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The impact of health information management professionals on patient safety: a systematic review. | PSNet

psnet.ahrq.gov/issue/impact-health-information-management-professionals-patient-safety-systematic-review

August 25, 2021 - Review The impact of health information management professionals on patient safety: a systematic review. Citation Text: Kemp T, Butler‐Henderson K, Allen P, et al. The impact of health information management professionals on patient safety: a systematic review. Health Info Libr J. 2021;3…

Blood and blood products transfusion errors: what can we do to improve patient safety. | PSNet

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September 23, 2020 - Review Blood and blood products transfusion errors: what can we do to improve patient safety. Citation Text: Brown C, Brown M. Blood and blood products transfusion errors: what can we do to improve patient safety? Br J Nurs. 2023;32(7):326-332. doi:10.12968/bjon.2023.32.7.326. Copy Cit…

What happens to the medication regimens of older adults during and after an acute hospitalization? | PSNet

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May 19, 2021 - Study What happens to the medication regimens of older adults during and after an acute hospitalization? Citation Text: Harris CM, Sridharan A, Landis R, et al. What happens to the medication regimens of older adults during and after an acute hospitalization? J Patient Saf. 2013;9(3):15…

Implementation of a standardized tool for root cause analysis selection. | PSNet

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November 06, 2024 - Study Implementation of a standardized tool for root cause analysis selection. Citation Text: Wahlstedt E, Levy BE, Scott E, et al. Implementation of a standardized tool for root cause analysis selection. J Patient Saf. 2025;21(2):101-105. doi:10.1097/pts.0000000000001291. Copy Citatio…

Combined SNA and LDA methods to understand adverse medical events | PSNet

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November 15, 2023 - Journal Article Combined SNA and LDA methods to understand adverse medical events Citation Text: Zhu L, Reychav I, McHaney R, et al. Combined SNA and LDA methods to understand adverse medical events. Int J Risk Saf Med. 2019;30(3):129-153. doi:10.3233/JRS-180052. Copy Citation Form…

Frequency and clinical importance of pages sent to the wrong physician. | PSNet

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October 31, 2011 - Study Frequency and clinical importance of pages sent to the wrong physician. Citation Text: Wong BM, Quan S, Cheung M, et al. Frequency and clinical importance of pages sent to the wrong physician. Arch Intern Med. 2009;169(11):1072-3. doi:10.1001/archinternmed.2009.117. Copy Citation…

The state of the evidence for computerized provider order entry: a systematic review and analysis of the quality of the literature. | PSNet

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August 04, 2021 - Review The state of the evidence for computerized provider order entry: a systematic review and analysis of the quality of the literature. Citation Text: Weir C, Staggers N, Phansalkar S. The state of the evidence for computerized provider order entry: a systematic review and analysis …

Healthcare Inspection: Evaluation of the Veterans Health Administration's National Consult Delay Review and Associated Fact Sheet. | PSNet

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September 10, 2014 - Book/Report Healthcare Inspection: Evaluation of the Veterans Health Administration's National Consult Delay Review and Associated Fact Sheet. Citation Text: Healthcare Inspection: Evaluation of the Veterans Health Administration's National Consult Delay Review and Associated Fact Sheet.…

Addressing adultification of black pediatric patients in the emergency department: a framework to decrease disparities. | PSNet

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October 27, 2021 - Commentary Addressing adultification of black pediatric patients in the emergency department: a framework to decrease disparities. Citation Text: Koch A, Kozhumam A. Addressing adultification of black pediatric patients in the emergency department: a framework to decrease disparities. He…

Interventions to improve follow-up of laboratory test results pending at discharge: a systematic review. | PSNet

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May 19, 2021 - Review Interventions to improve follow-up of laboratory test results pending at discharge: a systematic review. Citation Text: Whitehead NS, Williams L, Meleth S, et al. Interventions to Improve Follow-Up of Laboratory Test Results Pending at Discharge: A Systematic Review. J Hosp Med. 2…

Wrong-site nerve blocks: 10 yr experience in a large multihospital health-care system. | PSNet

psnet.ahrq.gov/issue/wrong-site-nerve-blocks-10-yr-experience-large-multihospital-health-care-system

January 14, 2011 - Study Wrong-site nerve blocks: 10 yr experience in a large multihospital health-care system. Citation Text: Hudson ME, Chelly JE, Lichter JR. Wrong-site nerve blocks: 10 yr experience in a large multihospital health-care system. Br J Anaesth. 2015;114(5):818-24. doi:10.1093/bja/aeu490. …

Identification errors involving clinical laboratories: a College of American Pathologists Q-Probes study of patient and specimen identification errors at 120 institutions. | PSNet

psnet.ahrq.gov/issue/identification-errors-involving-clinical-laboratories-college-american-pathologists-q-probes

February 15, 2010 - Study Identification errors involving clinical laboratories: a College of American Pathologists Q-Probes study of patient and specimen identification errors at 120 institutions. Citation Text: Pathologists C of A, Valenstein PN, Raab SS, et al. Identification errors involving clinical …

A call to bridge across silos during care transitions. | PSNet

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November 20, 2024 - Commentary A call to bridge across silos during care transitions. Citation Text: Sheikh F, Gathecha E, Bellantoni M, et al. A Call to Bridge Across Silos during Care Transitions. Jt Comm J Qual Patient Saf. 2018;44(5):270-278. doi:10.1016/j.jcjq.2017.10.006. Copy Citation Format: …

An observational analysis of surgical team compliance with perioperative safety practices after crew resource management training. | PSNet

psnet.ahrq.gov/issue/observational-analysis-surgical-team-compliance-perioperative-safety-practices-after-crew

May 04, 2012 - Study An observational analysis of surgical team compliance with perioperative safety practices after crew resource management training. Citation Text: France DJ, Leming-Lee S, Jackson T, et al. An observational analysis of surgical team compliance with perioperative safety practices a…

Cross-Check QA: a quality assurance workflow to prevent missed diagnoses by alerting inadvertent discordance between the radiologist and AI in the interpretation of high acuity CT scans. | PSNet

psnet.ahrq.gov/issue/cross-check-qa-quality-assurance-workflow-prevent-missed-diagnoses-alerting-inadvertent

March 04, 2015 - Study Cross-Check QA: a quality assurance workflow to prevent missed diagnoses by alerting inadvertent discordance between the radiologist and AI in the interpretation of high acuity CT scans. Citation Text: Chekmeyan M, Baccei SJ, Garwood ER. Cross-Check QA: a quality assurance workflow…

Automated communication tools and computer-based medication reconciliation to decrease hospital discharge medication errors. | PSNet

psnet.ahrq.gov/issue/automated-communication-tools-and-computer-based-medication-reconciliation-decrease-hospital

September 23, 2020 - Study Automated communication tools and computer-based medication reconciliation to decrease hospital discharge medication errors. Citation Text: Smith KJ, Handler S, Kapoor WN, et al. Automated Communication Tools and Computer-Based Medication Reconciliation to Decrease Hospital Dischar…

Building a learning organization. | PSNet

psnet.ahrq.gov/issue/building-learning-organization

June 16, 2011 - Study Classic Building a learning organization. Citation Text: Garvin DA. Building a learning organization. Harv Bus Rev. 1993;71(4):78-91. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…

Learning Health Systems | PSNet

psnet.ahrq.gov/issue/learning-health-systems

December 24, 2008 - Multi-use Website Learning Health Systems Citation Text: Learning Health Systems Agency for Health Research and Quality. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL …

Shifting the learning curve. | PSNet

psnet.ahrq.gov/issue/shifting-learning-curve

March 09, 2009 - Commentary Shifting the learning curve. Citation Text: Reynolds T, Kong M-L. Shifting the learning curve. BMJ. 2010;341:c6260. doi:10.1136/bmj.c6260. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

Learning from Investigations. | PSNet

psnet.ahrq.gov/issue/learning-investigations

July 28, 2013 - Book/Report Learning from Investigations. Citation Text: Learning from Investigations. Commission for Healthcare Audit and Inspection. London, England; Healthcare Commission: 2008. ISBN 9781845621636. Copy Citation Save Save to your library Print Downlo…

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