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  1. The impact of computerised physician order entry and clinical decision support on pharmacist–physician communication in the hospital setting: a qualitative study. | PSNet

    psnet.ahrq.gov/issue/impact-computerised-physician-order-entry-and-clinical-decision-support-pharmacist-physician
    August 24, 2016 - Study The impact of computerised physician order entry and clinical decision support on pharmacist–physician communication in the hospital setting: a qualitative study. Citation Text: Pontefract SK, Coleman JJ, Vallance HK, et al. The impact of computerised physician order entry and clin…

  2. Look-alike medications in the perioperative setting: scoping review of medication incidents and risk reduction interventions. | PSNet

    psnet.ahrq.gov/issue/look-alike-medications-perioperative-setting-scoping-review-medication-incidents-and-risk
    October 04, 2023 - Review Look-alike medications in the perioperative setting: scoping review of medication incidents and risk reduction interventions. Citation Text: Ryan AN, Robertson KL, Glass BD. Look-alike medications in the perioperative setting: scoping review of medication incidents and risk reduct…

  3. The safety of warfarin therapy in the nursing home setting. | PSNet

    psnet.ahrq.gov/issue/safety-warfarin-therapy-nursing-home-setting
    March 11, 2011 - Study The safety of warfarin therapy in the nursing home setting. Citation Text: Gurwitz JH, Field T, Radford MJ, et al. The safety of warfarin therapy in the nursing home setting. Am J Med. 2007;120(6):539-44. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3…

  4. Systems errors versus physicians' errors: finding the balance in medical education. | PSNet

    psnet.ahrq.gov/issue/systems-errors-versus-physicians-errors-finding-balance-medical-education
    October 12, 2012 - Commentary Systems errors versus physicians' errors: finding the balance in medical education. Citation Text: Casarett D, Helms C. Systems errors versus physicians' errors: finding the balance in medical education. Acad Med. 1999;74(1):19-22. Copy Citation Format: Google …

  5. Medication reconciliation accuracy and patient understanding of intended medication changes on hospital discharge. | PSNet

    psnet.ahrq.gov/issue/medication-reconciliation-accuracy-and-patient-understanding-intended-medication-changes
    July 29, 2020 - Study Medication reconciliation accuracy and patient understanding of intended medication changes on hospital discharge. Citation Text: Ziaeian B, Araujo KLB, Van Ness PH, et al. Medication reconciliation accuracy and patient understanding of intended medication changes on hospital disch…

  6. Pharmacist-led admission medication reconciliation before and after the implementation of an electronic medication management system. | PSNet

    psnet.ahrq.gov/issue/pharmacist-led-admission-medication-reconciliation-and-after-implementation-electronic
    January 15, 2025 - Study Pharmacist-led admission medication reconciliation before and after the implementation of an electronic medication management system. Citation Text: Sardaneh AA, Burke R, Ritchie A, et al. Pharmacist-led admission medication reconciliation before and after the implementation of an …

  7. Wrong-site surgery in California, 2007–2014. | PSNet

    psnet.ahrq.gov/issue/wrong-site-surgery-california-2007-2014
    July 27, 2023 - Study Wrong-site surgery in California, 2007–2014. Citation Text: Moshtaghi O, Haidar YM, Sahyouni R, et al. Wrong-site surgery in California, 2007-2014. Otolaryngol Head Neck Surg. 2017;157(1):48-52. doi:10.1177/0194599817693226. Copy Citation Format: DOI Google Scholar Pu…

  8. Bariatric surgery with operating room teams that stayed fixed during the day: a multicenter study analyzing the effects on patient outcomes, teamwork and safety climate, and procedure duration. | PSNet

    psnet.ahrq.gov/issue/bariatric-surgery-operating-room-teams-stayed-fixed-during-day-multicenter-study-analyzing
    December 21, 2014 - Study Bariatric surgery with operating room teams that stayed fixed during the day: a multicenter study analyzing the effects on patient outcomes, teamwork and safety climate, and procedure duration. Citation Text: Stepaniak PS, Heij C, Buise MP, et al. Bariatric surgery with operating r…

  9. The mindful path to nursing accuracy: a quasi-experimental study on minimizing medication administration errors. | PSNet

    psnet.ahrq.gov/issue/mindful-path-nursing-accuracy-quasi-experimental-study-minimizing-medication-administration
    March 03, 2019 - Study The mindful path to nursing accuracy: a quasi-experimental study on minimizing medication administration errors. Citation Text: Ekkens CL, Gordon PA. The mindful path to nursing accuracy: a quasi-experimental study on minimizing medication administration errors. Holist Nurs Pract. …

  10. Eight CT lessons that we learned the hard way: an analysis of current patterns of radiological error and discrepancy with particular emphasis on CT. | PSNet

    psnet.ahrq.gov/issue/eight-ct-lessons-we-learned-hard-way-analysis-current-patterns-radiological-error-and
    September 24, 2018 - Study Eight CT lessons that we learned the hard way: an analysis of current patterns of radiological error and discrepancy with particular emphasis on CT. Citation Text: McCreadie G, Oliver TB. Eight CT lessons that we learned the hard way: an analysis of current patterns of radiologic…

  11. Best practices: an electronic drug alert program to improve safety in an accountable care environment. | PSNet

    psnet.ahrq.gov/issue/best-practices-electronic-drug-alert-program-improve-safety-accountable-care-environment
    May 29, 2019 - Study Best practices: an electronic drug alert program to improve safety in an accountable care environment. Citation Text: Griesbach S, Lustig A, Malsin L, et al. Best Practices: An Electronic Drug Alert Program to Improve Safety in an Accountable Care Environment. J Manag Care Spec Pha…

  12. Identifying health information technology related safety event reports from patient safety event report databases. | PSNet

    psnet.ahrq.gov/issue/identifying-health-information-technology-related-safety-event-reports-patient-safety-event
    July 07, 2021 - Study Identifying health information technology related safety event reports from patient safety event report databases. Citation Text: Fong A, Adams KT, Gaunt MJ, et al. Identifying health information technology related safety event reports from patient safety event report databases. J …

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73874/psn-pdf
    September 29, 2021 - The generalizability of a medication administration discrepancy detection system: quantitative comparative analysis September 29, 2021 Kirkendall E, Huth H, Rauenbuehler B, et al. The generalizability of a medication administration discrepancy detection system: quantitative comparative analysis. JMIR Med Inform. 2…

  14. Preventability of voluntarily reported or trigger tool–identified medication errors in a pediatric institution by information technology: a retrospective cohort study. | PSNet

    psnet.ahrq.gov/issue/preventability-voluntarily-reported-or-trigger-tool-identified-medication-errors-pediatric
    September 01, 2016 - Study Preventability of voluntarily reported or trigger tool–identified medication errors in a pediatric institution by information technology: a retrospective cohort study. Citation Text: Stultz JS, Nahata MC. Preventability of Voluntarily Reported or Trigger Tool-Identified Medication …

  15. Error or "act of God"? A study of patients' and operating room team members' perceptions of error definition, reporting, and disclosure. | PSNet

    psnet.ahrq.gov/issue/error-or-act-god-study-patients-and-operating-room-team-members-perceptions-error-definition
    August 10, 2011 - Study Error or "act of God"? A study of patients' and operating room team members' perceptions of error definition, reporting, and disclosure. Citation Text: Espin S, Levinson W, Regehr G, et al. Error or "act of God"? A study of patients' and operating room team members' perceptions o…

  16. Multi-level analysis of national nursing students' disclosure of patient safety concerns. | PSNet

    psnet.ahrq.gov/issue/multi-level-analysis-national-nursing-students-disclosure-patient-safety-concerns
    April 28, 2021 - Study Multi-level analysis of national nursing students' disclosure of patient safety concerns. Citation Text: Palese A, Gonella S, Grassetti L, et al. Multi-level analysis of national nursing students' disclosure of patient safety concerns. Med Educ. 2018;52(11):1156-1166. doi:10.1111/m…

  17. First-year analysis of the Operating Room Black Box study. | PSNet

    psnet.ahrq.gov/issue/first-year-analysis-operating-room-black-box-study
    October 16, 2019 - Study Emerging Classic First-year analysis of the Operating Room Black Box study. Citation Text: Jung JJ, Jüni P, Lebovic G, et al. First-year Analysis of the Operating Room Black Box Study. Ann Surg. 2020;271(1):122-127. doi:10.1097/SLA.0000000000002863. Copy…

  18. The Harvard Medical Practice Study trigger system performance in deceased patients. | PSNet

    psnet.ahrq.gov/issue/harvard-medical-practice-study-trigger-system-performance-deceased-patients
    March 02, 2022 - Study The Harvard Medical Practice Study trigger system performance in deceased patients. Citation Text: Klein DO, Rennenberg RJMW, Koopmans RP, et al. The Harvard medical practice study trigger system performance in deceased patients. BMC Health Serv Res. 2019;19(1):16. doi:10.1186/s129…

  19. Evaluation of near-miss wrong-patient events in radiology reports. | PSNet

    psnet.ahrq.gov/issue/evaluation-near-miss-wrong-patient-events-radiology-reports
    June 13, 2015 - Study Evaluation of near-miss wrong-patient events in radiology reports. Citation Text: Sadigh G, Loehfelm T, Applegate KE, et al. JOURNAL CLUB: Evaluation of Near-Miss Wrong-Patient Events in Radiology Reports. AJR Am J Roentgenol. 2015;205(2):337-43. doi:10.2214/AJR.14.13339. Copy Ci…

  20. Avoiding the unintended consequences of growth in medical care: how might more be worse? | PSNet

    psnet.ahrq.gov/issue/avoiding-unintended-consequences-growth-medical-care-how-might-more-be-worse
    April 24, 2018 - Commentary Classic Avoiding the unintended consequences of growth in medical care: how might more be worse? Citation Text: Fisher ES, Welch HG. Avoiding the unintended consequences of growth in medical care: how might more be worse? JAMA. 1999;281(5):446-53. …
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