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psnet.ahrq.gov/issue/institutional-disclosure-promise-and-problems
August 12, 2015 - Study
Institutional disclosure: promise and problems.
Citation Text:
Wolk SW, Sine DM, Paull DE. Institutional disclosure: promise and problems. J Healthc Risk Manag. 2014;33(3):24-32. doi:10.1002/jhrm.21132.
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psnet.ahrq.gov/issue/how-teams-work-or-dont-primary-care-field-study-internal-medicine-practices
November 28, 2012 - Study
How teams work—or don’t—in primary care: a field study on internal medicine practices.
Citation Text:
Chesluk BJ, Holmboe ES. How teams work--or don't--in primary care: a field study on internal medicine practices. Health Aff (Millwood). 2010;29(5):874-879. doi:10.1377/hlthaff.2009…
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psnet.ahrq.gov/issue/post-event-debriefings-during-neonatal-care-why-are-we-not-doing-them-and-how-can-we-start
January 15, 2014 - Commentary
Post-event debriefings during neonatal care: why are we not doing them, and how can we start?
Citation Text:
Sawyer T, Loren D, Halamek LP. Post-event debriefings during neonatal care: why are we not doing them, and how can we start? J Perinatol. 2016;36(6):415-9. doi:10.1038/…
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psnet.ahrq.gov/issue/human-factors-analysis-technical-and-team-skills-among-surgical-trainees-during-procedural
March 03, 2011 - Study
A human factors analysis of technical and team skills among surgical trainees during procedural simulations in a simulated operating theatre.
Citation Text:
Moorthy K, Munz Y, Adams S, et al. A human factors analysis of technical and team skills among surgical trainees during pro…
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psnet.ahrq.gov/issue/development-pragmatic-measure-evaluating-and-optimizing-rapid-response-systems
August 20, 2014 - Study
Development of a pragmatic measure for evaluating and optimizing rapid response systems.
Citation Text:
Bonafide CP, Roberts KE, Priestley MA, et al. Development of a pragmatic measure for evaluating and optimizing rapid response systems. Pediatrics. 2012;129(4):e874-81. doi:10.1…
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psnet.ahrq.gov/issue/provider-and-pharmacist-responses-warfarin-drug-drug-interaction-alerts-study-healthcare
July 29, 2020 - Study
Provider and pharmacist responses to warfarin drug–drug interaction alerts: a study of healthcare downstream of CPOE alerts.
Citation Text:
Miller AM, Boro MS, Korman NE, et al. Provider and pharmacist responses to warfarin drug-drug interaction alerts: a study of healthcare downst…
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psnet.ahrq.gov/issue/variability-concentrations-intravenous-drug-infusions-prepared-critical-care-unit
March 02, 2011 - Study
Variability in the concentrations of intravenous drug infusions prepared in a critical care unit.
Citation Text:
Wheeler DW, Degnan BA, Sehmi JS, et al. Variability in the concentrations of intravenous drug infusions prepared in a critical care unit. Intensive Care Med. 2008;34(8…
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psnet.ahrq.gov/issue/retrieval-medicine-review-and-guide-uk-practitioners-part-2-safety-patient-retrieval-systems
March 09, 2016 - Commentary
Retrieval medicine: a review and guide for UK practitioners. Part 2: safety in patient retrieval systems.
Citation Text:
Hearns S, Shirley PJ. Retrieval medicine: a review and guide for UK practitioners. Part 2: safety in patient retrieval systems. Emerg Med J. 2006;23(12):9…
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psnet.ahrq.gov/issue/power-written-word-reflection-reduces-errors-omission
April 24, 2018 - Study
The power of written word: reflection reduces errors of omission.
Citation Text:
Rao A, Heidemann LA, Hartley S, et al. The power of written word: reflection reduces errors of omission. Clin Teach. 2024;21(1):e13630. doi:10.1111/tct.13630.
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psnet.ahrq.gov/issue/performance-characteristics-methodology-quantify-adverse-events-over-time-hospitalized
December 01, 2010 - Study
Performance characteristics of a methodology to quantify adverse events over time in hospitalized patients.
Citation Text:
Sharek PJ, Parry G, Goldmann DA, et al. Performance characteristics of a methodology to quantify adverse events over time in hospitalized patients. Health Se…
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psnet.ahrq.gov/issue/frequency-and-severity-parenteral-nutrition-medication-errors-large-childrens-hospital-after
April 11, 2011 - Study
Frequency and severity of parenteral nutrition medication errors at a large children's hospital after implementation of electronic ordering and compounding.
Citation Text:
MacKay M, Anderson C, Boehme S, et al. Frequency and Severity of Parenteral Nutrition Medication Errors at a L…
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psnet.ahrq.gov/issue/peer-support-and-second-victim-programs-anesthesia-professionals-involved-stressful-or
October 26, 2022 - Study
Peer support and second victim programs for anesthesia professionals involved in stressful or traumatic clinical events.
Citation Text:
Finney RE, Jacob AK. Peer support and second victim programs for anesthesia professionals involved in stressful or traumatic clinical events. Adv …
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psnet.ahrq.gov/issue/unintended-adverse-consequences-clinical-decision-support-system-two-cases
October 23, 2018 - Commentary
Unintended adverse consequences of a clinical decision support system: two cases.
Citation Text:
Stone EG. Unintended adverse consequences of a clinical decision support system: two cases. J Am Med Inform Assoc. 2018;25(5):564-567. doi:10.1093/jamia/ocx096.
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psnet.ahrq.gov/issue/effectiveness-surgical-safety-checklist-correcting-errors-literature-review-applying-reasons
January 10, 2018 - Review
Effectiveness of the surgical safety checklist in correcting errors: a literature review applying Reason's Swiss cheese model.
Citation Text:
Collins SJ, Newhouse R, Porter J, et al. Effectiveness of the surgical safety checklist in correcting errors: a literature review applying …
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psnet.ahrq.gov/issue/medication-errors-and-adverse-drug-events-pediatric-inpatients
January 19, 2011 - Study
Classic
Medication errors and adverse drug events in pediatric inpatients.
Citation Text:
Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001;285(16):2114-20.
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psnet.ahrq.gov/issue/medication-orders-are-written-clearly-and-transcribed-accurately-implementing-medication
May 27, 2011 - Commentary
Medication orders are written clearly and transcribed accurately – implementing Medication Management Standard 3.20 and National Patient Safety Goal 2b.
Citation Text:
Laselle TJ, May SK. Medication Orders are Written Clearly and Transcribed Accurately – Implementing Medicatio…
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psnet.ahrq.gov/issue/using-lean-automation-human-touch-improve-medication-safety-step-closer-perfect-dose
September 16, 2015 - Study
Using Lean "automation with a human touch" to improve medication safety: a step closer to the "perfect dose."
Citation Text:
Ching JM, Williams BL, Idemoto LM, et al. Using lean "automation with a human touch" to improve medication safety: a step closer to the "perfect dose". Jt Co…
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psnet.ahrq.gov/issue/clinical-case-electronic-health-record-drug-alert-fatigue-consequences-patient-outcome
August 02, 2023 - Commentary
A clinical case of electronic health record drug alert fatigue: consequences for patient outcome.
Citation Text:
Carspecken W, Sharek PJ, Longhurst CA, et al. A clinical case of electronic health record drug alert fatigue: consequences for patient outcome. Pediatrics. 2013;131…
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digital.ahrq.gov/ahrq-funded-projects/evaluation-computerized-clinical-decision-support-system-and-electronic-health/annual-summary/2010
January 01, 2010 - Evaluation of a computerized clinical decision support system and EHR-linked registry to improve management of hypertension in community-based health centers - 2010
Project Name
Evaluation of a Computerized Clinical Decision Support System and Electronic Health Record (EHR)-linked Registry to Improv…
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psnet.ahrq.gov/issue/types-diagnostic-errors-neurological-emergencies-emergency-department
October 30, 2019 - Study
Types of diagnostic errors in neurological emergencies in the emergency department.
Citation Text:
Dubosh NM, Edlow JA, Lefton M, et al. Types of diagnostic errors in neurological emergencies in the emergency department. Diagnosis (Berl). 2015;2(1):21-28. doi:10.1515/dx-2014-0040. …