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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40992/psn-pdf
    December 15, 2011 - Should patients get direct access to their laboratory test results?: An answer with many questions. December 15, 2011 Giardina TD, Singh H. Should patients get direct access to their laboratory test results? An answer with many questions. JAMA. 2011;306(22):2502-2503. doi:10.1001/jama.2011.1797. https://psnet.ahrq…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40428/psn-pdf
    May 04, 2011 - Does user-centred design affect the efficiency, usability and safety of CPOE order sets? May 4, 2011 Chan J, Shojania KG, Easty AC, et al. Does user-centred design affect the efficiency, usability and safety of CPOE order sets? J Am Med Inform Assoc. 2011;18(3):276-81. doi:10.1136/amiajnl-2010-000026. https://psne…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43218/psn-pdf
    July 28, 2014 - Risk management—learning from the mistakes of others. July 28, 2014 Meydan C. Risk management--learning from the mistakes of others. J Eval Clin Pract. 2014;20(4):505-7. doi:10.1111/jep.12165. https://psnet.ahrq.gov/issue/risk-management-learning-mistakes-others This commentary introduces a structured process for …
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41498/psn-pdf
    December 31, 2014 - Standard practices for computerized clinical decision support in community hospitals: a national survey. December 31, 2014 Ash JS, McCormack JL, Sittig DF, et al. Standard practices for computerized clinical decision support in community hospitals: a national survey. J Am Med Inform Assoc. 2012;19(6):980-7. doi:10.…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44788/psn-pdf
    May 31, 2017 - Patient handoffs: is cross cover or night shift better? May 31, 2017 Higgins A, Brannen ML, Heiman HL, et al. Patient Handoffs: Is Cross Cover or Night Shift Better? J Patient Saf. 2017;13(2):88-92. doi:10.1097/PTS.0000000000000126. https://psnet.ahrq.gov/issue/patient-handoffs-cross-cover-or-night-shift-better Du…
  6. Psn-Pdf (pdf file)

    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…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44192/psn-pdf
    November 10, 2015 - Hospital ratings: a guide for the perplexed. November 10, 2015 Zuger A. Hospital ratings: a guide for the perplexed. JAMA. 2015;313(19):1911-2. doi:10.1001/jama.2015.5269. https://psnet.ahrq.gov/issue/hospital-ratings-guide-perplexed Concerns have been raised about the variability of measures used to rate safety a…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39110/psn-pdf
    June 10, 2018 - Order scanning systems may pull multiple pages through the scanner at the same time, leading to drug omissions. June 10, 2018 ISMP Medication Safety Alert! Acute Care Edition. November 5, 2009;14:1-3. https://psnet.ahrq.gov/issue/order-scanning-systems-may-pull-multiple-pages-through-scanner-same-time- leading-dru…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/862619/psn-pdf
    February 14, 2024 - FDA urged to move faster to fix pulse oximeters for darker-skinned patients. February 14, 2024 McFarling UL. STAT. February 2, 2024. https://psnet.ahrq.gov/issue/fda-urged-move-faster-fix-pulse-oximeters-darker-skinned-patients Unequal care has been hardwired into the health system through the persistent implicit …
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50875/psn-pdf
    February 05, 2020 - Implementing Closing the Loop. Safe Practices for Diagnostic Results February 5, 2020 Partnership for HIT Patient Safety. Plymouth Meeting, PA: ECRI Institute; 2020. https://psnet.ahrq.gov/issue/implementing-closing-loop-safe-practices-diagnostic-results Health information technology (HIT) can improve record keepi…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45058/psn-pdf
    February 18, 2017 - Learning from incidents in healthcare: the journey, not the arrival, matters. February 18, 2017 Leistikow I, Mulder S, Vesseur J, et al. Learning from incidents in healthcare: the journey, not the arrival, matters. BMJ Qual Saf. 2017;26(3):252-256. doi:10.1136/bmjqs-2015-004853. https://psnet.ahrq.gov/issue/learni…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35724/psn-pdf
    May 26, 2010 - A prospective study of patient safety in the operating room. May 26, 2010 Christian CK, Gustafson ML, Roth EM, et al. A prospective study of patient safety in the operating room. Surgery. 2006;139(2):159-173. https://psnet.ahrq.gov/issue/prospective-study-patient-safety-operating-room This study used a multidisci…
  13. Psn-Pdf (pdf file)

    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…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39378/psn-pdf
    March 17, 2010 - Exploring emergency physician–hospitalist handoff interactions: development of the Handoff Communication Assessment. March 17, 2010 Apker J, Mallak LA, Applegate B, et al. Exploring emergency physician-hospitalist handoff interactions: development of the Handoff Communication Assessment. Ann Emerg Med. 2010;55(2):…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865932/psn-pdf
    May 22, 2024 - Cognitive Load Theory and its Impact on Diagnostic Accuracy. May 22, 2024 Knees M, Raffel KE, Kissler M, et al. Rockville, MD: Agency for Healthcare Research and Quality; May 2024. Publication No. 24-0010-2-EF. https://psnet.ahrq.gov/issue/cognitive-load-theory-and-its-impact-diagnostic-accuracy Cognition plays a…
  16. Psn-Pdf (pdf file)

    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 …
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38346/psn-pdf
    April 01, 2010 - Human factors engineering in healthcare systems: the problem of human error and accident management. April 1, 2010 Cacciabue PC, Vella G. Human factors engineering in healthcare systems: the problem of human error and accident management. Int J Med Inform. 2010;79(4):e1-17. doi:10.1016/j.ijmedinf.2008.10.005. http…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40556/psn-pdf
    June 29, 2011 - A review of medical error taxonomies: a human factors perspective. June 29, 2011 Taib IA, McIntosh AS, Caponecchia C, et al. A review of medical error taxonomies: A human factors perspective. Saf Sci. 2011;49(5):607-615. doi:10.1016/j.ssci.2010.12.014. https://psnet.ahrq.gov/issue/review-medical-error-taxonomies-h…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43826/psn-pdf
    June 01, 2015 - Radiation Oncology Incident Learning System. June 1, 2015 American Society for Radiation Oncology and American Association of Physicists in Medicine. https://psnet.ahrq.gov/issue/radiation-oncology-incident-learning-system Reporting of near misses and adverse events can provide a foundation for learning from error.…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50809/psn-pdf
    January 15, 2020 - Electronic Health Record (EHR) Safety and Usability: See What We Mean. January 15, 2020 MedStar Health National Center for Human Factors in Healthcare. https://psnet.ahrq.gov/issue/electronic-health-record-ehr-safety-and-usability-see-what-we-mean Electronic health records (EHR) optimize information functions in c…

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