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psnet.ahrq.gov/issue/grading-recommendations-enhanced-patient-safety-sentinel-event-analysis-recommendation
April 15, 2020 - Study
Grading recommendations for enhanced patient safety in sentinel event analysis: the recommendation improvement matrix.
Citation Text:
Bos K, van der Laan MJ, Groeneweg J, et al. Grading recommendations for enhanced patient safety in sentinel event analysis: the recommendation impro…
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psnet.ahrq.gov/issue/nature-reported-safety-events-related-care-coordination-operating-room-setting-tertiary
May 11, 2022 - Study
The nature of reported safety events related to care coordination in the operating room setting in a tertiary academic center.
Citation Text:
Krishnan S, Wheeler KK, Pimentel MP, et al. The nature of reported safety events related to care coordination in the operating room setting …
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psnet.ahrq.gov/issue/ergonomic-and-human-factors-affecting-anesthetic-vigilance-and-monitoring-performance
May 31, 2011 - Review
Classic
Ergonomic and human factors affecting anesthetic vigilance and monitoring performance in the operating room environment.
Citation Text:
Biebuyck J F, Weinger M B, Englund C E. Ergonomic and Human Factors Affecting Anesthetic Vigilance and Monitori…
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psnet.ahrq.gov/issue/adverse-event-reporting-practices-us-hospitals-results-national-survey
December 30, 2014 - Study
Adverse-event-reporting practices by US hospitals: results of a national survey.
Citation Text:
Farley DO, Haviland A, Champagne S, et al. Adverse-event-reporting practices by US hospitals: results of a national survey. Qual Saf Health Care. 2008;17(6):416-23. doi:10.1136/qshc.20…
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psnet.ahrq.gov/issue/adverse-events-operating-room-definitions-prevalence-and-characteristics-systematic-review
July 25, 2018 - Review
Adverse events in the operating room: definitions, prevalence, and characteristics. A systematic review.
Citation Text:
Jung JJ, Elfassy J, Jüni P, et al. Adverse Events in the Operating Room: Definitions, Prevalence, and Characteristics. A Systematic Review. World J Surg. 2019;4…
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psnet.ahrq.gov/issue/frequency-and-nature-communication-and-handoff-failures-medical-malpractice-claims
June 22, 2022 - Study
Frequency and nature of communication and handoff failures in medical malpractice claims.
Citation Text:
Humphrey KE, Sundberg M, Milliren CE, et al. Frequency and nature of communication and handoff failures in medical malpractice claims. J Patient Saf. 2022;18(2):130-137. doi:10.…
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psnet.ahrq.gov/node/33827/psn-pdf
February 01, 2017 - Finally,
we implemented TeamSTEPPS in clinical settings and conducted research on how to improve patient … more than 3500 new Master Trainers were trained by AHRQ,
and these early adopters trained others and implemented
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psnet.ahrq.gov/issue/laboratory-medicine-handoff-gaps-experienced-primary-care-practices-report-shared-networks
September 01, 2012 - High-priority drug-drug interaction clinical decision support overrides in a newly implemented
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psnet.ahrq.gov/issue/ambulatory-prescribing-errors-among-community-based-providers-two-states
July 10, 2008 - June 29, 2011
Perceptions of standards-based electronic prescribing systems as implemented
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psnet.ahrq.gov/issue/preventable-adverse-drug-events-descriptive-epidemiology
October 17, 2012 - High-priority drug-drug interaction clinical decision support overrides in a newly implemented
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psnet.ahrq.gov/issue/using-network-organisational-architecture-support-development-learning-healthcare-systems
December 02, 2014 - Improvement Project: initial results of a statewide perinatal hypertension quality improvement initiative implemented
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psnet.ahrq.gov/issue/adherence-drug-drug-interaction-alerts-high-risk-patients-trial-context-enhanced-alerting
February 21, 2018 - March 11, 2011
Perceptions of standards-based electronic prescribing systems as implemented
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psnet.ahrq.gov/issue/errors-associated-outpatient-computerized-prescribing-systems
June 28, 2010 - November 1, 2011
Perceptions of standards-based electronic prescribing systems as implemented
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psnet.ahrq.gov/issue/identifying-right-patient-nurse-and-consumer-perspectives-verifying-patient-identity-during
September 03, 2011 - Improvement Project: initial results of a statewide perinatal hypertension quality improvement initiative implemented
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psnet.ahrq.gov/issue/computerized-physician-order-entry-clinical-decision-support-long-term-care-facilities-costs
March 29, 2010 - High-priority drug-drug interaction clinical decision support overrides in a newly implemented
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psnet.ahrq.gov/issue/prevalence-and-nature-adverse-medical-device-events-hospitalized-children
October 05, 2011 - Improvement Project: initial results of a statewide perinatal hypertension quality improvement initiative implemented
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psnet.ahrq.gov/issue/comprehensive-evaluation-using-computerised-provider-order-entry-system-hospital-discharge
August 24, 2015 - Improving medication safety in a paediatric hospital: a mixed-methods evaluation of a newly implemented
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psnet.ahrq.gov/issue/comparison-methods-identifying-patients-risk-medication-related-harm
March 04, 2011 - High-priority drug-drug interaction clinical decision support overrides in a newly implemented
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psnet.ahrq.gov/issue/prevention-pediatric-medication-errors-hospital-pharmacists-and-potential-benefit
December 15, 2011 - Improving medication safety in a paediatric hospital: a mixed-methods evaluation of a newly implemented
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psnet.ahrq.gov/web-mm/copy-and-paste
December 10, 2014 - be interesting to know how often the narrative plan of the medical record differs from actual orders implemented … Perceived increase in mortality after process and policy changes implemented with computerized physician