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psnet.ahrq.gov/node/37006/psn-pdf
May 04, 2015 - A proposal to use common ground that exists between
the medical and legal professions to promote a culture of
safety.
May 4, 2015
Pegalis SE, 51 N.Y.L. SCH. L. REV. 1057 (2006-2007).
https://psnet.ahrq.gov/issue/proposal-use-common-ground-exists-between-medical-and-legal-professions-
promote-culture
The author p…
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psnet.ahrq.gov/node/39723/psn-pdf
February 01, 2011 - Barriers and facilitators to chemotherapy patients'
engagement in medical error prevention.
February 1, 2011
Schwappach DLB, Wernli M. Barriers and facilitators to chemotherapy patients' engagement in medical
error prevention. Ann Oncol. 2011;22(2):424-30. doi:10.1093/annonc/mdq346.
https://psnet.ahrq.gov/issue/ba…
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psnet.ahrq.gov/node/49425/psn-pdf
November 01, 2003 - Misread Label
November 1, 2003
Franklin BD. Misread Label. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/misread-label
The Case
An infant was born with sluggish respirations. During labor the infant’s mother had received meperidine
[Demerol, a pain medication], a narcotic with a half-life of 2.5-4.0 hours…
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psnet.ahrq.gov/node/72755/psn-pdf
February 17, 2021 - Renal medication-related clinical decision support (CDS)
alerts and overrides in the inpatient setting following
implementation of a commercial electronic health record:
implications for designing more effective alerts.
February 17, 2021
Shah SN, Amato MG, Garlo KG, et al. Renal medication-related clinical decisio…
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psnet.ahrq.gov/node/34684/psn-pdf
May 27, 2011 - Effect of computerized physician order entry and a team
intervention on prevention of serious medication errors.
May 27, 2011
Bates DW, Leape L, Cullen DJ, et al. Effect of computerized physician order entry and a team intervention
on prevention of serious medication errors. JAMA. 1998;280(15):1311-6.
https://psne…
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psnet.ahrq.gov/node/46584/psn-pdf
December 06, 2017 - Alterations in Spanish language interpretation during
pediatric critical care family meetings.
December 6, 2017
Sinow CS, Corso I, Lorenzo J, et al. Alterations in Spanish Language Interpretation During Pediatric Critical
Care Family Meetings. Crit Care Med. 2017;45(11):1915-1921. doi:10.1097/CCM.0000000000002650.
…
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psnet.ahrq.gov/node/47153/psn-pdf
October 12, 2018 - Clinicians' perceptions of medication errors with opioids
in cancer and palliative care services: a priority setting
report.
October 12, 2018
Heneka N, Shaw T, Azzi C, et al. Clinicians' perceptions of medication errors with opioids in cancer and
palliative care services: a priority setting report. Support Care Ca…
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psnet.ahrq.gov/node/60934/psn-pdf
September 23, 2020 - Hospital ward adaptation during the COVID-19 pandemic:
a national survey of academic medical centers.
September 23, 2020
Auerbach AD, O'Leary KJ, Greysen SR, et al. Hospital ward adaptation during the COVID-19 pandemic: a
national survey of academic medical centers. J Hosp Med. 2020;15(8):483-488. doi:10.12788/jhm.…
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psnet.ahrq.gov/node/855429/psn-pdf
November 15, 2023 - Effect of complementary interventions to redesign care
on teamwork and quality for hospitalized medical
patients: a pragmatic controlled trial.
November 15, 2023
O’Leary KJ, Johnson JK, Williams MV, et al. Effect of complementary interventions to redesign care on
teamwork and quality for hospitalized medical patie…
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psnet.ahrq.gov/node/39315/psn-pdf
March 21, 2017 - Risk managers, physicians, and disclosure of harmful
medical errors.
March 21, 2017
Loren DJ, Garbutt J, Dunagan C, et al. Risk managers, physicians, and disclosure of harmful medical
errors. Jt Comm J Qual Patient Saf. 2010;36(3):101-8.
https://psnet.ahrq.gov/issue/risk-managers-physicians-and-disclosure-harmful-…
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psnet.ahrq.gov/node/37787/psn-pdf
May 28, 2008 - Adoption of health information technology for medication
safety in US hospitals, 2006.
May 28, 2008
Furukawa MF, Raghu TS, Spaulding TJ, et al. Adoption of health information technology for medication
safety in U.S. Hospitals, 2006. Health Aff (Millwood). 2008;27(3):865-75. doi:10.1377/hlthaff.27.3.865.
https://ps…
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psnet.ahrq.gov/node/844787/psn-pdf
September 11, 2019 - TRIAD XII: are patients aware of and agree with DNR or
POLST orders in their medical records.
September 11, 2019
Mirarchi FL, Juhasz K, Cooney TE, et al. TRIAD XII: Are Patients Aware of and Agree With DNR or POLST
Orders in Their Medical Records. J Patient Saf. 2019;15(3):230-237. doi:10.1097/PTS.0000000000000631.…
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psnet.ahrq.gov/node/857453/psn-pdf
December 06, 2023 - Post-implementation optimization of medication alerts in
hospital computerized provider order entry systems: a
scoping review.
December 6, 2023
Ledger TS, Brooke-Cowden K, Coiera E. Post-implementation optimization of medication alerts in hospital
computerized provider order entry systems: a scoping review. J Am M…
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psnet.ahrq.gov/node/866646/psn-pdf
September 04, 2024 - Adverse events and perceived abandonment: learning
from patients' accounts of medical mishaps.
September 4, 2024
Schlesinger M, Dhingra I, Fain BA, et al. Adverse events and perceived abandonment: learning from
patients’ accounts of medical mishaps. BMJ Open Qual. 2024;13(3):e002848. doi:10.1136/bmjoq-2024-
002848…
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psnet.ahrq.gov/node/40750/psn-pdf
September 07, 2011 - Are temporary staff associated with more severe
emergency department medication errors?
September 7, 2011
Pham JC, Andrawis M, Shore AD, et al. Are temporary staff associated with more severe emergency
department medication errors? J Healthc Qual. 2011;33(4):9-18. doi:10.1111/j.1945-1474.2010.00116.x.
https://psne…
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psnet.ahrq.gov/node/50751/psn-pdf
December 18, 2019 - Using a machine learning system to identify and prevent
medication prescribing errors: a clinical and cost analysis
evaluation.
December 18, 2019
Rozenblum R, Rodriguez-Monguio R, Volk LA, et al. Using a machine learning system to identify and
prevent medication prescribing errors: A clinical and cost analysis eva…
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psnet.ahrq.gov/node/44453/psn-pdf
June 21, 2016 - Inadequacies of physical examination as a cause of
medical errors and adverse events: a collection of
vignettes.
June 21, 2016
Verghese A, Charlton B, Kassirer JP, et al. Inadequacies of Physical Examination as a Cause of Medical
Errors and Adverse Events: A Collection of Vignettes. Am J Med. 2015;128(12):1322-4.e…
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psnet.ahrq.gov/node/37974/psn-pdf
March 04, 2011 - The impact of medical errors on ninety-day costs and
outcomes: an examination of surgical patients.
March 4, 2011
Encinosa W, Hellinger FJ. The impact of medical errors on ninety-day costs and outcomes: an examination
of surgical patients. Health Serv Res. 2008;43(6):2067-85. doi:10.1111/j.1475-6773.2008.00882.x.
…
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psnet.ahrq.gov/node/35927/psn-pdf
February 17, 2011 - Claims, errors, and compensation payments in medical
malpractice litigation.
February 17, 2011
Studdert DM, Mello MM, Gawande AA, et al. Claims, errors, and compensation payments in medical
malpractice litigation. N Engl J Med. 2006;354(19):2024-33.
https://psnet.ahrq.gov/issue/claims-errors-and-compensation-payme…
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psnet.ahrq.gov/node/42882/psn-pdf
November 23, 2016 - Structuring patient and family involvement in medical
error event disclosure and analysis.
November 23, 2016
Etchegaray J, Ottosen M, Burress L, et al. Structuring patient and family involvement in medical error event
disclosure and analysis. Health Aff (Millwood). 2014;33(1):46-52. doi:10.1377/hlthaff.2013.0831.
…