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  1. psnet.ahrq.gov/issue/assessment-unintentional-duplicate-orders-emergency-department-clinicians-and-after
    October 19, 2022 - Study Assessment of unintentional duplicate orders by emergency department clinicians before and after implementation of a visual aid in the electronic health record ordering system. Citation Text: Horng S, Joseph JW, Calder S, et al. Assessment of Unintentional Duplicate Orders by Emerg…
  2. psnet.ahrq.gov/issue/indication-documentation-and-indication-based-prescribing-within-electronic-prescribing
    December 18, 2019 - Review Indication documentation and indication-based prescribing within electronic prescribing systems: a systematic review and narrative synthesis. Citation Text: Feather C, Appelbaum N, Darzi A, et al. Indication documentation and indication-based prescribing within electronic prescrib…
  3. psnet.ahrq.gov/issue/high-rates-adverse-drug-events-highly-computerized-hospital
    August 04, 2021 - Study Classic High rates of adverse drug events in a highly computerized hospital. Citation Text: Nebeker JR, Hoffman JM, Weir C, et al. High rates of adverse drug events in a highly computerized hospital. Arch Intern Med. 2005;165(10):1111-6. Copy Citation …
  4. psnet.ahrq.gov/issue/what-do-medical-records-tell-us-about-potentially-harmful-co-prescribing
    December 19, 2011 - Study Classic What do medical records tell us about potentially harmful co-prescribing? Citation Text: Lafata JE, Simpkins J, Kaatz S, et al. What do medical records tell us about potentially harmful co-prescribing? Jt Comm J Qual Patient Saf. 2007;33(7):395-4…
  5. psnet.ahrq.gov/issue/development-and-testing-objective-structured-clinical-exam-osce-assess-socio-cultural
    January 15, 2014 - Study Development and testing of an objective structured clinical exam (OSCE) to assess socio-cultural dimensions of patient safety competency. Citation Text: Ginsburg LR, Tregunno D, Norton PG, et al. Development and testing of an objective structured clinical exam (OSCE) to assess soci…
  6. psnet.ahrq.gov/issue/free-text-computerized-provider-order-entry-orders-used-workaround-communicating-medication
    July 29, 2020 - Study Free-text computerized provider order entry orders used as workaround for communicating medication information. Citation Text: Kandaswamy S, Grimes J, Hoffman D, et al. Free-text computerized provider order entry orders used as workaround for communicating medication information. J…
  7. psnet.ahrq.gov/issue/effects-health-information-technology-patient-outcomes-systematic-review
    December 03, 2018 - Review Classic Effects of health information technology on patient outcomes: a systematic review. Citation Text: Brenner SK, Kaushal R, Grinspan Z, et al. Effects of health information technology on patient outcomes: a systematic review. J Am Med Inform Assoc. 2…
  8. psnet.ahrq.gov/issue/how-does-audit-and-feedback-influence-intentions-health-professionals-improve-practice
    February 14, 2024 - Study How does audit and feedback influence intentions of health professionals to improve practice? A laboratory experiment and field study in cardiac rehabilitation. Citation Text: Gude WT, van Engen-Verheul MM, van der Veer SN, et al. How does audit and feedback influence intentions of…
  9. psnet.ahrq.gov/issue/lost-information-during-handover-critically-injured-trauma-patients-mixed-methods-study
    October 04, 2023 - Study Lost information during the handover of critically injured trauma patients: a mixed-methods study. Citation Text: Zakrison TL, Rosenbloom B, McFarlan A, et al. Lost information during the handover of critically injured trauma patients: a mixed-methods study. BMJ Qual Saf. 2016;25(1…
  10. psnet.ahrq.gov/issue/burden-serious-harms-diagnostic-error-usa
    June 03, 2020 - Study Burden of serious harms from diagnostic error in the USA. Citation Text: Newman-Toker DE, Nassery N, Schaffer AC, et al. Burden of serious harms from diagnostic error in the USA. BMJ Qual Saf. 2024;33(2):109-120. doi:10.1136/bmjqs-2021-014130. Copy Citation Format: DO…
  11. psnet.ahrq.gov/issue/using-potentially-aggressiveviolent-patient-huddle-improve-health-care-safety
    November 16, 2022 - Commentary Using a potentially aggressive/violent patient huddle to improve health care safety. Citation Text: Larson LA, Finley JL, Gross TL, et al. Using a Potentially Aggressive/Violent Patient Huddle to Improve Health Care Safety. Jt Comm J Qual Patient Saf. 2019;45(2):74-80. doi:10.…
  12. psnet.ahrq.gov/issue/collaborative-case-review-systems-based-approach-patient-safety-event-investigation-and
    May 04, 2022 - Study Collaborative case review: a systems-based approach to patient safety event investigation and analysis. Citation Text: Lacson R, Khorasani R, Fiumara K, et al. Collaborative case review: a systems-based approach to patient safety event investigation and analysis. J Patient Saf. 202…
  13. psnet.ahrq.gov/issue/harnessing-situ-simulation-identify-human-errors-and-latent-safety-threats-adult-tracheostomy
    September 23, 2020 - Study Harnessing in situ simulation to identify human errors and latent safety threats in adult tracheostomy care. Citation Text: Hassan B, Tawfik M-M, Schiff E, et al. Harnessing in situ simulation to identify human errors and latent safety threats in adult tracheostomy care. Jt Comm J …
  14. psnet.ahrq.gov/issue/unintentional-therapeutic-errors-involving-insulin-ambulatory-setting-reported-poison-centers
    June 06, 2018 - Study Unintentional therapeutic errors involving insulin in the ambulatory setting reported to poison centers. Citation Text: Spiller HA, Borys DJ, Ryan ML, et al. Unintentional therapeutic errors involving insulin in the ambulatory setting reported to poison centers. Ann Pharmacother.…
  15. psnet.ahrq.gov/issue/simulation-based-teamwork-training-emergency-department-staff-does-it-improve-clinical-team
    December 22, 2009 - Study Classic Simulation based teamwork training for emergency department staff: does it improve clinical team performance when added to an existing didactic teamwork curriculum? Citation Text: Shapiro MJ, Morey JC, Small SD, et al. Simulation based teamwork t…
  16. psnet.ahrq.gov/issue/early-warning-systems-and-rapid-response-systems-prevention-patient-deterioration-acute-adult
    July 29, 2020 - Review Early warning systems and rapid response systems for the prevention of patient deterioration on acute adult hospital wards. Citation Text: McGaughey J, Fergusson DA, Van Bogaert P, et al. Early warning systems and rapid response systems for the prevention of patient deterioration …
  17. psnet.ahrq.gov/issue/patient-and-family-engagement-catheter-associated-urinary-tract-infection-cauti-prevention
    February 07, 2022 - Review Patient and family engagement in catheter-associated urinary tract infection (CAUTI) prevention: a systematic review. Citation Text: Mangal S, Pho A, Arcia A, et al. Patient and family engagement in catheter-associated urinary tract infection (CAUTI) prevention: a systematic revie…
  18. psnet.ahrq.gov/issue/quality-improvement-initiative-decrease-central-line-associated-bloodstream-infections-during
    November 16, 2022 - Commentary Quality improvement initiative to decrease central line-associated bloodstream infections during the COVID-19 pandemic: a "zero harm" approach. Citation Text: Redstone CS, Zadeh M, Wilson M-A, et al. Quality improvement initiative to decrease central line-associated bloodstrea…
  19. psnet.ahrq.gov/issue/prescribers-responses-alerts-during-medication-ordering-long-term-care-setting
    February 26, 2009 - Study Prescribers' responses to alerts during medication ordering in the long term care setting. Citation Text: Judge J, Field T, DeFlorio M, et al. Prescribers' responses to alerts during medication ordering in the long term care setting. J Am Med Inform Assoc. 2006;13(4):385-90. Co…
  20. psnet.ahrq.gov/issue/clinical-application-computerized-system-physician-order-entry-clinical-decision-support
    February 26, 2009 - Study Clinical application of a computerized system for physician order entry with clinical decision support to prevent adverse drug events in long-term care. Citation Text: Rochon P, Field T, Bates DW, et al. Clinical application of a computerized system for physician order entry with…