-
psnet.ahrq.gov/node/34059/psn-pdf
March 11, 2011 - Strategies for detecting adverse drug events among older
persons in the ambulatory setting.
March 11, 2011
Field T, Gurwitz JH, Harrold LR, et al. Strategies for detecting adverse drug events among older persons in
the ambulatory setting. J Am Med Inform Assoc. 2004;11(6):492-8.
https://psnet.ahrq.gov/issue/strate…
-
psnet.ahrq.gov/node/36337/psn-pdf
October 26, 2010 - Technology, governance and patient safety: systems
issues in technology and patient safety.
October 26, 2010
Balka E, Doyle-Waters M, Lecznarowicz D, et al. Technology, governance and patient safety: systems
issues in technology and patient safety. Int J Med Inform. 2007;76 Suppl 1:S35-47.
https://psnet.ahrq.gov/i…
-
psnet.ahrq.gov/node/856641/psn-pdf
January 01, 2009 - WebAIRS Anesthesia Incident Reporting System.
January 1, 2009
Australian and New Zealand Tripartite Anaesthetic Data Committee.
https://psnet.ahrq.gov/issue/webairs-anesthesia-incident-reporting-system
Reporting errors in anesthesiology practice can motivate and inform safety improvement work. This website
serves …
-
psnet.ahrq.gov/node/34048/psn-pdf
May 27, 2011 - Computerized physician order entry: helpful or harmful?
May 27, 2011
Berger RG, Kichak JP. Computerized physician order entry: helpful or harmful? J Am Med Inform Assoc.
2004;11(2):100-3.
https://psnet.ahrq.gov/issue/computerized-physician-order-entry-helpful-or-harmful
The authors critically review the published …
-
psnet.ahrq.gov/node/35178/psn-pdf
April 23, 2014 - Computer visualisation of patient safety in primary care: a
systems approach adapted from management science
and engineering.
April 23, 2014
Singh R, Singh A, Fox C, et al. Computer visualisation of patient safety in primary care: a systems
approach adapted from management science and engineering. Inform Prim Care…
-
psnet.ahrq.gov/node/839330/psn-pdf
November 02, 2022 - Diagnosis: Reducing Errors and Improving Quality.
November 2, 2022
Schiff G. Chapter In: Loscalzo J, Fauci A, Kasper D, et al, eds. Harrison's Principles of Internal Medicine,
21e. New York, NY: McGraw Hill; 2022
https://psnet.ahrq.gov/issue/diagnosis-reducing-errors-and-improving-quality
The task of performing a …
-
psnet.ahrq.gov/node/60719/psn-pdf
July 22, 2020 - How real-time data can change the patient safety game.
July 22, 2020
Diesing G. How real-time data can change the patient safety game. J AHIMA. 2020;July 1.
https://psnet.ahrq.gov/issue/how-real-time-data-can-change-patient-safety-game
Use of data can improve the response of clinicians to patient concerns and deter…
-
psnet.ahrq.gov/node/41040/psn-pdf
January 04, 2012 - Implementing an electronic medical record with
computerized prescriber order entry at a critical access
hospital.
January 4, 2012
Horning R. Implementing an electronic medical record with computerized prescriber order entry at a critical
access hospital. Am J Health Syst Pharm. 2011;68(23):2288-92. doi:10.2146/ajh…
-
psnet.ahrq.gov/node/838645/psn-pdf
January 19, 2022 - LeDeR - Learning from Lives and Deaths.
January 19, 2022
Norah Frye Centre for Disability Studies; Bristol, England.
https://psnet.ahrq.gov/issue/leder-learning-lives-and-deaths
People with a Learning Disability and autistic people (LeDeR) is a National Health Service-sponsored
initiative that seeks to improve the…
-
psnet.ahrq.gov/node/44966/psn-pdf
March 16, 2016 - Confidential Physician Feedback Reports: Designing for
Optimal Impact on Performance.
March 16, 2016
McNamara P, Shaller D, De La Mare J, Ivers N. Rockville, MD: Agency for Healthcare Research and
Quality; March 2016. AHRQ Publication No. 16-0017-EF.
https://psnet.ahrq.gov/issue/confidential-physician-feedback-rep…
-
psnet.ahrq.gov/node/34607/psn-pdf
June 12, 2018 - A clinician's guide to surgical fires: how they occur, how
to prevent them, how to put them out.
June 12, 2018
A clinician's guide to surgical fires. How they occur, how to prevent them, how to put them out. Health
Devices. 2003;32(1):5-24.
https://psnet.ahrq.gov/issue/clinicians-guide-surgical-fires-how-they-occu…
-
psnet.ahrq.gov/node/36830/psn-pdf
March 28, 2011 - Making use of mortality data to improve quality and safety
in general practice: a review of current approaches.
March 28, 2011
Baker R, Sullivan E, Camosso-Stefinovic J, et al. Making use of mortality data to improve quality and safety
in general practice: a review of current approaches. Qual Saf Health Care. 2007;…
-
psnet.ahrq.gov/node/47144/psn-pdf
June 13, 2018 - Canadian Anesthesia Incident Reporting System.
June 13, 2018
Canadian Anaesthesiologists Society.
https://psnet.ahrq.gov/issue/canadian-anesthesia-incident-reporting-system
Reporting mistakes in anesthesiology practice can motivate and inform error reduction work. This website
provides a secure tool for submitting…
-
psnet.ahrq.gov/node/42829/psn-pdf
December 18, 2013 - To make hospitals less deadly, a dose of data.
December 18, 2013
Rosenberg T.
https://psnet.ahrq.gov/issue/make-hospitals-less-deadly-dose-data
Preventable adverse events may result in more harm than previously thought. Highlighting inconsistencies
in publicly reported hospital safety data, this newspaper article …
-
psnet.ahrq.gov/node/45086/psn-pdf
July 02, 2019 - Half-life of a printed handoff document.
July 2, 2019
Rosenbluth G, Jacolbia R, Milev D, et al. Half-life of a printed handoff document. BMJ Qual Saf.
2016;25(5):324-8. doi:10.1136/bmjqs-2015-004585.
https://psnet.ahrq.gov/issue/half-life-printed-handoff-document
Despite advances in handoff practices, printed sign…
-
psnet.ahrq.gov/node/44964/psn-pdf
March 09, 2016 - EHRs in the ER: as doctors adapt, concerns emerge
about medical errors.
March 9, 2016
Luthra S.
https://psnet.ahrq.gov/issue/ehrs-er-doctors-adapt-concerns-emerge-about-medical-errors
Many emergency departments have recently implemented electronic health records, which has introduced
new safety hazards. This news…
-
psnet.ahrq.gov/node/60885/psn-pdf
September 02, 2020 - Becoming a High Reliability Organization.
September 2, 2020
VHA Forum. Summer 2020;1-12.
https://psnet.ahrq.gov/issue/becoming-high-reliability-organization
High reliability attainment is a stated goal for health care organizations. This special issue covers
established initiatives at the United States Veterans He…
-
psnet.ahrq.gov/node/44223/psn-pdf
November 22, 2016 - Patient Safety and Incident Management Toolkit.
November 22, 2016
Edmonton, AB: Canadian Patient Safety Institute. June 2015.
https://psnet.ahrq.gov/issue/patient-safety-and-incident-management-toolkit
Engaging patients and families in safety can uncover concerns and inform improvement efforts. This three-
compone…
-
psnet.ahrq.gov/node/44278/psn-pdf
July 01, 2015 - When doctors don't talk to doctors.
July 1, 2015
Bond A.
https://psnet.ahrq.gov/issue/when-doctors-dont-talk-doctors
Clinician communication with patients and families during transitions has been a focus of safety
improvement efforts. This newspaper article describes insights from a resident physician regarding ho…
-
psnet.ahrq.gov/node/39690/psn-pdf
July 21, 2010 - Characteristics of quality and patient safety curricula in
major teaching hospitals.
July 21, 2010
Pingleton SK, Davis DA, Dickler RM. Characteristics of quality and patient safety curricula in major
teaching hospitals. Am J Med Qual. 2010;25(4):305-11. doi:10.1177/1062860610367677.
https://psnet.ahrq.gov/issue/ch…