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psnet.ahrq.gov/node/46266/psn-pdf
July 19, 2017 - New unintended adverse consequences of electronic
health records.
July 19, 2017
Sittig DF, Wright A, Ash J, et al. New Unintended Adverse Consequences of Electronic Health Records.
Yearb Med Inform. 2016;(1):7-12.
https://psnet.ahrq.gov/issue/new-unintended-adverse-consequences-electronic-health-records
Pressures…
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psnet.ahrq.gov/node/46114/psn-pdf
June 07, 2017 - Standardizing concentrations of adult drug infusions in
Indiana.
June 7, 2017
Walroth TA, Dossett HA, Doolin M, et al. Standardizing concentrations of adult drug infusions in Indiana.
Am J Health Syst Pharm. 2017;74(7):491-497. doi:10.2146/ajhp151018.
https://psnet.ahrq.gov/issue/standardizing-concentrations-adult…
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psnet.ahrq.gov/node/39922/psn-pdf
October 13, 2010 - What’s past is prologue: organizational learning from a
serious patient injury.
October 13, 2010
Tamuz M, Franchois KE, Thomas EJ. What’s past is prologue: Organizational learning from a serious
patient injury. Saf Sci. 2010;49(1). doi:10.1016/j.ssci.2010.06.005.
https://psnet.ahrq.gov/issue/whats-past-prologue-or…
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psnet.ahrq.gov/node/35736/psn-pdf
May 27, 2011 - Video capture of clinical care to enhance patient safety.
May 27, 2011
Weinger MB, Gonzales DC, Slagle J, et al. Video capture of clinical care to enhance patient safety. Qual
Saf Health Care. 2004;13(2):136-44.
https://psnet.ahrq.gov/issue/video-capture-clinical-care-enhance-patient-safety
This study describes th…
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psnet.ahrq.gov/node/43149/psn-pdf
July 23, 2014 - FDASIA Health IT Report: Proposed Strategy and
Recommendations for a Risk-Based Framework.
July 23, 2014
Washington, DC: Office of the National Coordinator for Health Information Technology, Federal
Communications Commission. Silver Spring, MD: Food and Drug Administration. April 2014.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/36470/psn-pdf
September 27, 2010 - Prioritizing patient safety interventions in small and rural
hospitals.
September 27, 2010
Casey M, Wakefield M, Coburn AF, et al. Prioritizing patient safety interventions in small and rural
hospitals. Jt Comm J Qual Patient Saf. 2006;32(12):693-702.
https://psnet.ahrq.gov/issue/prioritizing-patient-safety-interv…
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psnet.ahrq.gov/node/38839/psn-pdf
August 05, 2009 - Polypharmacy in hospitalized older adult cancer patients:
experience from a prospective, observational study of an
oncology-acute care for elders unit.
August 5, 2009
Flood KL, Carroll MB, Le C, et al. Polypharmacy in hospitalized older adult cancer patients: experience
from a prospective, observational study of…
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psnet.ahrq.gov/node/34780/psn-pdf
March 28, 2005 - Disseminating innovations in health care.
March 28, 2005
Berwick DM. Disseminating Innovations in Health Care. JAMA. 2003;289(15):1969-1975.
doi:10.1001/jama.289.15.1969.
https://psnet.ahrq.gov/issue/disseminating-innovations-health-care
This commentary and review discusses the ability to adopt growing numbers of …
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psnet.ahrq.gov/node/44836/psn-pdf
January 27, 2016 - Advancing the next generation of handover research and
practice with cognitive load theory.
January 27, 2016
Young JQ, Wachter R, Cate OT, et al. Advancing the next generation of handover research and practice
with cognitive load theory. BMJ Qual Saf. 2016;25(2):66-70. doi:10.1136/bmjqs-2015-004181.
https://psnet.…
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psnet.ahrq.gov/node/42489/psn-pdf
May 19, 2014 - Improving medication administration safety in solid organ
transplant patients through barcode-assisted medication
administration.
May 19, 2014
Bonkowski J, Weber RJ, Melucci J, et al. Improving medication administration safety in solid organ
transplant patients through barcode-assisted medication administration. A…
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psnet.ahrq.gov/node/50372/psn-pdf
September 25, 2019 - Prevalence and predictability of low-yield inpatient
laboratory diagnostic tests.
September 25, 2019
Xu S, Hom J, Balasubramanian S, et al. Prevalence and Predictability of Low-Yield Inpatient Laboratory
Diagnostic Tests. JAMA Netw Open. 2019;2(9):e1910967. doi:10.1001/jamanetworkopen.2019.10967.
https://psnet.ahr…
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psnet.ahrq.gov/node/45418/psn-pdf
May 09, 2017 - Context-sensitive decision support (infobuttons) in
electronic health records: a systematic review.
May 9, 2017
Cook DA, Teixeira MT, Heale BS, et al. Context-sensitive decision support (infobuttons) in electronic health
records: a systematic review. J Am Med Inform Assoc. 2017;24(2):460-468. doi:10.1093/jamia/ocw1…
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psnet.ahrq.gov/node/50558/psn-pdf
October 16, 2019 - Multidisciplinary simulation activity effectively prepares
residents for participation in patient safety activities.
October 16, 2019
Weis JJ, Croft CL, Bhoja R, et al. Multidisciplinary simulation activity effectively prepares residents for
participation in patient safety activities. J Surg Educ. 2019;76(6):e232-e…
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psnet.ahrq.gov/node/35216/psn-pdf
December 22, 2009 - An educational intervention to enhance nurse leaders'
perceptions of patient safety culture.
December 22, 2009
Ginsburg LR, Norton PG, Casebeer A, et al. An educational intervention to enhance nurse leaders'
perceptions of patient safety culture. Health Serv Res. 2005;40(4):997-1020.
https://psnet.ahrq.gov/issue/e…
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psnet.ahrq.gov/node/841785/psn-pdf
December 21, 2022 - Request for Information: Creating a National Healthcare
System Action Alliance to Advance Patient Safety.
December 21, 2022
Agency for Healthcare Research and Quality. Fed Register. December 12, 2022;87:76046-76048.
https://psnet.ahrq.gov/issue/request-information-creating-national-healthcare-system-action-alliance…
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psnet.ahrq.gov/node/43498/psn-pdf
October 06, 2016 - Creating a distraction simulation for safe medication
administration.
October 6, 2016
Thomas CM, McIntosh CE, Allen R. Creating a Distraction Simulation for Safe Medication Administration.
Clin Simul Nurs. 2014;10(8). doi:10.1016/j.ecns.2014.03.004.
https://psnet.ahrq.gov/issue/creating-distraction-simulation-safe…
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psnet.ahrq.gov/node/46403/psn-pdf
September 06, 2017 - Supplemental Issue: Quality and Safety Education for
Nurses (QSEN) program.
September 6, 2017
Quality and Safety Education for Nurses.
https://psnet.ahrq.gov/issue/supplemental-issue-quality-and-safety-education-nurses-qsen-program
Patient safety and quality improvement competencies are developed through interprof…
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psnet.ahrq.gov/node/44465/psn-pdf
November 20, 2015 - Why even good physicians do not wash their hands.
November 20, 2015
Redelmeier DA, Shafir E. Why even good physicians do not wash their hands. BMJ Qual Saf.
2015;24(12):744-7. doi:10.1136/bmjqs-2015-004319.
https://psnet.ahrq.gov/issue/why-even-good-physicians-do-not-wash-their-hands
Insufficient hand hygiene comp…
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psnet.ahrq.gov/node/45331/psn-pdf
August 03, 2016 - Health information technologies: from hazardous to the
dark side.
August 3, 2016
Saunders C, Rutkowski AF, Pluyter J, et al. Health information technologies: From hazardous to the dark
side. J Assoc Inf Sci Technol. 2016;67(7). doi:10.1002/asi.23671.
https://psnet.ahrq.gov/issue/health-information-technologies-haz…
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psnet.ahrq.gov/node/35130/psn-pdf
March 11, 2011 - A trial of automated decision support alerts for
contraindicated medications using computerized
physician order entry.
March 11, 2011
Galanter W, Didomenico RJ, Polikaitis A. A trial of automated decision support alerts for contraindicated
medications using computerized physician order entry. J Am Med Inform Assoc…