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Using Health Care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective risk analysis system. | PSNet

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January 17, 2012 - Study Classic Using Health Care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective risk analysis system. Citation Text: DeRosier JM, Stalhandske E, Bagian JP, et al. Using health care Failure Mode and Effect Analysis: the V…

Physicians failed to write flawless prescriptions when computerized physician order entry system crashed. | PSNet

psnet.ahrq.gov/issue/physicians-failed-write-flawless-prescriptions-when-computerized-physician-order-entry-system

January 21, 2015 - Study Physicians failed to write flawless prescriptions when computerized physician order entry system crashed. Citation Text: Hsu C-C, Chou C-L, Chen T-J, et al. Physicians Failed to Write Flawless Prescriptions When Computerized Physician Order Entry System Crashed. Clin Ther. 2015;37(…

Implementing medication reconciliation in outpatient pediatrics. | PSNet

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September 23, 2020 - Study Implementing medication reconciliation in outpatient pediatrics. Citation Text: Rappaport DI, Collins B, Koster A, et al. Implementing medication reconciliation in outpatient pediatrics. Pediatrics. 2011;128(6):e1600-7. doi:10.1542/peds.2011-0993. Copy Citation Format: …

Failure to follow-up test results for ambulatory patients: a systematic review. | PSNet

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March 23, 2012 - Review Classic Failure to follow-up test results for ambulatory patients: a systematic review. Citation Text: Callen JL, Westbrook JI, Georgiou A, et al. Failure to Follow-Up Test Results for Ambulatory Patients: A Systematic Review. J Gen Intern Med. 2011;27(10…

Wrong-site and wrong-patient procedures in the Universal Protocol era: analysis of a prospective database of physician self-reported occurrences. | PSNet

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October 13, 2010 - Study Wrong-site and wrong-patient procedures in the Universal Protocol era: analysis of a prospective database of physician self-reported occurrences. Citation Text: Stahel PF, Sabel A, Victoroff MS, et al. Wrong-site and wrong-patient procedures in the universal protocol era: analysis …

Just what the doctor ordered: missed ordering of venous thromboembolism chemoprophylaxis is associated with increased VTE events in high-risk general surgery patients. | PSNet

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September 07, 2022 - Study Just what the doctor ordered: missed ordering of venous thromboembolism chemoprophylaxis is associated with increased VTE events in high-risk general surgery patients. Citation Text: Baimas-George MR, Ross SW, Yang H, et al. Just what the doctor ordered: missed ordering of venous t…

Integrating and evaluating the data quality and utility of smart pump information in detecting medication administration errors: evaluation study. | PSNet

psnet.ahrq.gov/issue/integrating-and-evaluating-data-quality-and-utility-smart-pump-information-detecting

September 09, 2020 - Study Integrating and evaluating the data quality and utility of smart pump information in detecting medication administration errors: evaluation study. Citation Text: Ni Y, Lingren T, Huth H, et al. Integrating and evaluating the data quality and utility of smart pump information in det…

An empirical model to estimate the potential impact of medication safety alerts on patient safety, health care utilization, and cost in ambulatory care. | PSNet

psnet.ahrq.gov/issue/empirical-model-estimate-potential-impact-medication-safety-alerts-patient-safety-health-care

September 01, 2016 - Study An empirical model to estimate the potential impact of medication safety alerts on patient safety, health care utilization, and cost in ambulatory care. Citation Text: Weingart SN, Simchowitz B, Padolsky H, et al. An empirical model to estimate the potential impact of medication sa…

U.S. adoption of computerized physician order entry systems. | PSNet

psnet.ahrq.gov/issue/us-adoption-computerized-physician-order-entry-systems

April 24, 2018 - Study Classic U.S. adoption of computerized physician order entry systems. Citation Text: Cutler DM, Feldman NE, Horwitz JR. U.S. adoption of computerized physician order entry systems. Health Aff (Millwood). 2005;24(6):1654-63. Copy Citation Format: …

Patient safety perceptions of primary care providers after implementation of an electronic medical record system. | PSNet

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December 21, 2014 - Study Patient safety perceptions of primary care providers after implementation of an electronic medical record system. Citation Text: McGuire MJ, Noronha G, Samal L, et al. Patient safety perceptions of primary care providers after implementation of an electronic medical record system. …

A systems approach to morbidity and mortality conference. | PSNet

psnet.ahrq.gov/issue/systems-approach-morbidity-and-mortality-conference

July 22, 2020 - Study Classic A systems approach to morbidity and mortality conference. Citation Text: Szostek JH, Wieland ML, Loertscher LL, et al. A systems approach to morbidity and mortality conference. Am J Med. 2010;123(7):663-668. doi:10.1016/j.amjmed.2010.03.010. Co…

Patient safety implications of wearing a face mask for prevention in the era of COVID-19 pandemic: a systematic review and consensus recommendations. | PSNet

psnet.ahrq.gov/issue/patient-safety-implications-wearing-face-mask-prevention-era-covid-19-pandemic-systematic

September 16, 2020 - Review Patient safety implications of wearing a face mask for prevention in the era of COVID-19 pandemic: a systematic review and consensus recommendations. Citation Text: Balestracci B, La Regina M, Di Sessa D, et al. Patient safety implications of wearing a face mask for prevention in …

Optimizing Therapy to Prevent Avoidable Hospital Admissions in Multimorbid Older Adults (OPERAM): cluster randomised controlled trial. | PSNet

psnet.ahrq.gov/issue/optimizing-therapy-prevent-avoidable-hospital-admissions-multimorbid-older-adults-operam

December 21, 2022 - Study Optimizing Therapy to Prevent Avoidable Hospital Admissions in Multimorbid Older Adults (OPERAM): cluster randomised controlled trial. Citation Text: Blum MR, Sallevelt B, Spinewine A, et al. Optimizing Therapy to Prevent Avoidable Hospital Admissions in Multimorbid Older Adults (O…

Registered nurses' and medical doctors' experiences of patient safety in health information exchange during interorganizational care transitions: a qualitative review. | PSNet

psnet.ahrq.gov/issue/registered-nurses-and-medical-doctors-experiences-patient-safety-health-information-exchange

July 22, 2020 - Review Registered nurses' and medical doctors' experiences of patient safety in health information exchange during interorganizational care transitions: a qualitative review. Citation Text: Hyvämäki P, Kääriäinen M, Tuomikoski A-M, et al. Registered nurses' and medical doctors' experienc…

Reasons for bias in ambulance clinicians' assessments of non-conveyed patients: a mixed-methods study. | PSNet

psnet.ahrq.gov/issue/reasons-bias-ambulance-clinicians-assessments-non-conveyed-patients-mixed-methods-study

January 26, 2022 - Study Reasons for bias in ambulance clinicians' assessments of non-conveyed patients: a mixed-methods study. Citation Text: Johansson H, Lundgren K, Hagiwara MA. Reasons for bias in ambulance clinicians’ assessments of non-conveyed patients: a mixed-methods study. BMC Emerg Med. 2022;22(…

Effects of the introduction of the WHO "Surgical Safety Checklist" on in-hospital mortality: a cohort study. | PSNet

psnet.ahrq.gov/issue/effects-introduction-who-surgical-safety-checklist-hospital-mortality-cohort-study

April 24, 2018 - Study Effects of the introduction of the WHO "Surgical Safety Checklist" on in-hospital mortality: a cohort study. Citation Text: van Klei WA, Hoff RG, van Aarnhem EEHL, et al. Effects of the introduction of the WHO "Surgical Safety Checklist" on in-hospital mortality: a cohort study. …

Room of hazards: a comparison of differences in safety hazard recognition among various hospital-based healthcare professionals and trainees in a simulated patient room. | PSNet

psnet.ahrq.gov/issue/room-hazards-comparison-differences-safety-hazard-recognition-among-various-hospital-based

April 01, 2020 - Study Room of hazards: a comparison of differences in safety hazard recognition among various hospital-based healthcare professionals and trainees in a simulated patient room. Citation Text: Wang M, Banda B, Rodwin BA, et al. Room of hazards: a comparison of differences in safety hazard …

Implementation of a mandatory checklist of protocols and objectives improves compliance with a wide range of evidence-based intensive care unit practices. | PSNet

psnet.ahrq.gov/issue/implementation-mandatory-checklist-protocols-and-objectives-improves-compliance-wide-range

September 22, 2010 - Study Implementation of a mandatory checklist of protocols and objectives improves compliance with a wide range of evidence-based intensive care unit practices. Citation Text: Byrnes MC, Schuerer DJE, Schallom ME, et al. Implementation of a mandatory checklist of protocols and objectiv…

Lessons learned from a national hospital antibiotic stewardship implementation project. | PSNet

psnet.ahrq.gov/issue/lessons-learned-national-hospital-antibiotic-stewardship-implementation-project

July 20, 2022 - Study Lessons learned from a national hospital antibiotic stewardship implementation project. Citation Text: Cosgrove SE, Ahn R, Dullabh P, et al. Lessons learned from a national hospital antibiotic stewardship implementation project. Jt Comm J Qual Patient Saf. 2024;50(6):435-441. doi:1…

Human factors considerations in using personal protective equipment in the COVID-19 pandemic context: a bi-national survey study. | PSNet

psnet.ahrq.gov/issue/human-factors-considerations-using-personal-protective-equipment-covid-19-pandemic-context-bi

July 08, 2020 - Study Human factors considerations in using personal protective equipment in the COVID-19 pandemic context: a bi-national survey study. Citation Text: Parush A, Wacht O, Gomes R, et al. Human Factors Considerations in Using Personal Protective Equipment in the COVID-19 Pandemic Context: …

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