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Clinical decision support alert malfunctions: analysis and empirically derived taxonomy. | PSNet

psnet.ahrq.gov/issue/clinical-decision-support-alert-malfunctions-analysis-and-empirically-derived-taxonomy

December 04, 2016 - Study Clinical decision support alert malfunctions: analysis and empirically derived taxonomy. Citation Text: Wright A, Ai A, Ash JS, et al. Clinical decision support alert malfunctions: analysis and empirically derived taxonomy. J Am Med Inform Assoc. 2018;25(5):496-506. doi:10.1093/jam…

"It is not the fault of the health care team - it is the way the system works": a mixed-methods quality improvement study of patients with advanced cancer and family members reveals challenges navigating a fragmented healthcare system and the administrative and financial burdens of care. | PSNet

psnet.ahrq.gov/issue/it-not-fault-health-care-team-it-way-system-works-mixed-methods-quality-improvement-study

March 24, 2019 - Study "It is not the fault of the health care team - it is the way the system works": a mixed-methods quality improvement study of patients with advanced cancer and family members reveals challenges navigating a fragmented healthcare system and the administrative and financial burdens of care. …

Comparing the variability of ingredient, strength, and dose form information from electronic prescriptions with RxNorm drug product descriptions. | PSNet

psnet.ahrq.gov/issue/comparing-variability-ingredient-strength-and-dose-form-information-electronic-prescriptions

March 20, 2024 - Study Comparing the variability of ingredient, strength, and dose form information from electronic prescriptions with RxNorm drug product descriptions. Citation Text: Lester CA, Flynn AJ, Marshall VD, et al. Comparing the variability of ingredient, strength, and dose form information fro…

What can we learn from in-depth analysis of human errors resulting in diagnostic errors in the emergency department: an analysis of serious adverse event reports. | PSNet

psnet.ahrq.gov/issue/what-can-we-learn-depth-analysis-human-errors-resulting-diagnostic-errors-emergency

June 08, 2022 - Study What can we learn from in-depth analysis of human errors resulting in diagnostic errors in the emergency department: an analysis of serious adverse event reports. Citation Text: Baartmans MC, Hooftman J, Zwaan L, et al. What can we learn from in-depth analysis of human errors resul…

National surveillance of emergency department visits for outpatient adverse drug events. | PSNet

psnet.ahrq.gov/issue/national-surveillance-emergency-department-visits-outpatient-adverse-drug-events

February 27, 2009 - Study Classic National surveillance of emergency department visits for outpatient adverse drug events. Citation Text: Budnitz DS, Pollock DA, Weidenbach KN, et al. National surveillance of emergency department visits for outpatient adverse drug events. JAMA. 200…

Relationships between medications used in a mental health hospital and types of medication errors: a cross-sectional study over an 8-year period. | PSNet

psnet.ahrq.gov/issue/relationships-between-medications-used-mental-health-hospital-and-types-medication-errors

November 29, 2023 - Study Relationships between medications used in a mental health hospital and types of medication errors: a cross-sectional study over an 8-year period. Citation Text: Lebas R, Calvet B, Schadler L, et al. Relationships between medications used in a mental health hospital and types of med…

Demonstrating high reliability on accountability measures at The Johns Hopkins Hospital. | PSNet

psnet.ahrq.gov/issue/demonstrating-high-reliability-accountability-measures-johns-hopkins-hospital

January 27, 2016 - Study Demonstrating high reliability on accountability measures at The Johns Hopkins Hospital. Citation Text: Pronovost P, Demski R, Callender T, et al. Demonstrating high reliability on accountability measures at the Johns Hopkins Hospital. Jt Comm J Qual Patient Saf. 2013;39(12):531…

Prospective evaluation of a multifaceted intervention to improve outcomes in intensive care: the Promoting Respect and Ongoing Safety through Patient Engagement Communication and Technology study. | PSNet

psnet.ahrq.gov/issue/prospective-evaluation-multifaceted-intervention-improve-outcomes-intensive-care-promoting

August 03, 2022 - Study Classic Prospective evaluation of a multifaceted intervention to improve outcomes in intensive care: the Promoting Respect and Ongoing Safety through Patient Engagement Communication and Technology study. Citation Text: Dykes PC, Rozenblum R, Dalal A, et a…

Impact of teamwork and communication training interventions on safety culture and patient safety in emergency departments: a systematic review. | PSNet

psnet.ahrq.gov/issue/impact-teamwork-and-communication-training-interventions-safety-culture-and-patient-safety

October 07, 2020 - Review Impact of teamwork and communication training interventions on safety culture and patient safety in emergency departments: a systematic review. Citation Text: Alsabri M, Boudi Z, Lauque D, et al. Impact of teamwork and communication training interventions on safety culture and pat…

When disasters strike the emergency department: a case series and narrative review. | PSNet

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September 30, 2020 - Commentary When disasters strike the emergency department: a case series and narrative review. Citation Text: Barten DG, Klokman VW, Cleef S, et al. When disasters strike the emergency department: a case series and narrative review. Int J Emerg Med. 2021;14(1):49. doi:10.1186/s12245-021-…

Changes to primary care delivery during the COVID-19 pandemic and perceived impact on medication safety: a survey study. | PSNet

psnet.ahrq.gov/issue/changes-primary-care-delivery-during-covid-19-pandemic-and-perceived-impact-medication-safety

January 18, 2023 - Study Changes to primary care delivery during the COVID-19 pandemic and perceived impact on medication safety: a survey study. Citation Text: Gleeson LL, Ludlow A, Wallace E, et al. Changes to primary care delivery during the COVID-19 pandemic and perceived impact on medication safety: a…

Are operating room distractions, interruptions, and disruptions associated with performance and patient safety? A systematic review and meta-analysis. | PSNet

psnet.ahrq.gov/issue/are-operating-room-distractions-interruptions-and-disruptions-associated-performance-and

December 02, 2020 - Review Are operating room distractions, interruptions, and disruptions associated with performance and patient safety? A systematic review and meta-analysis. Citation Text: Mcmullan RD, Urwin R, Gates PJ, et al. Are operating room distractions, interruptions and disruptions associated wi…

Missed diagnosis of cancer in primary care: insights from malpractice claims data. | PSNet

psnet.ahrq.gov/issue/missed-diagnosis-cancer-primary-care-insights-malpractice-claims-data

March 15, 2017 - Study Missed diagnosis of cancer in primary care: insights from malpractice claims data. Citation Text: Aaronson E, Quinn GR, Wong CI, et al. Missed diagnosis of cancer in primary care: Insights from malpractice claims data. J Healthc Risk Manag. 2019;39(2):19-29. doi:10.1002/jhrm.21385.…

Incident reporting system does not detect adverse drug events: a problem for quality improvement. | PSNet

psnet.ahrq.gov/issue/incident-reporting-system-does-not-detect-adverse-drug-events-problem-quality-improvement

February 10, 2011 - Study Classic Incident reporting system does not detect adverse drug events: a problem for quality improvement. Citation Text: Cullen DJ, Bates DW, Small SD, et al. The incident reporting system does not detect adverse drug events: a problem for quality improvem…

Why test results are still getting "lost" to follow-up: a qualitative study of implementation gaps. | PSNet

psnet.ahrq.gov/issue/why-test-results-are-still-getting-lost-follow-qualitative-study-implementation-gaps

June 22, 2022 - Study Why test results are still getting "lost" to follow-up: a qualitative study of implementation gaps. Citation Text: 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;3…

Does root cause analysis improve patient safety? A systematic review at the Department of Veterans Affairs. | PSNet

psnet.ahrq.gov/issue/does-root-cause-analysis-improve-patient-safety-systematic-review-department-veterans-affairs

March 24, 2021 - Review Does root cause analysis improve patient safety? A systematic review at the Department of Veterans Affairs. Citation Text: Shah F, Falconer EA, Cimiotti JP. Does root cause analysis improve patient safety? A systematic review at the Department of Veterans Affairs. Qual Manag Healt…

Readiness of US general surgery residents for independent practice. | PSNet

psnet.ahrq.gov/issue/readiness-us-general-surgery-residents-independent-practice

April 24, 2018 - Study Classic Readiness of US general surgery residents for independent practice. Citation Text: George BC, Bohnen JD, Williams RG, et al. Readiness of US General Surgery Residents for Independent Practice. Ann Surg. 2017;266(4):582-594. doi:10.1097/SLA.00000000…

Filling a gap in safety metrics: development of a patient-centred framework to identify and categorise patient-reported breakdowns related to the diagnostic process in ambulatory care. | PSNet

psnet.ahrq.gov/issue/filling-gap-safety-metrics-development-patient-centred-framework-identify-and-categorise

February 15, 2023 - Study Filling a gap in safety metrics: development of a patient-centred framework to identify and categorise patient-reported breakdowns related to the diagnostic process in ambulatory care. Citation Text: Bell SK, Bourgeois FC, DesRoches CM, et al. Filling a gap in safety metrics: devel…

NICU medication errors: identifying a risk profile for medication errors in the neonatal intensive care unit. | PSNet

psnet.ahrq.gov/issue/nicu-medication-errors-identifying-risk-profile-medication-errors-neonatal-intensive-care

September 21, 2008 - Study NICU medication errors: identifying a risk profile for medication errors in the neonatal intensive care unit. Citation Text: Stavroudis TA, Shore AD, Morlock L, et al. NICU medication errors: identifying a risk profile for medication errors in the neonatal intensive care unit. J Pe…

Increased mortality and costs associated with adverse events in intensive care unit patients. | PSNet

psnet.ahrq.gov/issue/increased-mortality-and-costs-associated-adverse-events-intensive-care-unit-patients

January 16, 2008 - Study Increased mortality and costs associated with adverse events in intensive care unit patients. Citation Text: Cantor N, Durr KM, McNeill K, et al. Increased mortality and costs associated with adverse events in intensive care unit patients. J Intensive Care Med. 2022;37(8):1075-1081…

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