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psnet.ahrq.gov/node/45055/psn-pdf
December 04, 2016 - Analysis of clinical decision support system
malfunctions: a case series and survey.
December 4, 2016
Wright A, Hickman T-TT, McEvoy D, et al. Analysis of clinical decision support system malfunctions: a case
series and survey. J Am Med Inform Assoc. 2016;23(6):1068-1076. doi:10.1093/jamia/ocw005.
https://psnet.ah…
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psnet.ahrq.gov/node/855429/psn-pdf
November 15, 2023 - Effect of complementary interventions to redesign care
on teamwork and quality for hospitalized medical
patients: a pragmatic controlled trial.
November 15, 2023
O’Leary KJ, Johnson JK, Williams MV, et al. Effect of complementary interventions to redesign care on
teamwork and quality for hospitalized medical patie…
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psnet.ahrq.gov/node/838238/psn-pdf
October 05, 2022 - Spreading a strategy to prevent suicide after psychiatric
hospitalization: results of a quality improvement spread
initiative.
October 5, 2022
Riblet NB, Varela M, Ashby W, et al. Spreading a strategy to prevent suicide after psychiatric
hospitalization: results of a quality improvement spread initiative. Jt Comm …
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psnet.ahrq.gov/node/35737/psn-pdf
July 15, 2010 - Shepherding change: how the market, healthcare
providers, and public policy can deliver quality care for
the 21st century.
July 15, 2010
Kennedy P, Pronovost P. Shepherding change: how the market, healthcare providers, and public policy
can deliver quality care for the 21st century. Crit Care Med. 2006;34(3 Suppl)…
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psnet.ahrq.gov/node/37776/psn-pdf
January 31, 2011 - Barcoded medication administration: a last line of
defense.
January 31, 2011
Cescon DW, Etchells E. Barcoded medication administration: a last line of defense. JAMA.
2008;299(18):2200-2. doi:10.1001/jama.299.18.2200.
https://psnet.ahrq.gov/issue/barcoded-medication-administration-last-line-defense
Barcoding techn…
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psnet.ahrq.gov/node/39477/psn-pdf
April 28, 2010 - Effects of an adverse-drug-event alert system on cost and
quality outcomes in community hospitals.
April 28, 2010
Piontek F, Kohli R, Conlon P, et al. Effects of an adverse-drug-event alert system on cost and quality
outcomes in community hospitals. Am J Health Syst Pharm. 2010;67(8):613-20. doi:10.2146/ajhp090056.…
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psnet.ahrq.gov/node/41746/psn-pdf
October 10, 2012 - The relationship of self-report of quality to practice size
and health information technology.
October 10, 2012
Gorman PN, O'Malley JP, Fagnan LJ. The relationship of self-report of quality to practice size and health
information technology. J Am Board Fam Med. 2012;25(5):614-24. doi:10.3122/jabfm.2012.05.120063.
…
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psnet.ahrq.gov/node/44044/psn-pdf
June 21, 2015 - A collaborative learning network approach to
improvement: the CUSP learning network.
June 21, 2015
Weaver SJ, Lofthus J, Sawyer M, et al. A Collaborative Learning Network Approach to Improvement: The
CUSP Learning Network. Jt Comm J Qual Patient Saf. 2015;41(4):147-159.
https://psnet.ahrq.gov/issue/collaborative-l…
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psnet.ahrq.gov/node/855097/psn-pdf
November 08, 2023 - Use of the Second Victim Experience and Support Tool
(SVEST) to assess the impact of a departmental peer
support program on anesthesia professionals' second
victim experiences (SVEs) and perceptions of support two
years after implementation.
November 8, 2023
Pelikan M, Finney RE, Jacob A. AANA J. 2023;91(5):…
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psnet.ahrq.gov/node/40306/psn-pdf
May 07, 2015 - The benefits of health information technology: a review of
the recent literature shows predominantly positive
results.
May 7, 2015
Buntin MB, Burke MF, Hoaglin MC, et al. The Benefits Of Health Information Technology: A Review Of The
Recent Literature Shows Predominantly Positive Results. Health Aff. 2011;30(3):46…
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psnet.ahrq.gov/node/35853/psn-pdf
May 20, 2015 - What practices will most improve safety? Evidence-based
medicine meets patient safety.
May 20, 2015
Leape L, Berwick DM, Bates DW. What practices will most improve safety? Evidence-based medicine
meets patient safety. JAMA. 2002;288(4):501-7.
https://psnet.ahrq.gov/issue/what-practices-will-most-improve-safety-evi…
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psnet.ahrq.gov/node/36163/psn-pdf
September 29, 2010 - Improving the bar-coded medication administration
system at the Department of Veterans Affairs.
September 29, 2010
Mills PD, Neily J, Mims E, et al. Improving the bar-coded medication administration system at the
Department of Veterans Affairs. Am J Health Syst Pharm. 2006;63(15):1442-7.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/37997/psn-pdf
June 16, 2011 - Revealing and resolving patient safety defects: the impact
of leadership WalkRounds on frontline caregiver
assessments of patient safety.
June 16, 2011
Frankel A, Grillo SP, Pittman M, et al. Revealing and resolving patient safety defects: the impact of
leadership WalkRounds on frontline caregiver assessments of p…
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psnet.ahrq.gov/node/36460/psn-pdf
May 27, 2011 - Medication errors related to computerized order entry for
children.
May 27, 2011
Walsh KE, Adams WG, Bauchner H, et al. Medication errors related to computerized order entry for
children. Pediatrics. 2006;118(5):1872-1879.
https://psnet.ahrq.gov/issue/medication-errors-related-computerized-order-entry-children
Th…
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psnet.ahrq.gov/node/41497/psn-pdf
April 05, 2013 - Avoiding handover fumbles: a controlled trial of a
structured handover tool versus traditional handover
methods.
April 5, 2013
Payne CE, Stein JM, Leong T, et al. Avoiding handover fumbles: a controlled trial of a structured handover
tool versus traditional handover methods. BMJ Qual Saf. 2012;21(11):925-32. doi:1…
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psnet.ahrq.gov/node/39768/psn-pdf
August 18, 2010 - Medical team training and coaching in the veterans health
administration; assessment and impact on the first 32
facilities in the programme.
August 18, 2010
Neily J, Mills PD, Lee P, et al. Medical team training and coaching in the Veterans Health Administration;
assessment and impact on the first 32 facilities in…
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psnet.ahrq.gov/node/44189/psn-pdf
September 09, 2015 - Variation in printed handoff documents: results and
recommendations from a multicenter needs assessment.
September 9, 2015
Rosenbluth G, Bale JF, Starmer AJ, et al. Variation in printed handoff documents: Results and
recommendations from a multicenter needs assessment. J Hosp Med. 2015;10(8):517-24.
doi:10.1002/jh…
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psnet.ahrq.gov/node/846449/psn-pdf
March 22, 2023 - Healthcare professionals' perception of safety culture and
the Operating Room (OR) Black Box technology before
clinical implementation: a cross-sectional survey.
March 22, 2023
Strandbygaard J, Dose N, Moeller KE, et al. Healthcare professionals’ perception of safety culture and the
Operating Room (OR) Black Box t…
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psnet.ahrq.gov/node/72670/psn-pdf
January 27, 2021 - System issues leading to "found-on-floor" incidents: a
multi-incident analysis.
January 27, 2021
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.
https://psnet.ahrq.gov/issue/sys…
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psnet.ahrq.gov/node/43402/psn-pdf
October 20, 2014 - The WHO surgical safety checklist: survey of patients'
views.
October 20, 2014
Russ SJ, Rout S, Caris J, et al. The WHO surgical safety checklist: survey of patients’ views. BMJ Qual
Saf. 2014;23(11). doi:10.1136/bmjqs-2013-002772.
https://psnet.ahrq.gov/issue/who-surgical-safety-checklist-survey-patients-views
T…