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"It is not the fault of the health care team - it is the way the system works": a mixed-methods quality improvement study of patients with advanced cancer and family members reveals challenges navigating a fragmented healthcare system and the administrative and financial burdens of care. | PSNet

psnet.ahrq.gov/issue/it-not-fault-health-care-team-it-way-system-works-mixed-methods-quality-improvement-study

March 24, 2019 - Study "It is not the fault of the health care team - it is the way the system works": a mixed-methods quality improvement study of patients with advanced cancer and family members reveals challenges navigating a fragmented healthcare system and the administrative and financial burdens of care. …

Information technology interventions to improve medication safety in primary care: a systematic review. | PSNet

psnet.ahrq.gov/issue/information-technology-interventions-improve-medication-safety-primary-care-systematic-review

July 29, 2020 - Review Information technology interventions to improve medication safety in primary care: a systematic review. Citation Text: Lainer M, Mann E, Sönnichsen A. Information technology interventions to improve medication safety in primary care: a systematic review. Int J Qual Health Care. 20…

Critical drug–drug interactions for use in electronic health records systems with computerized physician order entry: review of leading approaches. | PSNet

psnet.ahrq.gov/issue/critical-drug-drug-interactions-use-electronic-health-records-systems-computerized-physician

December 21, 2017 - Study Critical drug–drug interactions for use in electronic health records systems with computerized physician order entry: review of leading approaches. Citation Text: Classen DC, Phansalkar S, Bates DW. Critical Drug-Drug Interactions for Use in Electronic Health Records Systems With…

Does the implementation of an electronic prescribing system create unintended medication errors? A study of the sociotechnical context through the analysis of reported medication incidents. | PSNet

psnet.ahrq.gov/issue/does-implementation-electronic-prescribing-system-create-unintended-medication-errors-study

August 24, 2016 - Study Does the implementation of an electronic prescribing system create unintended medication errors? A study of the sociotechnical context through the analysis of reported medication incidents. Citation Text: Redwood S, Rajakumar A, Hodson J, et al. Does the implementation of an elec…

High rates of adverse drug events in a highly computerized hospital. | PSNet

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August 04, 2021 - Study Classic High rates of adverse drug events in a highly computerized hospital. Citation Text: Nebeker JR, Hoffman JM, Weir C, et al. High rates of adverse drug events in a highly computerized hospital. Arch Intern Med. 2005;165(10):1111-6. Copy Citation …

Impact of a nationwide prospective drug utilization review program to improve prescribing safety of potentially inappropriate medications in older adults: an interrupted time series with segmented regression analysis. | PSNet

psnet.ahrq.gov/issue/impact-nationwide-prospective-drug-utilization-review-program-improve-prescribing-safety

May 17, 2017 - Study Impact of a nationwide prospective drug utilization review program to improve prescribing safety of potentially inappropriate medications in older adults: an interrupted time series with segmented regression analysis. Citation Text: Jang S, Jeong S, Kang E, et al. Impact of a natio…

Methicillin-resistant Staphylococcus aureus central line–associated bloodstream infections in US intensive care units, 1997-2007. | PSNet

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April 05, 2013 - Study Methicillin-resistant Staphylococcus aureus central line–associated bloodstream infections in US intensive care units, 1997-2007. Citation Text: Burton DC, Edwards JR, Horan TC, et al. Methicillin-resistant Staphylococcus aureus central line-associated bloodstream infections in U…

Reducing medication errors in critical care patients: pharmacist key resources and relationship with medicines optimisation. | PSNet

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June 07, 2023 - Study Reducing medication errors in critical care patients: pharmacist key resources and relationship with medicines optimisation. Citation Text: Bourne RS, Shulman R, Jennings JK. Reducing medication errors in critical care patients: pharmacist key resources and relationship with medici…

National study on the distribution, causes, and consequences of voluntarily reported medication errors between the ICU and non-ICU settings. | PSNet

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January 05, 2012 - Study National study on the distribution, causes, and consequences of voluntarily reported medication errors between the ICU and non-ICU settings. Citation Text: Latif A, Rawat N, Pustavoitau A, et al. National study on the distribution, causes, and consequences of voluntarily reported…

Investigating the association of alerts from a national mortality surveillance system with subsequent hospital mortality in England: an interrupted time series analysis. | PSNet

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October 20, 2021 - Study Investigating the association of alerts from a national mortality surveillance system with subsequent hospital mortality in England: an interrupted time series analysis. Citation Text: Cecil E, Bottle A, Esmail A, et al. Investigating the association of alerts from a national morta…

Preoperative surgical briefings do not delay operating room start times and are popular with surgical team members. | PSNet

psnet.ahrq.gov/issue/preoperative-surgical-briefings-do-not-delay-operating-room-start-times-and-are-popular

March 02, 2022 - Study Preoperative surgical briefings do not delay operating room start times and are popular with surgical team members. Citation Text: Ali M, Osborne A, Bethune R, et al. Preoperative surgical briefings do not delay operating room start times and are popular with surgical team member…

Self-reported medical, medication and laboratory error in eight countries: risk factors for chronically ill adults. | PSNet

psnet.ahrq.gov/issue/self-reported-medical-medication-and-laboratory-error-eight-countries-risk-factors

September 19, 2012 - Study Self-reported medical, medication and laboratory error in eight countries: risk factors for chronically ill adults. Citation Text: Scobie A. Self-reported medical, medication and laboratory error in eight countries: risk factors for chronically ill adults. Int J Qual Health Care. 2…

Protocolization of analgesia and sedation through smart technology in intensive care: improving patient safety. | PSNet

psnet.ahrq.gov/issue/protocolization-analgesia-and-sedation-through-smart-technology-intensive-care-improving

March 09, 2022 - Study Protocolization of analgesia and sedation through smart technology in intensive care: improving patient safety. Citation Text: Ojeda IM, Sánchez-Cuervo M, Candela-Toha Á, et al. Protocolization of Analgesia and Sedation Through Smart Technology in Intensive Care: Improving Patient …

Simulation-based training improves physicians' performance in patient care in high-stakes clinical setting of cardiac surgery. | PSNet

psnet.ahrq.gov/issue/simulation-based-training-improves-physicians-performance-patient-care-high-stakes-clinical

October 07, 2020 - Study Simulation-based training improves physicians' performance in patient care in high-stakes clinical setting of cardiac surgery. Citation Text: Bruppacher HR, Alam SK, LeBlanc VR, et al. Simulation-based training improves physicians' performance in patient care in high-stakes clini…

Medication administration discrepancies persist despite electronic ordering. | PSNet

psnet.ahrq.gov/issue/medication-administration-discrepancies-persist-despite-electronic-ordering

May 04, 2012 - Study Medication administration discrepancies persist despite electronic ordering. Citation Text: FitzHenry F, Peterson JF, Arrieta M, et al. Medication Administration Discrepancies Persist Despite Electronic Ordering. J Am Med Inform Assoc. 2007;14(6):756-764. doi:10.1197/jamia.m2359.…

The effect of universal glove and gown use on adverse events in intensive care unit patients. | PSNet

psnet.ahrq.gov/issue/effect-universal-glove-and-gown-use-adverse-events-intensive-care-unit-patients

December 09, 2015 - Study The effect of universal glove and gown use on adverse events in intensive care unit patients. Citation Text: Croft LD, Harris AD, Pineles L, et al. The Effect of Universal Glove and Gown Use on Adverse Events in Intensive Care Unit Patients. Clin Infect Dis. 2015;61(4):545-53. doi:…

What do medical records tell us about potentially harmful co-prescribing? | PSNet

psnet.ahrq.gov/issue/what-do-medical-records-tell-us-about-potentially-harmful-co-prescribing

December 19, 2011 - Study Classic What do medical records tell us about potentially harmful co-prescribing? Citation Text: Lafata JE, Simpkins J, Kaatz S, et al. What do medical records tell us about potentially harmful co-prescribing? Jt Comm J Qual Patient Saf. 2007;33(7):395-4…

Benchmarking surgical incident reports using a database and a triage system to reduce adverse outcomes. | PSNet

psnet.ahrq.gov/issue/benchmarking-surgical-incident-reports-using-database-and-triage-system-reduce-adverse

June 18, 2008 - Study Benchmarking surgical incident reports using a database and a triage system to reduce adverse outcomes. Citation Text: Antonacci AC, Lam S, Lavarias V, et al. Benchmarking surgical incident reports using a database and a triage system to reduce adverse outcomes. Arch Sur…

Development and testing of an objective structured clinical exam (OSCE) to assess socio-cultural dimensions of patient safety competency. | PSNet

psnet.ahrq.gov/issue/development-and-testing-objective-structured-clinical-exam-osce-assess-socio-cultural

January 15, 2014 - Study Development and testing of an objective structured clinical exam (OSCE) to assess socio-cultural dimensions of patient safety competency. Citation Text: Ginsburg LR, Tregunno D, Norton PG, et al. Development and testing of an objective structured clinical exam (OSCE) to assess soci…

Unintended consequences: quantifying the benefits, iatrogenic harms and downstream cascade costs of musculoskeletal MRI in UK primary care. | PSNet

psnet.ahrq.gov/issue/unintended-consequences-quantifying-benefits-iatrogenic-harms-and-downstream-cascade-costs

March 17, 2021 - Study Unintended consequences: quantifying the benefits, iatrogenic harms and downstream cascade costs of musculoskeletal MRI in UK primary care. Citation Text: Sajid IM, Parkunan A, Frost K. Unintended consequences: quantifying the benefits, iatrogenic harms and downstream cascade costs…

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