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psnet.ahrq.gov/node/45273/psn-pdf
October 13, 2018 - Using an inpatient portal to engage families in pediatric
hospital care.
October 13, 2018
Kelly MM, Hoonakker P, Dean SM. Using an inpatient portal to engage families in pediatric hospital care. J
Am Med Inform Assoc. 2017;24(1):153-161. doi:10.1093/jamia/ocw070.
https://psnet.ahrq.gov/issue/using-inpatient-portal…
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psnet.ahrq.gov/node/42935/psn-pdf
February 12, 2014 - Socio-technical issues and challenges in implementing
safe patient handovers: insights from ethnographic case
studies.
February 12, 2014
Balka E, Tolar M, Coates S, et al. Socio-technical issues and challenges in implementing safe patient
handovers: insights from ethnographic case studies. Int J Med Inform. 2013;8…
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psnet.ahrq.gov/node/38261/psn-pdf
December 03, 2008 - Systematic assessment of culture review as a tool to
assess errors in the clinical microbiology laboratory.
December 3, 2008
Goodyear N, Ulness BK, Prentice JL, et al. Systematic assessment of culture review as a tool to assess
errors in the clinical microbiology laboratory. Arch Pathol Lab Med. 2008;132(11):1792-5…
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psnet.ahrq.gov/node/837702/psn-pdf
July 20, 2022 - Patient safety informatics: meeting the challenges of
emerging digital health.
July 20, 2022
McInerney C, Benn J, Dowding D, et al. Patient safety informatics: meeting the challenges of emerging
digital health. Stud Health Technol Inform. 2022;290:364-368. doi:10.3233/shti220097.
https://psnet.ahrq.gov/issue/patie…
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psnet.ahrq.gov/node/43677/psn-pdf
November 19, 2014 - Reporting and Learning Systems for Medication Errors:
The Role of Pharmacovigilance Centres.
November 19, 2014
Bencheikh SR, Cousins D, Benabdallah G, et al. Geneva, Switzerland: World Health Organization; October
2014. ISBN: 9789241507943.
https://psnet.ahrq.gov/issue/reporting-and-learning-systems-medication-err…
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psnet.ahrq.gov/node/37947/psn-pdf
May 04, 2010 - Computerized physician order entry of medications and
clinical decision support can improve problem list
documentation compliance.
May 4, 2010
Galanter W, Hier DB, Jao C, et al. Computerized physician order entry of medications and clinical decision
support can improve problem list documentation compliance. Int J …
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psnet.ahrq.gov/node/866072/psn-pdf
June 05, 2024 - WHO Global Report on Patient Safety.
June 5, 2024
Geneva, Switzerland: World Health Organization; 2024. ISBN 9789240095458.
https://psnet.ahrq.gov/issue/who-global-report-patient-safety
Comparative data can help to inform and motivate patient safety improvement efforts. This report uses the
seven objectives of the…
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psnet.ahrq.gov/node/46791/psn-pdf
May 23, 2018 - Medication Safety Dashboard.
May 23, 2018
National Health Service.
https://psnet.ahrq.gov/issue/medication-safety-dashboard
Data surveillance and transparency are core to measuring and informing improvement efforts. This website
provides detailed data that links ambulatory care prescribing activity to National Hea…
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psnet.ahrq.gov/node/50867/psn-pdf
February 05, 2020 - Cognitive testing of older clinicians prior to
recredentialing.
February 5, 2020
Cooney L, Balcezak T. Cognitive Testing of Older Clinicians Prior to Recredentialing. JAMA.
2020;323(2):179-180. doi:10.1001/jama.2019.18665.
https://psnet.ahrq.gov/issue/cognitive-testing-older-clinicians-prior-recredentialing
In an…
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psnet.ahrq.gov/node/47971/psn-pdf
June 14, 2019 - Evidence-based medicine: a cornerstone for clinical care
but not for quality improvement.
June 14, 2019
Mondoux S, Shojania KG. Evidence-based medicine: A cornerstone for clinical care but not for quality
improvement. J Eval Clin Pract. 2019;25(3):363-368. doi:10.1111/jep.13135.
https://psnet.ahrq.gov/issue/eviden…
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psnet.ahrq.gov/node/43977/psn-pdf
November 16, 2015 - Patient perspectives on test result communication in
primary care: a qualitative study.
November 16, 2015
Litchfield I, Bentham L, Lilford RJ, et al. Patient perspectives on test result communication in primary care:
a qualitative study. Br J Med Pract. 2015;65(632):e133-e140. doi:10.3399/bjgp15X683929.
https://ps…
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psnet.ahrq.gov/node/44509/psn-pdf
October 07, 2015 - Medication errors affecting pediatric patients: unique
challenges for this special population.
October 7, 2015
Grissinger M. PA-PSRS Patient Saf Advis. September 2015;12:96-102.
https://psnet.ahrq.gov/issue/medication-errors-affecting-pediatric-patients-unique-challenges-special-
population
This article analyzed …
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psnet.ahrq.gov/node/50575/psn-pdf
October 23, 2019 - Dynamic pocket card for implementing ISBAR in shift
handover communication.
October 23, 2019
Schmidt T, Kocher DR, Mahendran P, et al. Dynamic Pocket Card for Implementing ISBAR in Shift
Handover Communication. Stud Health Technol Inform. 2019;267:224-229. doi:10.3233/SHTI190831.
https://psnet.ahrq.gov/issue/dynam…
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psnet.ahrq.gov/node/35971/psn-pdf
May 27, 2011 - Effectiveness of computerized provider order entry with
dose range checking on prescribing errors.
May 27, 2011
Boling B, McKibben M, Hingl J, et al. Effectiveness of Computerized Provider Order Entry with Dose Range
Checking on Prescribing Errors. J Patient Saf. 2008;1(4). doi:10.1097/01.jps.0000215339.03807.fd.
…
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psnet.ahrq.gov/node/38474/psn-pdf
March 10, 2011 - Using computerized provider order entry and clinical
decision support to improve referring physicians'
implementation of consultants' medical
recommendations.
March 10, 2011
Were MC, Abernathy G, Hui SL, et al. Using computerized provider order entry and clinical decision
support to improve referring physicians' …
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psnet.ahrq.gov/node/48082/psn-pdf
June 19, 2019 - Unintended discontinuation of medication following
hospitalisation: a retrospective cohort study.
June 19, 2019
Redmond P, McDowell R, Grimes TC, et al. Unintended discontinuation of medication following
hospitalisation: a retrospective cohort study. BMJ Open. 2019;9(6):e024747. doi:10.1136/bmjopen-2018-
024747.
…
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psnet.ahrq.gov/node/42078/psn-pdf
February 27, 2013 - Findings and Lessons From the Enabling Patient-
Centered Care Through Health IT Grant Initiative.
February 27, 2013
Rockville, MD: Agency for Healthcare Research and Quality; January 2013. AHRQ Publication No. 13-
0011-EF.
https://psnet.ahrq.gov/issue/findings-and-lessons-enabling-patient-centered-car…
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psnet.ahrq.gov/node/45647/psn-pdf
February 22, 2017 - Bias in the ER. Doctors suffer from the same cognitive
distortions as the rest of us.
February 22, 2017
Lewis M. Nautilus. February 9, 2017.
https://psnet.ahrq.gov/issue/bias-er-doctors-suffer-same-cognitive-distortions-rest-us
Physicians' decision-making can be diminished when they are tired, distracted, or too n…
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psnet.ahrq.gov/node/46854/psn-pdf
June 20, 2018 - FDA Safety Communication: recommendations to reduce
surgical fires and related patient injury.
June 20, 2018
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration. May 29, 2018.
https://psnet.ahrq.gov/issue/fda-safety-communication-recommendations-reduce-surgical-fires-and-related-
patient-inju…
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psnet.ahrq.gov/node/36190/psn-pdf
May 27, 2011 - Lessons from "unexpected increased mortality after
implementation of a commercially sold computerized
physician order entry system."
May 27, 2011
Sittig DF, Ash JS, Zhang J, et al. Lessons from "Unexpected increased mortality after implementation of a
commercially sold computerized physician order entry system". P…