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  1. Psn-Pdf (pdf file)

    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…
  2. Psn-Pdf (pdf file)

    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-…
  3. Psn-Pdf (pdf file)

    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 …
  4. Psn-Pdf (pdf file)

    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…
  5. Psn-Pdf (pdf file)

    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…
  6. Psn-Pdf (pdf file)

    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…
  7. Psn-Pdf (pdf file)

    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 …
  8. Psn-Pdf (pdf file)

    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…
  9. Psn-Pdf (pdf file)

    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…
  10. Psn-Pdf (pdf file)

    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…
  11. Psn-Pdf (pdf file)

    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…
  12. Psn-Pdf (pdf file)

    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…
  13. Psn-Pdf (pdf file)

    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…
  14. Psn-Pdf (pdf file)

    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…
  15. Psn-Pdf (pdf file)

    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…
  16. Psn-Pdf (pdf file)

    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…
  17. Psn-Pdf (pdf file)

    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…
  18. Psn-Pdf (pdf file)

    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 …
  19. Psn-Pdf (pdf file)

    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…
  20. Psn-Pdf (pdf file)

    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…

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