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psnet.ahrq.gov/node/40189/psn-pdf
February 02, 2011 - Addition of electronic prescription transmission to
computerized prescriber order entry: effect on dispensing
errors in community pharmacies.
February 2, 2011
Moniz TT, Seger AC, Keohane CA, et al. Addition of electronic prescription transmission to computerized
prescriber order entry: Effect on dispensing errors …
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psnet.ahrq.gov/node/47102/psn-pdf
June 26, 2018 - Transition to a new electronic health record and pediatric
medication safety: lessons learned in pediatrics within a
large academic health system.
June 26, 2018
Whalen K, Lynch E, Moawad I, et al. Transition to a new electronic health record and pediatric medication
safety: lessons learned in pediatrics within a l…
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psnet.ahrq.gov/node/37910/psn-pdf
February 28, 2011 - Public reporting of antibiotic timing in patients with
pneumonia: lessons from a flawed performance measure.
February 28, 2011
Wachter R, Flanders S, Fee C, et al. Public reporting of antibiotic timing in patients with pneumonia:
lessons from a flawed performance measure. Ann Intern Med. 2008;149(1):29-32.
https:/…
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psnet.ahrq.gov/node/39822/psn-pdf
February 17, 2011 - The disclosure dilemma—large-scale adverse events.
February 17, 2011
Dudzinski DM, Hébert PC, Foglia MB, et al. The disclosure dilemma--large-scale adverse events. New Engl
J Med. 2010;363(10):978-986. doi:10.1056/NEJMhle1003134.
https://psnet.ahrq.gov/issue/disclosure-dilemma-large-scale-adverse-events
Error disc…
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psnet.ahrq.gov/node/39662/psn-pdf
April 30, 2014 - Patient record review of the incidence, consequences,
and causes of diagnostic adverse events.
April 30, 2014
Zwaan L, de Bruijne M, Wagner C, et al. Patient record review of the incidence, consequences, and causes
of diagnostic adverse events. Arch Intern Med. 2010;170(12):1015-21.
doi:10.1001/archinternmed.2010.…
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psnet.ahrq.gov/node/45555/psn-pdf
June 15, 2017 - Variations in GPs' decisions to investigate suspected
lung cancer: a factorial experiment using multimedia
vignettes.
June 15, 2017
Sheringham J, Sequeira R, Myles J, et al. Variations in GPs' decisions to investigate suspected lung
cancer: a factorial experiment using multimedia vignettes. BMJ Qual Saf. 2017;26(6…
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psnet.ahrq.gov/node/867037/psn-pdf
January 01, 2025 - Medicine communication from hospital to residential aged
care facilities: a cross-sectional survey of aged care
facility staff.
October 30, 2024
Browning S, Raleigh RA, Hattingh HL. Medicine communication from hospital to residential aged care
facilities: a cross-sectional survey of aged care facility staff. Int J…
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psnet.ahrq.gov/node/44545/psn-pdf
December 20, 2017 - Work conditions, mental workload and patient care
quality: a multisource study in the emergency
department.
December 20, 2017
Weigl M, Müller A, Holland S, et al. Work conditions, mental workload and patient care quality: a
multisource study in the emergency department. BMJ Qual Saf. 2016;25(7):499-508. doi:10.113…
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psnet.ahrq.gov/node/43224/psn-pdf
June 11, 2014 - Look alike/sound alike drugs: a literature review on
causes and solutions.
June 11, 2014
Ciociano N, Bagnasco L. Look alike/sound alike drugs: a literature review on causes and solutions. Int J
Clin Pharm. 2014;36(2):233-242. doi:10.1007/s11096-013-9885-6.
https://psnet.ahrq.gov/issue/look-alikesound-alike-drugs-l…
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psnet.ahrq.gov/issue/abbott-diabetes-care-blood-glucose-meters
May 04, 2022 - Government Resource
Abbott Diabetes Care blood glucose meters.
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November 9, 2005
This announcement alerts patients and practition…
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psnet.ahrq.gov/node/41266/psn-pdf
January 03, 2017 - Surfacing safety hazards using standardized operating
room briefings and debriefings at a large regional medical
center.
January 3, 2017
Bandari J, Schumacher K, Simon M, et al. Surfacing safety hazards using standardized operating room
briefings and debriefings at a large regional medical center. Jt Comm J Qual P…
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psnet.ahrq.gov/node/38645/psn-pdf
February 15, 2011 - A comprehensive pharmacist intervention to reduce
morbidity in patients 80 years or older: a randomized
controlled trial.
February 15, 2011
Gillespie U, Alassaad A, Henrohn D, et al. A comprehensive pharmacist intervention to reduce morbidity in
patients 80 years or older: a randomized controlled trial. Arch Inter…
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psnet.ahrq.gov/node/44831/psn-pdf
January 27, 2016 - IHI Skilled Nursing Facility Trigger Tool for Measuring
Adverse Events.
January 27, 2016
Adler L, Moore J, Federico F. Cambridge, MA: Institute for Healthcare Improvement; November 2015.
https://psnet.ahrq.gov/issue/ihi-skilled-nursing-facility-trigger-tool-measuring-adverse-events
Prior research has shown that sa…
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psnet.ahrq.gov/node/47921/psn-pdf
June 18, 2019 - Using incident reports to assess communication failures
and patient outcomes.
June 18, 2019
Umberfield E, Ghaferi AA, Krein SL, et al. Using Incident Reports to Assess Communication Failures and
Patient Outcomes. Jt Comm J Qual Patient Saf. 2019;45(6):406-413. doi:10.1016/j.jcjq.2019.02.006.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/40675/psn-pdf
November 28, 2016 - Patients' and family members' views on how clinicians
enact and how they should enact incident disclosure: the
"100 patient stories" qualitative study.
November 28, 2016
Iedema R, Allen S, Britton K, et al. Patients' and family members' views on how clinicians enact and how
they should enact incident disclosure: t…
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psnet.ahrq.gov/node/73252/psn-pdf
January 01, 2022 - Why test results are still getting "lost" to follow-up: a
qualitative study of implementation gaps.
May 12, 2021
Zimolzak AJ, Shahid U, Giardina TD, et al. Why test results are still getting "lost" to follow-up: a qualitative
study of implementation gaps. J Gen Intern Med. 2022;37(1):137-144. doi:10.1007/s11606-021…
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psnet.ahrq.gov/innovation/johns-hopkins-venous-thromboembolism-vte-collaborative-studies-and-implements-methods
June 19, 2024 - The Johns Hopkins Venous Thromboembolism (VTE) Collaborative Studies and Implements Methods to Prevent Avoidable Cases of Hospital Associated VTE
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Apri…
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April 22, 2021 - The Johns Hopkins Venous Thromboembolism (VTE)
Collaborative Studies and Implements Methods to Prevent
Avoidable Cases of Hospital Associated VTE
April 7, 2022
https://psnet.ahrq.gov/innovation/johns-hopkins-venous-thromboembolism-vte-collaborative-studies-and-
implements-methods
Summary
Venous thromboembolism (…
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psnet.ahrq.gov/perspective/preparing-health-reform-federal-government-and-nursing-workforce
September 01, 2012 - Preparing for Health Reform: The Federal Government and the Nursing Workforce
Peter I. Buerhaus, PhD, RN | September 1, 2012
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Citation Text:
Buerhaus P. Preparing for Health Reform: The Federal G…
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psnet.ahrq.gov/perspective/errors-and-near-misses-what-health-care-could-learn-aviation
September 01, 2006 - Errors and Near Misses: What Health Care Could Learn From Aviation
Carl Macrae, PhD | December 1, 2016
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Citation Text:
Macrae C. Errors and Near Misses: What Health Care Could Learn From Aviation…