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psnet.ahrq.gov/node/35373/psn-pdf
July 20, 2009 - Medical groups' adoption of electronic health records and
information systems.
July 20, 2009
Gans DN, Kralewski J, Hammons T, et al. Medical Groups’ Adoption Of Electronic Health Records And
Information Systems. Health Aff. 2005;24(5):1323-1333. doi:10.1377/hlthaff.24.5.1323.
https://psnet.ahrq.gov/issue/medical-g…
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psnet.ahrq.gov/node/36431/psn-pdf
March 28, 2011 - Using the internet to deliver education on drug safety.
March 28, 2011
Franklin B, O'Grady K, Parr J, et al. Using the internet to deliver education on drug safety. Qual Saf Health
Care. 2006;15(5):329-33.
https://psnet.ahrq.gov/issue/using-internet-deliver-education-drug-safety
The project team implemented a web-…
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psnet.ahrq.gov/node/40829/psn-pdf
January 05, 2014 - Guide to Reducing Unintended Consequences of
Electronic Health Records.
January 5, 2014
Jones SS, Koppel R, Ridgely MS, Palen TE, Wu S, Harrison MI. Rockville, MD: Agency for Healthcare
Research and Quality; August 2011.
https://psnet.ahrq.gov/issue/guide-reducing-unintended-consequences-electronic-health-records
…
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psnet.ahrq.gov/node/47556/psn-pdf
November 28, 2018 - Improving Diagnosis.
November 28, 2018
Deutsch E, ed. PA-PSRS Pa Patient Saf Advis. 2018 Oct 31;15(suppl 1):1-70.
https://psnet.ahrq.gov/issue/improving-diagnosis
This special issue raises awareness of challenges to reducing diagnostic error. Articles discuss insights
from experts about how to improve diagnosis, t…
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psnet.ahrq.gov/node/50633/psn-pdf
November 06, 2019 - Findings of Two Inaugural Leapfrog Surveys 2019.
November 6, 2019
Washington DC: Leapfrog Group; 2019.
https://psnet.ahrq.gov/issue/findings-two-inaugural-leapfrog-surveys-2019
Ambulatory surgery centers (ASC) are established venues for surgical care despite engagement in
assessment to ensure their safety. This re…
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psnet.ahrq.gov/node/38341/psn-pdf
April 02, 2009 - CPOE: it don't come easy.
April 2, 2009
Anderson HJ. CPOE: it don't come easy. Health Data Manag. 2009;17(1):18-20, 22, 24 passim.
https://psnet.ahrq.gov/issue/cpoe-it-dont-come-easy
Although shifting from paper-based or verbal orders to computerized physician order entry (CPOE)
systems could reduce medical errors…
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psnet.ahrq.gov/node/47315/psn-pdf
August 01, 2018 - Agent of change.
August 1, 2018
Gale SF. Chief Learning Officer. July/August 2018;17:22-25.
https://psnet.ahrq.gov/issue/agent-change
Organizational learning is an essential element of safety culture. This article reports how one hospital
leader drew from the success of aviation strategies to design and implement …
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psnet.ahrq.gov/node/42030/psn-pdf
April 18, 2013 - Reducing hospital errors: interventions that build safety
culture.
April 18, 2013
Singer SJ, Vogus TJ. Reducing hospital errors: interventions that build safety culture. Annu Rev Public
Health. 2013;34:373-96. doi:10.1146/annurev-publhealth-031912-114439.
https://psnet.ahrq.gov/issue/reducing-hospital-errors-inter…
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psnet.ahrq.gov/node/41411/psn-pdf
October 19, 2012 - Minnesota Hospital Association Statewide Project: SAFE
from FALLS.
October 19, 2012
Apold J, Quigley PA. Minnesota Hospital Association Statewide Project: SAFE from FALLS. J Nurs Care
Qual. 2012;27(4):299-306. doi:10.1097/NCQ.0b013e3182599d1b.
https://psnet.ahrq.gov/issue/minnesota-hospital-association-statewide-p…
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psnet.ahrq.gov/node/37951/psn-pdf
May 26, 2011 - The Leapfrog Group's CPOE standard and evaluation tool.
May 26, 2011
Metzger JB, Welebob E, Turisco F, et al. Patient Saf Qual Healthc. July/August
2008;5:22-25.
https://psnet.ahrq.gov/issue/leapfrog-groups-cpoe-standard-and-evaluation-tool
This article describes an evaluation tool designed for…
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psnet.ahrq.gov/node/37931/psn-pdf
September 25, 2008 - Can a structured checklist prevent problems with
laparoscopic equipment?
September 25, 2008
Verdaasdonk EGG, Stassen LPS, Hoffmann WF, et al. Can a structured checklist prevent problems with
laparoscopic equipment? Surg Endosc. 2008;22(10):2238-43. doi:10.1007/s00464-008-0029-3.
https://psnet.ahrq.gov/issue/can-st…
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psnet.ahrq.gov/node/38677/psn-pdf
August 18, 2010 - Impact of a computerized physician order-entry system.
August 18, 2010
Stone WM, Smith BE, Shaft JD, et al. Impact of a computerized physician order-entry system. J Am Coll
Surg. 2009;208(5):960-7; discussion 967-9. doi:10.1016/j.jamcollsurg.2009.01.042.
https://psnet.ahrq.gov/issue/impact-computerized-physician-or…
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psnet.ahrq.gov/node/34622/psn-pdf
March 17, 2011 - National Confidential Enquiry into Patient Outcome and
Death.
March 17, 2011
National Confidential Enquiry into Patient Outcome and Death; NCEPOD
https://psnet.ahrq.gov/issue/national-confidential-enquiry-patient-outcome-and-death
Launched under the title National Confidential Enquiry into Perioperative Deaths (NC…
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psnet.ahrq.gov/node/41972/psn-pdf
January 23, 2013 - Impact of a pharmacotherapy alerting system on
medication errors.
January 23, 2013
Natali BJ, Varkey AC, Garey KW, et al. Impact of a pharmacotherapy alerting system on medication errors.
American Journal of Health-System Pharmacy. 2012;70(1). doi:10.2146/ajhp120126.
https://psnet.ahrq.gov/issue/impact-pharmacothe…
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psnet.ahrq.gov/node/36456/psn-pdf
May 27, 2011 - Evaluation and certification of computerized physician
order entry systems.
May 27, 2011
Classen D, Avery A, Bates DW. Evaluation and certification of computerized provider order entry systems.
J Am Med Inform Assoc. 2007;14(1):48-55.
https://psnet.ahrq.gov/issue/evaluation-and-certification-computerized-physician…
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psnet.ahrq.gov/node/42714/psn-pdf
August 19, 2017 - SWITCH for safety: perioperative hand-off tools.
August 19, 2017
Johnson F, Logsdon P, Fournier K, et al. SWITCH for safety: Perioperative hand-off tools. AORN J.
2013;98(5):494-504; quiz 505-7. doi:10.1016/j.aorn.2013.08.016.
https://psnet.ahrq.gov/issue/switch-safety-perioperative-hand-tools
This commentary desc…
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psnet.ahrq.gov/node/33902/psn-pdf
December 22, 2014 - National Quality Measures Clearinghouse (NQMC).
December 22, 2014
Agency for Healthcare Research and Quality. 1998-2018.
https://psnet.ahrq.gov/issue/national-quality-measures-clearinghouse-nqmc
This web-accessible database provided access to evidence-based quality measures and measure sets.
The mission of the Nat…
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psnet.ahrq.gov/node/35085/psn-pdf
July 24, 2018 - Working Knowledge: How Organizations Manage What
They Know.
July 24, 2018
Davenport TH, Prusak L. Boston MA: Harvard Business School Press; 1998. ISBN: 0875846556.
https://psnet.ahrq.gov/issue/working-knowledge-how-organizations-manage-what-they-know
Two innovators in management consulting introduce core concepts …
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psnet.ahrq.gov/node/35354/psn-pdf
September 28, 2005 - Crew resource management training--clinicians' reactions
and attitudes.
September 28, 2005
France DJ, Stiles RA, Gaffney FA, et al. Crew resource management training-Clinicians' reactions and
attitudes. AORN J. 2006;82(2):213-224. doi:10.1016/s0001-2092(06)60313-x.
https://psnet.ahrq.gov/issue/crew-resource-manage…
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psnet.ahrq.gov/node/37247/psn-pdf
December 15, 2011 - Perinatal clinical decision support system: a
documentation tool for patient safety.
December 15, 2011
Provost C, Gray M. Perinatal clinical decision support system: a documentation tool for patient safety. Nurs
Womens Health. 2007;11(4):407-10.
https://psnet.ahrq.gov/issue/perinatal-clinical-decision-support-syst…