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psnet.ahrq.gov/node/43726/psn-pdf
September 01, 2016 - Differences of reasons for alert overrides on
contraindicated co-prescriptions by admitting
department.
September 1, 2016
Ahn EK, Cho S-Y, Shin D, et al. Differences of Reasons for Alert Overrides on Contraindicated Co-
prescriptions by Admitting Department. Healthc Inform Res. 2014;20(4):280-7.
doi:10.4258/hir.2…
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psnet.ahrq.gov/node/41717/psn-pdf
September 01, 2016 - A clinical data warehouse-based process for refining
medication orders alerts.
September 1, 2016
Boussadi A, Caruba T, Zapletal E, et al. A clinical data warehouse-based process for refining medication
orders alerts. J Am Med Inform Assoc. 2012;19(5):782-5. doi:10.1136/amiajnl-2012-000850.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/38587/psn-pdf
May 06, 2009 - Creating a better discharge summary: improvement in
quality and timeliness using an electronic discharge
summary.
May 6, 2009
O'Leary KJ, Liebovitz DM, Feinglass J, et al. Creating a better discharge summary: improvement in quality
and timeliness using an electronic discharge summary. J Hosp Med. 2009;4(4):219-225…
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psnet.ahrq.gov/node/46936/psn-pdf
April 11, 2018 - You've detailed your last wishes, but doctors may not see
them.
April 11, 2018
Lamas D.
https://psnet.ahrq.gov/issue/youve-detailed-your-last-wishes-doctors-may-not-see-them
Advance care planning can affect patient safety if the information is unheeded, unavailable, or unread.
Reporting on a physician's experienc…
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psnet.ahrq.gov/node/35127/psn-pdf
February 24, 2011 - Beyond the medical record: other modes of error
acknowledgment.
February 24, 2011
Rosenthal M, Cornett PL, Sutcliffe K, et al. Beyond the medical record: other modes of error
acknowledgment. J Gen Intern Med. 2005;20(5):404-9.
https://psnet.ahrq.gov/issue/beyond-medical-record-other-modes-error-acknowledgment
Thi…
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psnet.ahrq.gov/node/46386/psn-pdf
April 03, 2018 - The impact of electronic health records on diagnosis.
April 3, 2018
Graber ML, Byrne C, Johnston D. The impact of electronic health records on diagnosis. Diagnosis (Berl).
2017;4(4):211-223. doi:10.1515/dx-2017-0012.
https://psnet.ahrq.gov/issue/impact-electronic-health-records-diagnosis
Health information technol…
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psnet.ahrq.gov/node/866256/psn-pdf
July 10, 2024 - Disclosure programmes in the US--an inadequate
response to medical error.
July 10, 2024
Handley GM. Disclosure programmes in the US—an inadequate response to medical error. BMJ.
2024;385:q1318. doi:10.1136/bmj.q1318.
https://psnet.ahrq.gov/issue/disclosure-programmes-us-inadequate-response-medical-error
Communica…
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psnet.ahrq.gov/node/34644/psn-pdf
December 23, 2008 - Medication-prescribing errors in a teaching hospital: a 9-
year experience.
December 23, 2008
Lesar TS, Lomaestro BM, Pohl H. Medication-prescribing errors in a teaching hospital. A 9-year
experience. Arch Intern Med. 1997;157(14):1569-76.
https://psnet.ahrq.gov/issue/medication-prescribing-errors-teaching-hospita…
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psnet.ahrq.gov/node/40278/psn-pdf
March 09, 2011 - Safety issues related to the electronic medical record
(EMR): synthesis of the literature from the last decade,
2000–2009.
March 9, 2011
Harrington L, Kennerly DA, Johnson C. Safety issues related to the electronic medical record (EMR):
synthesis of the literature from the last decade, 2000-2009. J Healthc Manag. …
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psnet.ahrq.gov/node/60589/psn-pdf
June 23, 2020 - Medication Safety During the COVID-19 Pandemic: What
Have We Learned in the United States.
June 23, 2020
Institute for Safe Medication Practices and US Food and Drug Administration Division of Drug Information.
June 23, 2020.
https://psnet.ahrq.gov/issue/medication-safety-during-covid-19-pandemic-what-have-we-lear…
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psnet.ahrq.gov/node/45673/psn-pdf
December 07, 2016 - Report on the Safe Use of Pick Lists in Ambulatory Care
Settings.
December 7, 2016
Rizk S, Oguntebi G, Graber ML, Johnston D. Research Triangle Park, NC: RTI International; 2016.
https://psnet.ahrq.gov/issue/report-safe-use-pick-lists-ambulatory-care-settings
Standard term selection tools—like pick lists or drop-d…
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psnet.ahrq.gov/node/47872/psn-pdf
March 27, 2019 - Overview of the Environmental Scan of Primary Care-
Based Effort To Reduce Readmissions.
March 27, 2019
Hochman M, Bourgoin A, Saluja S, et al. Rockville, MD: Agency for Healthcare Research and Quality;
March 2019. AHRQ Publication No. 18(19)-0055-EF.
https://psnet.ahrq.gov/issue/overview-environmental-scan-primar…
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psnet.ahrq.gov/node/852278/psn-pdf
August 09, 2023 - Identifying failure modes in telemedicine: an instructional
needs assessment.
August 9, 2023
Monkman H, Kuziemsky C, Homco J, et al. Identifying failure modes in telemedicine: an instructional needs
assessment. Stud Health Technol Inform. 2023;304:39-43. doi:10.3233/shti230365.
https://psnet.ahrq.gov/issue/identif…
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psnet.ahrq.gov/node/60969/psn-pdf
November 08, 2023 - Network of Patient Safety Databases Chartbook.
November 8, 2023
Rockville, MD: Agency for Healthcare Research and Quality; September 2023. AHRQ Publication no. 23-
0082.
https://psnet.ahrq.gov/issue/network-patient-safety-databases-chartbook
The sharing of data is a core element of a learning health system. AHRQ h…
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psnet.ahrq.gov/node/46798/psn-pdf
March 14, 2018 - NHTSA Fatigue in EMS Project.
March 14, 2018
Patterson PD, ed. Prehosp Emerg Care. 2018;22(suppl 1):1-118.
https://psnet.ahrq.gov/issue/nhtsa-fatigue-ems-project
Health care worker fatigue is a persistent threat to patient safety. Articles in this special issue cover the
results of a National Highway Traffic Safet…
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psnet.ahrq.gov/node/37511/psn-pdf
February 06, 2008 - Validity of retrospective review of medical records as a
means of identifying adverse events: comparison
between medical records and accident reports.
February 6, 2008
Kobayashi M, Ikeda S, Kitazawa N, et al. Validity of retrospective review of medical records as a means of
identifying adverse events: comparison b…
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psnet.ahrq.gov/node/43938/psn-pdf
March 18, 2015 - Fixing a broken EHR: HIM working in the spotlight to
solve common EHR issues.
March 18, 2015
Butler M. J AHIMA. March 2015;86:18-23.
https://psnet.ahrq.gov/issue/fixing-broken-ehr-him-working-spotlight-solve-common-ehr-issues
Although health information technology presents opportunities to improve patient safety, …
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psnet.ahrq.gov/node/46479/psn-pdf
October 04, 2017 - Managing the Costs of Clinical Negligence in Trusts.
October 4, 2017
Comptroller and Auditor General, Department of Health; London, UK: National Audit Office; 2017. ISBN:
9781786041395.
https://psnet.ahrq.gov/issue/managing-costs-clinical-negligence-trusts
Applying evidence generated from complaints submitted to h…
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psnet.ahrq.gov/node/855437/psn-pdf
November 15, 2023 - Advancing Diagnostic Excellence for Maternal Health
Care: Proceedings of a Workshop–in Brief.
November 15, 2023
National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies
Press; 2023. ISBN: 9780309711937.
https://psnet.ahrq.gov/issue/advancing-diagnostic-excellence-maternal-h…
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psnet.ahrq.gov/node/44330/psn-pdf
September 02, 2015 - Health Literacy: Past, Present, and Future: Workshop
Summary.
September 2, 2015
Alper J; Roundtable on Health Literacy; Board on Population Health and Public Health Practice; Institute of
Medicine. Washington, DC: National Academies of Sciences, Engineering, and Medicine; 2015. ISBN:
9780309371544.
https://psnet.…