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Outpatient insulin-related adverse events due to mix-up errors: findings from two national surveillance systems, United States, 2012-2017. | PSNet

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March 10, 2021 - Study Outpatient insulin-related adverse events due to mix-up errors: findings from two national surveillance systems, United States, 2012-2017. Citation Text: Geller AI, Conrad AO, Weidle NJ, et al. Outpatient insulin‐related adverse events due to mix‐up errors: Findings from two nation…

Transforming the medication regimen review process using telemedicine to prevent adverse events. | PSNet

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November 11, 2015 - Study Transforming the medication regimen review process using telemedicine to prevent adverse events. Citation Text: Kane‐Gill SL, Wong A, Culley CM, et al. Transforming the medication regimen review process using telemedicine to prevent adverse events. J Am Geriatr Soc. 2020;69(2):530-…

The top patient safety strategies that can be encouraged for adoption now. | PSNet

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September 20, 2011 - Commentary The top patient safety strategies that can be encouraged for adoption now. Citation Text: Shekelle PG, Pronovost P, Wachter R, et al. The top patient safety strategies that can be encouraged for adoption now. Ann Intern Med. 2013;158(5 Pt 2):365-8. doi:10.7326/0003-4819-158-…

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

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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…

Correlation between the number of patient-reported adverse events, adverse drug events, and quality of life in older patients: an observational study. | PSNet

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August 10, 2022 - Study Correlation between the number of patient-reported adverse events, adverse drug events, and quality of life in older patients: an observational study. Citation Text: Beerlage-Davids CJ, Ponjee GHM, Vanhommerig JW, et al. Correlation between the number of patient-reported adverse ev…

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 …

Patient safety in emergency departments: a problem for health care systems? An international survey. | PSNet

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February 26, 2020 - Study Patient safety in emergency departments: a problem for health care systems? An international survey. Citation Text: Petrino R, Tuunainen E, Bruzzone G, et al. Patient safety in emergency departments: a problem for health care systems? An international survey. Eur J Emerg Med. 2023;…

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…

The development and piloting of the Ambulatory Electronic Health Record Evaluation Tool: lessons learned. | PSNet

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July 29, 2020 - Study The development and piloting of the Ambulatory Electronic Health Record Evaluation Tool: lessons learned. Citation Text: Co Z, Holmgren AJ, Classen DC, et al. The development and piloting of the Ambulatory Electronic Health Record Evaluation Tool: lessons learned. Appl Clin Inform.…

Cranky comments: detecting clinical decision support malfunctions through free-text override reasons. | PSNet

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April 29, 2018 - Study Cranky comments: detecting clinical decision support malfunctions through free-text override reasons. Citation Text: Aaron S, McEvoy DS, Ray S, et al. Cranky comments: detecting clinical decision support malfunctions through free-text override reasons. J Am Med Inform Assoc. 2019;2…

Rising drug allergy alert overrides in electronic health records: an observational retrospective study of a decade of experience. | PSNet

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July 06, 2022 - Study Rising drug allergy alert overrides in electronic health records: an observational retrospective study of a decade of experience. Citation Text: Topaz M, Seger DL, Slight SP, et al. Rising drug allergy alert overrides in electronic health records: an observational retrospective stu…

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

psnet.ahrq.gov/issue/patient-safety-perceptions-primary-care-providers-after-implementation-electronic-medical

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

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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…

Evaluation of the quality of 'do not use' medication abbreviation audits: a key enabler to successful implementation of audit and feedback. | PSNet

psnet.ahrq.gov/issue/evaluation-quality-do-not-use-medication-abbreviation-audits-key-enabler-successful

September 15, 2021 - Study Evaluation of the quality of 'do not use' medication abbreviation audits: a key enabler to successful implementation of audit and feedback. Citation Text: Li E, Marrandino J, Marshall S, et al. Evaluation of the quality of ‘do not use’ medication abbreviation audits: a key enabler…

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 …

The impact of drug shortages on children with cancer—the example of mechlorethamine. | PSNet

psnet.ahrq.gov/issue/impact-drug-shortages-children-cancer-example-mechlorethamine

February 15, 2023 - Study The impact of drug shortages on children with cancer—the example of mechlorethamine. Citation Text: Metzger ML, Billett A, Link MP. The impact of drug shortages on children with cancer--the example of mechlorethamine. N Engl J Med. 2012;367(26):2461-2463. doi:10.1056/NEJMp1212468. …

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