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psnet.ahrq.gov/issue/workarounds-electronic-health-record-systems-and-revised-sociotechnical-electronic-health
October 05, 2022 - Review
Workarounds in electronic health record systems and the revised Sociotechnical Electronic Health Record Workaround Analysis Framework: scoping review.
Citation Text:
Blijleven V, Hoxha F, Jaspers MWM. Workarounds in electronic health record systems and the revised sociotechnical E…
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psnet.ahrq.gov/issue/vestibular-syndromes-diagnosis-and-diagnostic-errors-patients-dizziness-presenting-emergency
May 17, 2023 - Study
Vestibular syndromes, diagnosis and diagnostic errors in patients with dizziness presenting to the emergency department: a cross-sectional study.
Citation Text:
Comolli L, Korda A, Zamaro E, et al. Vestibular syndromes, diagnosis and diagnostic errors in patients with dizziness pre…
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psnet.ahrq.gov/issue/relationship-between-job-burnout-psychosocial-factors-and-health-care-associated-infections
January 12, 2022 - Study
Relationship between job burnout, psychosocial factors and health care–associated infections in critical care units.
Citation Text:
Galletta M, Portoghese I, D'Aloja E, et al. Relationship between job burnout, psychosocial factors and health care-associated infections in critical c…
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psnet.ahrq.gov/sites/default/files/2020-05/final_may-spotlight-fatal_pca_slides_05.01.2020_cme_review-revised.pdf
January 01, 2020 - Review of nationally reported opioid-related sentinel events
found that 75% were attributable to medication … error and
improper monitoring
12
Opioid-Induced Respiratory Depression (3) 13
• Majority of PCA … Medication errors involving patient-controlled analgesia.
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www.ahrq.gov/research/findings/final-reports/index.html?page=20
January 01, 2024 - Grantee Final Reports: Patient Safety
Final reports from research grants administered since 2000 on a variety of patient safety topics, such as measure development, medication safety, and diagnostic safety.
The Agency for Healthcare Research and Quality Center for Quality Improvement and Patient Safety subdivis…
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psnet.ahrq.gov/issue/stop-silent-misdiagnosis-patients-preferences-matter
February 02, 2020 - August 5, 2020
Medication errors associated with transition from insulin pens to insulin
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psnet.ahrq.gov/issue/ai-cant-replace-doctors-it-can-make-them-better
September 03, 2014 - June 14, 2019
Evaluation of an electronic dosing calculator to reduce pediatric medication … errors.
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psnet.ahrq.gov/issue/managing-risks-direct-oral-anticoagulants
December 23, 2016 - September 23, 2020
Direct oral anticoagulants: a review of common medication errors.
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psnet.ahrq.gov/issue/profiles-patient-safety-authority-gradients-medical-error
August 28, 2019 - July 31, 2013
Profiles in patient safety: medication errors in the emergency department
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psnet.ahrq.gov/issue/forgive-and-forget-recognition-error-and-use-apology-preemptive-steps-adr-or-litigation
July 24, 2018 - December 16, 2020
Analysis of iatrogenic and in-hospital medication errors reported to
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psnet.ahrq.gov/issue/learning-serious-failings-care-main-report
August 23, 2017 - June 30, 2021
The effect of the fit between organizational culture and structure on medication … errors in medical group practices.
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psnet.ahrq.gov/issue/opioid-crisis-can-improving-diagnosis-help-solve-problem
February 25, 2019 - January 15, 2017
Guardians of grafts: reducing medication errors in transplant recipients
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psnet.ahrq.gov/issue/weak-oversight-allows-lab-failures-put-patients-risk
June 12, 2019 - March 11, 2020
At Walgreens, complaints of medication errors go missing.
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psnet.ahrq.gov/issue/losing-laura
June 06, 2018 - Related Resources From the Same Author(s)
Report faults Children's Hospital for medication … errors.
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psnet.ahrq.gov/issue/patients-put-risk-nhs-computer-fault
November 04, 2012 - Providers
Health Care Executives and Administrators
Information Professionals
Patients
Medication … Errors/Preventable Adverse Drug Events
View More
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digital.ahrq.gov/2020-year-review/research-summary/improving-medication-safety-accurate-e-prescribing-tool
January 01, 2020 - Improving Medication Safety with Accurate e-Prescribing Tool
Successful implementation of CancelRx, an e-prescribing functionality to electronically communicate medication discontinuation orders between electronic health records and pharmacies, can improve medication safety and reduce adverse drug events.
…
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psnet.ahrq.gov/node/836978/psn-pdf
May 16, 2022 - Check Twice, Transport Once
May 16, 2022
DePew A, Rice J, Chou J. Check Twice, Transport Once. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/check-twice-transport-once
The Case
Case #1: A 26-year-old woman (Patient A) presented to the Emergency Department (ED) with abdominal
pain and was diagnosed with “s…
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psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulness
February 01, 2014 - They concluded that each interruption results in a 12.7% increased risk of a medication error and that … individually and collectively, to ensure that they actually do reduce the frequency and severity of medication … errors without negative unanticipated consequences.( 5 )
Certain clinical environments such as the … errors ( 14 ) or interruptions.( 2 ) The adoption of this strategy appears somewhat limited perhaps … Keep away: Kaiser South San Francisco RNs don yellow sashes to reduce interruptions and medication errors
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psnet.ahrq.gov/issue/preventing-medical-errors-how-proceed-caution
January 24, 2024 - Newspaper/Magazine Article
Preventing medical errors: how to proceed with caution.
Citation Text:
Shaw G. Preventing Medical Errors. The Hearing Journal. 2014;67(7). doi:10.1097/01.hj.0000452244.07451.64.
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psnet.ahrq.gov/issue/residents-suggestions-reducing-errors-teaching-hospitals
August 20, 2018 - Commentary
Residents' suggestions for reducing errors in teaching hospitals.
Citation Text:
Volpp KGM, Grande D. Residents' suggestions for reducing errors in teaching hospitals. N Engl J Med. 2003;348(9):851-5.
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