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Communication through the electronic health record: frequency and implications of free text orders. | PSNet

psnet.ahrq.gov/issue/communication-through-electronic-health-record-frequency-and-implications-free-text-orders

May 12, 2021 - Study Communication through the electronic health record: frequency and implications of free text orders. Citation Text: Kandaswamy S, Hettinger AZ, Hoffman DJ, et al. Communication through the electronic health record: frequency and implications of free text orders. JAMIA Open. 2020;3(2…

Physician patient communication failure facilitates medication errors in older polymedicated patients with multiple comorbidities. | PSNet

psnet.ahrq.gov/issue/physician-patient-communication-failure-facilitates-medication-errors-older-polymedicated

November 02, 2010 - Study Physician patient communication failure facilitates medication errors in older polymedicated patients with multiple comorbidities. Citation Text: Mira JJ, Orozco-Beltrán D, Pérez-Jover V, et al. Physician patient communication failure facilitates medication errors in older polyme…

System issues leading to "found-on-floor" incidents: a multi-incident analysis. | PSNet

psnet.ahrq.gov/issue/system-issues-leading-found-floor-incidents-multi-incident-analysis

August 04, 2021 - Study System issues leading to "found-on-floor" incidents: a multi-incident analysis. Citation Text: Shaw J, Bastawrous M, Burns S, et al. System Issues Leading to “Found-on-Floor” Incidents: A Multi-Incident Analysis. J Patient Saf. 2021;17(1):30-35. doi:10.1097/pts.0000000000000294. …

Design and implementation of an application and associated services to support interdisciplinary medication reconciliation efforts at an integrated healthcare delivery network. | PSNet

psnet.ahrq.gov/issue/design-and-implementation-application-and-associated-services-support-interdisciplinary

February 15, 2011 - Study Design and implementation of an application and associated services to support interdisciplinary medication reconciliation efforts at an integrated healthcare delivery network. Citation Text: Poon EG, Blumenfeld B, Hamann C, et al. Design and Implementation of an Application and …

Register-based research of adverse events revealing incomplete records threatening patient safety. | PSNet

psnet.ahrq.gov/issue/register-based-research-adverse-events-revealing-incomplete-records-threatening-patient

October 06, 2021 - Review Register-based research of adverse events revealing incomplete records threatening patient safety. Citation Text: Kinnunen U-M, Kivekäs E, Palojoki S, et al. Register-based research of adverse events revealing incomplete records threatening patient safety. Stud Health Technol Info…

Errors upstream and downstream to the Universal Protocol associated with wrong surgery events in the Veterans Health Administration. | PSNet

psnet.ahrq.gov/issue/errors-upstream-and-downstream-universal-protocol-associated-wrong-surgery-events-veterans

November 21, 2012 - Study Errors upstream and downstream to the Universal Protocol associated with wrong surgery events in the Veterans Health Administration. Citation Text: Paull DE, Mazzia L, Neily J, et al. Errors upstream and downstream to the Universal Protocol associated with wrong surgery events in t…

Inpatient suicide and suicide attempts in Veterans Affairs hospitals. | PSNet

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January 02, 2017 - Study Inpatient suicide and suicide attempts in Veterans Affairs hospitals. Citation Text: Mills PD, DeRosier JM, Ballot BA, et al. Inpatient suicide and suicide attempts in Veterans Affairs hospitals. Jt Comm J Qual Patient Saf. 2008;34(8):482-488. Copy Citation Format: Go…

Patient safety trends in 2023: an analysis of 287,997 serious events and incidents from the nation’s largest event reporting database. | PSNet

psnet.ahrq.gov/issue/patient-safety-trends-2023-analysis-287997-serious-events-and-incidents-nations-largest-event

July 24, 2024 - Study Patient safety trends in 2023: an analysis of 287,997 serious events and incidents from the nation’s largest event reporting database. Citation Text: Kepner S, Jones RM. Patient safety trends in 2023: an analysis of 287,997 serious events and incidents from the nation’s largest eve…

How health care systems let our patients down: a systematic review into suicide deaths. | PSNet

psnet.ahrq.gov/issue/how-health-care-systems-let-our-patients-down-systematic-review-suicide-deaths

October 19, 2022 - Review How health care systems let our patients down: a systematic review into suicide deaths. Citation Text: Wyder M, Ray MK, Roennfeldt H, et al. How health care systems let our patients down: a systematic review into suicide deaths. Int J Qual Health Care. 2020;32(5):285-291. doi:10.1…

Sex differences in operating room care giver perceptions of patient safety: a pilot study from the Veterans Health Administration Medical Team Training Program. | PSNet

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June 14, 2011 - Study Sex differences in operating room care giver perceptions of patient safety: a pilot study from the Veterans Health Administration Medical Team Training Program. Citation Text: Carney BT, Mills PD, Bagian JP, et al. Sex differences in operating room care giver perceptions of patie…

Prescribing patterns of heart failure-exacerbating medications following a heart failure hospitalization. | PSNet

psnet.ahrq.gov/issue/prescribing-patterns-heart-failure-exacerbating-medications-following-heart-failure

January 26, 2022 - Study Prescribing patterns of heart failure-exacerbating medications following a heart failure hospitalization. Citation Text: Goyal P, Kneifati-Hayek J, Archambault A, et al. Prescribing patterns of heart failure-exacerbating medications following a heart failure hospitalization. JACC H…

Organisational culture: variation across hospitals and connection to patient safety climate. | PSNet

psnet.ahrq.gov/issue/organisational-culture-variation-across-hospitals-and-connection-patient-safety-climate

March 17, 2010 - Study Organisational culture: variation across hospitals and connection to patient safety climate. Citation Text: Speroff T, Nwosu S, Greevy R, et al. Organisational culture: variation across hospitals and connection to patient safety climate. Qual Saf Health Care. 2010;19(6):592-6. do…

The National Healthcare Safety Network's digital quality measures: CDC's automated measures for surveillance of patient safety. | PSNet

psnet.ahrq.gov/issue/national-healthcare-safety-networks-digital-quality-measures-cdcs-automated-measures

September 23, 2020 - Study The National Healthcare Safety Network's digital quality measures: CDC's automated measures for surveillance of patient safety. Citation Text: Shehab N, Alschuler L, McILvenna S, et al. The National Healthcare Safety Network’s digital quality measures: CDC’s automated measures for …

Human-AI teaming in critical care: a comparative analysis of data scientists' and clinicians' perspectives on AI augmentation and automation. | PSNet

psnet.ahrq.gov/issue/human-ai-teaming-critical-care-comparative-analysis-data-scientists-and-clinicians

July 10, 2013 - Study Human-AI teaming in critical care: a comparative analysis of data scientists' and clinicians' perspectives on AI augmentation and automation. Citation Text: Bienefeld N, Keller E, Grote G. Human-AI teaming in critical care: a comparative analysis of data scientists' and clinicians'…

Healthcare team resilience during COVID-19: a qualitative study. | PSNet

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February 20, 2019 - Study Healthcare team resilience during COVID-19: a qualitative study. Citation Text: Ambrose JW, Catchpole K, Evans HL, et al. Healthcare team resilience during COVID-19: a qualitative study. BMC Health Serv Res. 2024;24(1):459. doi:10.1186/s12913-024-10895-3. Copy Citation Format…

Hospital- and system-wide interventions for health care-associated infections: a systematic review. | PSNet

psnet.ahrq.gov/issue/hospital-and-system-wide-interventions-health-care-associated-infections-systematic-review

January 12, 2022 - Review Hospital- and system-wide interventions for health care-associated infections: a systematic review. Citation Text: Maurer NR, Hogan TH, Walker DM. Hospital- and system-wide interventions for health care-associated infections: a systematic review. Med Care Res Rev. 2021;78(6):643-6…

Interpreting and coding causal relationships for quality and safety using ICD-11. | PSNet

psnet.ahrq.gov/issue/interpreting-and-coding-causal-relationships-quality-and-safety-using-icd-11

November 15, 2017 - Commentary Interpreting and coding causal relationships for quality and safety using ICD-11. Citation Text: Januel J-M, Southern DA, Ghali WA. Interpreting and coding causal relationships for quality and safety using ICD-11. BMC Med Inform Decis Mak. 2023;21(Suppl 6):385. doi:10.1186/s12…

Errors in breast imaging: how to reduce errors and promote a safety environment. | PSNet

psnet.ahrq.gov/issue/errors-breast-imaging-how-reduce-errors-and-promote-safety-environment

July 22, 2020 - Commentary Errors in breast imaging: how to reduce errors and promote a safety environment. Citation Text: Sivarajah R, Dinh ML, Chetlen A. Errors in breast imaging: how to reduce errors and promote a safety environment. J Breast Imaging. 2021;3(2):221-230. doi:10.1093/jbi/wbaa118. Cop…

Emergency physician perceptions of electronic health record usability and safety. | PSNet

psnet.ahrq.gov/issue/emergency-physician-perceptions-electronic-health-record-usability-and-safety

August 24, 2022 - Study Emergency physician perceptions of electronic health record usability and safety. Citation Text: Pruitt ZM, Howe JL, Hettinger AZ, et al. Emergency physician perceptions of electronic health record usability and safety. J Patient Saf. 2021;17(8):e983-e987. doi:10.1097/pts.000000000…

Patient reported receipt of medication instructions for warfarin is associated with reduced risk of serious bleeding events. | PSNet

psnet.ahrq.gov/issue/patient-reported-receipt-medication-instructions-warfarin-associated-reduced-risk-serious

February 03, 2011 - Study Patient reported receipt of medication instructions for warfarin is associated with reduced risk of serious bleeding events. Citation Text: Metlay JP, Hennessy S, Localio R, et al. Patient reported receipt of medication instructions for warfarin is associated with reduced risk of…

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