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psnet.ahrq.gov/node/60192/psn-pdf
April 01, 2020 - Effective Reporting Could Improve Safe Use of Electronic
Health Records.
April 1, 2020
Philadelphia, PA: Pew Charitable Trusts; March 2020.
https://psnet.ahrq.gov/issue/effective-reporting-could-improve-safe-use-electronic-health-records
Electronic health records both enhance and challenge the safety of care proce…
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psnet.ahrq.gov/node/35485/psn-pdf
May 27, 2011 - Navigating the information technology highway:
computer solutions to reduce errors and enhance patient
safety.
May 27, 2011
Koshy R. Navigating the information technology highway: computer solutions to reduce errors and enhance
patient safety. Transfusion (Paris). 2005;45(4 Suppl):189S-205S.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/39505/psn-pdf
November 26, 2014 - Improving teamwork: impact of structured
interdisciplinary rounds on a medical teaching unit.
November 26, 2014
O'Leary KJ, Wayne DB, Haviley C, et al. Improving teamwork: impact of structured interdisciplinary rounds
on a medical teaching unit. J Gen Intern Med. 2010;25(8):826-32. doi:10.1007/s11606-010-1345-6.
h…
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psnet.ahrq.gov/node/40329/psn-pdf
August 25, 2011 - Using prospective clinical surveillance to identify adverse
events in hospital.
August 25, 2011
Forster AJ, Worthington JR, Hawken S, et al. Using prospective clinical surveillance to identify adverse
events in hospital. BMJ Qual Saf. 2011;20(9):756-63. doi:10.1136/bmjqs.2010.048694.
https://psnet.ahrq.gov/issue/u…
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psnet.ahrq.gov/node/40980/psn-pdf
December 31, 2014 - Transmitting and processing electronic prescriptions:
experiences of physician practices and pharmacies.
December 31, 2014
Grossman JM, Cross DA, Boukus ER, et al. Transmitting and processing electronic prescriptions:
experiences of physician practices and pharmacies. J Am Med Inform Assoc. 2012;19(3):353-9.
doi:1…
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psnet.ahrq.gov/node/43018/psn-pdf
March 19, 2014 - Improved obstetric safety through programmatic
collaboration.
March 19, 2014
Goffman D, Brodman M, Friedman AJ, et al. Improved obstetric safety through programmatic collaboration.
J Healthc Risk Manag. 2014;33(3):14-22. doi:10.1002/jhrm.21131.
https://psnet.ahrq.gov/issue/improved-obstetric-safety-through-program…
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psnet.ahrq.gov/node/50825/psn-pdf
January 22, 2020 - Investigation into Detection of Retained Vaginal Swabs
and Tampons Following Childbirth.
January 22, 2020
Farnborough, UK; Healthcare Safety Investigation Branch; December 18, 2019.
https://psnet.ahrq.gov/issue/investigation-detection-retained-vaginal-swabs-and-tampons-following-
childbirth
Maternal care during a…
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psnet.ahrq.gov/node/38803/psn-pdf
December 14, 2016 - Improving patient safety: effects of a safety program on
performance and culture in a department of radiology.
December 14, 2016
Donnelly LF, Dickerson JM, Goodfriend MA, et al. Improving patient safety: effects of a safety program on
performance and culture in a department of radiology. AJR Am J Roentgenol. 2009;1…
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psnet.ahrq.gov/node/45572/psn-pdf
March 22, 2017 - Ordering interruptions in a tertiary care center: a
prospective observational study.
March 22, 2017
Dadlez NM, Azzarone G, Sinnett MJ, et al. Ordering Interruptions in a Tertiary Care Center: A Prospective
Observational Study. Hosp Pediatr. 2017;7(3):134-139. doi:10.1542/hpeds.2016-0127.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/45927/psn-pdf
April 12, 2017 - How redesigning the abrasive alarms of hospital
soundscapes can save lives.
April 12, 2017
Couch C. Fast Company. April 3, 2017.
https://psnet.ahrq.gov/issue/how-redesigning-abrasive-alarms-hospital-soundscapes-can-save-lives
Alarm frequency can contribute to distractions and stress in the hospital environment. Re…
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psnet.ahrq.gov/node/72805/psn-pdf
March 03, 2021 - When machine learning goes off the rails. A guide to
managing the risks.
March 3, 2021
Babic B, Cohen IG, Evgeniou T, et al. Harv Bus Rev. 2021 January/February;99(1):76-
84.
https://psnet.ahrq.gov/issue/when-machine-learning-goes-rails-guide-managing-risks
This article discusses how machine lea…
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psnet.ahrq.gov/node/50838/psn-pdf
January 29, 2020 - Start the new year off right by preventing these top 10
medication errors and hazards.
January 29, 2020
ISMP Medication Safety Alert! Acute care edition. January 16, 2020;26(2):1-6.
https://psnet.ahrq.gov/issue/start-new-year-right-preventing-these-top-10-medication-errors-and-hazards
Medication errors routinely c…
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psnet.ahrq.gov/node/35836/psn-pdf
March 28, 2011 - Use of a standardized protocol to decrease medication
errors and adverse events related to sliding scale insulin.
March 28, 2011
Donihi AC, DiNardo MM, Devita MA, et al. Use of a standardized protocol to decrease medication errors
and adverse events related to sliding scale insulin. Qual Saf Health Care. 2006;15(2)…
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psnet.ahrq.gov/node/867347/psn-pdf
December 11, 2024 - Recommendations to ensure safety of AI in real-world
clinical care.
December 11, 2024
Sittig DF, Singh H. Recommendations to ensure safety of AI in real-world clinical care. JAMA.
2025;333(6):457-458. doi:10.1001/jama.2024.24598.
https://psnet.ahrq.gov/issue/recommendations-ensure-safety-ai-real-world-clinical-car…
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psnet.ahrq.gov/node/837908/psn-pdf
August 24, 2022 - Implication of the COVID-19 Pandemic for Patient Safety:
A Rapid Review.
August 24, 2022
Integrated Health Services. Geneva, Switzerland: World Health Organization; 2022. ISBN:
9789240055094.
https://psnet.ahrq.gov/issue/implication-covid-19-pandemic-patient-safety-rapid-review
The COVID-19 pandemic created new r…
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psnet.ahrq.gov/node/40603/psn-pdf
December 31, 2014 - ICU nurses' acceptance of electronic health records.
December 31, 2014
Carayon P, Cartmill R, Blosky MA, et al. ICU nurses' acceptance of electronic health records. J Am Med
Inform Assoc. 2011;18(6):812-9. doi:10.1136/amiajnl-2010-000018.
https://psnet.ahrq.gov/issue/icu-nurses-acceptance-electronic-health-records
…
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psnet.ahrq.gov/node/38925/psn-pdf
September 16, 2009 - A literature review of the individual and systems factors
that contribute to medication errors in nursing practice.
September 16, 2009
Brady A-M, Malone A-M, Fleming S. A literature review of the individual and systems factors that contribute
to medication errors in nursing practice. J Nurs Manag. 2009;17(6):679-97…
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psnet.ahrq.gov/node/44332/psn-pdf
July 29, 2015 - Health IT Safety Center Roadmap.
July 29, 2015
RTI International. Washington, DC: Office of the National Coordinator for Health Information Technology;
July 2015.
https://psnet.ahrq.gov/issue/health-it-safety-center-roadmap
The Institute of Medicine called for enhanced transparency in the reporting of health IT sa…
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psnet.ahrq.gov/node/838909/psn-pdf
October 26, 2022 - Designing safety interventions for specific contexts:
results from a literature review.
October 26, 2022
Karanikas N, Khan SR, Baker PRA, et al. Designing safety interventions for specific contexts: Results from
a literature review. Safety Sci. 2022;156:105906. doi:10.1016/j.ssci.2022.105906.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/47739/psn-pdf
February 20, 2019 - Artificial intelligence, bias and clinical safety.
February 20, 2019
Challen R, Denny J, Pitt M, et al. Artificial intelligence, bias and clinical safety. BMJ Qual Saf.
2019;28(3):231-237. doi:10.1136/bmjqs-2018-008370.
https://psnet.ahrq.gov/issue/artificial-intelligence-bias-and-clinical-safety
Artificial intell…