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psnet.ahrq.gov/issue/role-computerized-physician-order-entry-usability-reduction-prescribing-errors
June 23, 2021 - Study
Role of computerized physician order entry usability in the reduction of prescribing errors.
Citation Text:
Peikari HR, Zakaria MS, Yasin NM, et al. Role of computerized physician order entry usability in the reduction of prescribing errors. Healthc Inform Res. 2013;19(2):93-101. d…
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psnet.ahrq.gov/submit-case-landing
March 25, 2025 - Breadcrumb
Home
Training and Education
WebM&M: Case Studies
WebM&M Case Submission
PSNet is looking for interesting, provocative cases that illustrate key issues in patient safety such as medication errors, diagnostic errors, and adverse events that either had the potential …
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psnet.ahrq.gov/issue/racism-and-electronic-health-records-ehrs-perspectives-research-and-practice
March 27, 2024 - Commentary
Racism and electronic health records (EHRs): perspectives for research and practice.
Citation Text:
Emani S, Rodriguez JA, Bates DW. Racism and electronic health records (EHRs): perspectives for research and practice. J Am Med Inform Assoc. 2023;30(5):995-999. doi:10.1093/jami…
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psnet.ahrq.gov/issue/impact-non-interruptive-medication-laboratory-monitoring-alerts-ambulatory-care
March 10, 2011 - Study
Impact of non-interruptive medication laboratory monitoring alerts in ambulatory care.
Citation Text:
Lo HG, Matheny ME, Seger DL, et al. Impact of non-interruptive medication laboratory monitoring alerts in ambulatory care. J Am Med Inform Assoc. 2009;16(1):66-71. doi:10.1197/jami…
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psnet.ahrq.gov/issue/physicians-beliefs-about-using-emr-and-cpoe-pursuit-contextualized-understanding-health-it
May 16, 2012 - Study
Physicians' beliefs about using EMR and CPOE: in pursuit of a contextualized understanding of health IT use behavior.
Citation Text:
Holden RJ. Physicians' beliefs about using EMR and CPOE: in pursuit of a contextualized understanding of health IT use behavior. Int J Med Inform. …
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psnet.ahrq.gov/issue/adoption-order-entry-decision-support-chronic-care-physician-organizations
October 06, 2011 - Study
Adoption of order entry with decision support for chronic care by physician organizations.
Citation Text:
Simon JS, Rundall TG, Shortell SM. Adoption of order entry with decision support for chronic care by physician organizations. J Am Med Inform Assoc. 2007;14(4):432-9.
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psnet.ahrq.gov/issue/workarounds-intended-use-health-information-technology-narrative-review-human-factors
July 24, 2013 - Review
Emerging Classic
Workarounds to intended use of health information technology: a narrative review of the human factors engineering literature.
Citation Text:
Patterson ES. Workarounds to Intended Use of Health Information Technology: A Narrative Review of…
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psnet.ahrq.gov/issue/evaluating-accuracy-electronic-pediatric-drug-dosing-rules
May 08, 2017 - Study
Evaluating the accuracy of electronic pediatric drug dosing rules.
Citation Text:
Kirkendall E, Spooner A, Logan JR. Evaluating the accuracy of electronic pediatric drug dosing rules. J Am Med Inform Assoc. 2014;21(e1):e43-9. doi:10.1136/amiajnl-2013-001793.
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For…
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psnet.ahrq.gov/issue/maximizing-ability-health-it-and-ai-improve-patient-safety
May 22, 2015 - Commentary
Maximizing the ability of health IT and AI to improve patient safety.
Citation Text:
Singh H, Sittig DF, Classen DC. Maximizing the ability of health IT and AI to improve patient safety. JAMA Intern Med. 2025;185(1):10-12. doi:10.1001/jamainternmed.2024.4343.
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…
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psnet.ahrq.gov/issue/machine-learning-medication-prescription-systematic-review
October 16, 2013 - Study
Machine learning in medication prescription: a systematic review.
Citation Text:
Iancu A, Leb I, Prokosch H-U, et al. Machine learning in medication prescription: a systematic review. Int J Med Inform. 2023;180:105241. doi:10.1016/j.ijmedinf.2023.105241.
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Format:…
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psnet.ahrq.gov/issue/patient-perceptions-receiving-test-results-online-portals-mixed-methods-study
July 01, 2017 - Study
Patient perceptions of receiving test results via online portals: a mixed-methods study.
Citation Text:
Giardina TD, Baldwin J, Nystrom DT, et al. Patient perceptions of receiving test results via online portals: a mixed-methods study. J Am Med Inform Assoc. 2018;25(4):440-446. doi…
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psnet.ahrq.gov/node/47344/psn-pdf
September 11, 2018 - Quality and Safety Between Ward and Board: a Biography
of Artefacts Study.
September 11, 2018
Keen J, Nicklin E, Long A, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals
Library; 2018.
https://psnet.ahrq.gov/issue/quality-and-safety-between-ward-and-board-biography-artefacts-study
The …
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psnet.ahrq.gov/node/850347/psn-pdf
June 14, 2023 - Towards safe conversational agents in healthcare.
June 14, 2023
Denecke K. Towards Safe Conversational Agents in Healthcare. Stud Health Technol Inform.
2023;302:157-161. doi:10.3233/shti230094.
https://psnet.ahrq.gov/issue/towards-safe-conversational-agents-healthcare
The public is increasingly using conversation…
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psnet.ahrq.gov/node/45506/psn-pdf
November 30, 2016 - Is an indication-based prescribing system in our future?
November 30, 2016
ISMP Medication Safety Alert! Acute Care Edition. November 17, 2016;21:1-5.
https://psnet.ahrq.gov/issue/indication-based-prescribing-system-our-future
Health information technology has enhanced prescribers' ability to document the purpose o…
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psnet.ahrq.gov/node/49600/psn-pdf
April 01, 2010 - Bad Writing, Wrong Medication
April 1, 2010
Devine B. Bad Writing, Wrong Medication. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/bad-writing-wrong-medication
Case Objectives
Differentiate between a medication error and an adverse drug event.
Appreciate the system complexities involved in medication erro…
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psnet.ahrq.gov/node/33635/psn-pdf
July 01, 2006 - In Conversation with...Allan Frankel, MD
July 1, 2006
In Conversation with..Allan Frankel, MD. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-withallan-frankel-md
Dr. Robert Wachter, Editor, AHRQ WebM&M: Tell us a little bit about how you became interested in this
kind of work.
Dr. Allan …
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psnet.ahrq.gov/web-mm/situational-unawareness
August 01, 2009 - Situational (Un)Awareness
Citation Text:
Abramson EL, Kaushal R. Situational (Un)Awareness. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML E…
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psnet.ahrq.gov/web-mm/picture-speaks-1000-words
July 16, 2015 - A Picture Speaks 1000 Words
Citation Text:
Hemphill RR. A Picture Speaks 1000 Words. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …
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psnet.ahrq.gov/node/49808/psn-pdf
October 01, 2017 - High-Risk Medications, High-Risk Transfers
October 1, 2017
Staggers N. High-Risk Medications, High-Risk Transfers. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/high-risk-medications-high-risk-transfers
The Case
A 47-year-old woman with history of primary pulmonary arterial hypertension (PAH) was admitted …
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psnet.ahrq.gov/node/43149/psn-pdf
July 23, 2014 - FDASIA Health IT Report: Proposed Strategy and
Recommendations for a Risk-Based Framework.
July 23, 2014
Washington, DC: Office of the National Coordinator for Health Information Technology, Federal
Communications Commission. Silver Spring, MD: Food and Drug Administration. April 2014.
https://psnet.ahrq.gov/issue…