approach for improving operating room safety. Plast Reconstr Surg. 2009;123(1):399-402. doi:10.1097/PRS.0…

The Lancet Commission on lessons for the future from the COVID-19 pandemic. | PSNet

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January 12, 2022 - Commentary The Lancet Commission on lessons for the future from the COVID-19 pandemic. Citation Text: Sachs JD, Karim SSA, Aknin L, et al. The Lancet Commission on lessons for the future from the COVID-19 pandemic. Lancet. 2022;400(10359):1224-1280. doi:10.1016/s0140-6736(22)01585-9. C…

Submit Case | PSNet

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March 25, 2025 - Breadcrumb Home Training and Education WebM&M: Case Studies WebM&M Case Submission PSNet is looking for interesting, provocative cases that illustrate key issues in patient safety such as medication errors, diagnostic errors, and adverse events that either had the potential …

Academic year-end transfers of outpatients from outgoing to incoming residents: an unaddressed patient safety issue. | PSNet

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January 27, 2016 - Commentary Academic year-end transfers of outpatients from outgoing to incoming residents: an unaddressed patient safety issue. Citation Text: Young JQ, Wachter R. Academic year-end transfers of outpatients from outgoing to incoming residents: an unaddressed patient safety issue. JAMA.…

Medication administration in aged care facilities: a mixed-methods systematic review. | PSNet

psnet.ahrq.gov/issue/medication-administration-aged-care-facilities-mixed-methods-systematic-review-0

July 31, 2024 - Review Medication administration in aged care facilities: a mixed-methods systematic review. Citation Text: Garratt S, Dowling A, Manias E. Medication administration in aged care facilities: a mixed‐methods systematic review. J Adv Nurs. 2025;81(2):621-640. doi:10.1111/jan.16318. Copy …

Guideline for opioid therapy and chronic noncancer pain. | PSNet

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June 17, 2014 - Review Guideline for opioid therapy and chronic noncancer pain. Citation Text: Busse JW, Craigie S, Juurlink DN, et al. Guideline for opioid therapy and chronic noncancer pain. CMAJ. 2017;189(18):E659-E666. doi:10.1503/cmaj.170363. Copy Citation Format: DOI Google Scholar P…

The effect of blue-enriched lighting on medical error rate in a university hospital ICU. | PSNet

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March 10, 2021 - Study The effect of blue-enriched lighting on medical error rate in a university hospital ICU. Citation Text: Chen Y, Broman AT, Priest G, et al. The Effect of Blue-Enriched Lighting on Medical Error Rate in a University Hospital ICU. Jt Comm J Qual Saf. 2021;47(3):165-175. doi:10.1016/j…

Impact of age on anaesthesiologists' competence: a narrative review. | PSNet

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December 15, 2014 - Review Impact of age on anaesthesiologists' competence: a narrative review. Citation Text: Giacalone M, Zaouter C, Mion S, et al. Impact of age on anaesthesiologists' competence: A narrative review. Eur J Anaesthesiol. 2016;33(11):787-793. Copy Citation Format: Google Schol…

Training operating room teams in damage control surgery for trauma: a followup study of the Norwegian model. | PSNet

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December 29, 2014 - Study Training operating room teams in damage control surgery for trauma: a followup study of the Norwegian model. Citation Text: Hansen KS, Uggen PE, Brattebø G, et al. Training operating room teams in damage control surgery for trauma: a followup study of the Norwegian model. J Am Co…

Pain as the neglected patient safety concern: five years on. | PSNet

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July 31, 2019 - Commentary Pain as the neglected patient safety concern: five years on. Citation Text: Twycross A, Forgeron P, Chorne J, et al. Pain as the neglected patient safety concern: Five years on. J Child Health Care. 2016;20(4):537-541. doi:10.1177/1367493516643422. Copy Citation Format: …

Expert consensus on currently accepted measures of harm. | PSNet

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January 25, 2023 - Commentary Expert consensus on currently accepted measures of harm. Citation Text: Logan MS, Myers LC, Salmasian H, et al. Expert consensus on currently accepted measures of harm. J Patient Saf. 2021;17(8):e1726-e1731. doi:10.1097/pts.0000000000000754. Copy Citation Format: …

Assessing the value of electronic prescribing in ambulatory care: A focus group study. | PSNet

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September 01, 2016 - Study Assessing the value of electronic prescribing in ambulatory care: A focus group study. Citation Text: Weingart SN, Massagli M, Cyrulik A, et al. Assessing the value of electronic prescribing in ambulatory care: a focus group study. Int J Med Inform. 2009;78(9):571-8. doi:10.1016/j…

Improving team members' attention during the OR briefing or time out. | PSNet

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November 10, 2021 - Study Improving team members' attention during the OR briefing or time out. Citation Text: Braverman A. Improving team members' attention during the OR briefing or time out. AORN Journal. 2024;119(6):421-427. doi:10.1002/aorn.14144. Copy Citation Format: DOI Google Scholar …

Shift-to-shift handoff effects on patient safety and outcomes: a systematic review. | PSNet

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January 22, 2016 - Review Shift-to-shift handoff effects on patient safety and outcomes: a systematic review. Citation Text: Mardis M, Davis JJ, Benningfield B, et al. Shift-to-Shift Handoff Effects on Patient Safety and Outcomes. Am J Med Qual. 2017;32(1):34-42. doi:10.1177/1062860615612923. Copy Citati…

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