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psnet.ahrq.gov/issue/identifying-potential-patient-safety-issues-federal-electronic-health-record-surveillance
May 12, 2021 - Study
Identifying potential patient safety issues from the Federal Electronic Health Record Surveillance Program
Citation Text:
Pacheco TB, Hettinger AZ, Ratwani RM. Identifying Potential Patient Safety Issues From the Federal Electronic Health Record Surveillance Program. JAMA. 2019;322…
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psnet.ahrq.gov/issue/human-error-and-problem-causality-analysis-accidents
August 25, 2021 - Commentary
Classic
Human error and the problem of causality in analysis of accidents.
Citation Text:
Rasmussen J. Human error and the problem of causality in analysis of accidents. Philos Trans R Soc Lond B Biol Sci. 1990;327(1241):449-462.
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psnet.ahrq.gov/issue/randomised-controlled-trial-effect-continuous-electronic-physiological-monitoring-adverse
August 04, 2021 - Study
A randomised controlled trial of the effect of continuous electronic physiological monitoring on the adverse event rate in high risk medical and surgical patients.
Citation Text:
Watkinson PJ, Barber VS, Price JD, et al. A randomised controlled trial of the effect of continuous e…
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psnet.ahrq.gov/issue/characteristics-morbidity-and-mortality-conferences-associated-implementation-patient-safety
March 18, 2020 - Study
Characteristics of morbidity and mortality conferences associated with the implementation of patient safety improvement initiatives, an observational study.
Citation Text:
François P, Prate F, Vidal-Trecan G, et al. Characteristics of morbidity and mortality conferences associated …
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psnet.ahrq.gov/issue/mental-health-trigger-tool-development-and-testing-specialized-trigger-tool-mental-health
September 27, 2017 - Study
The mental health trigger tool: development and testing of a specialized trigger tool for mental health settings.
Citation Text:
Sajith SG, Fung D, Chua HC. The Mental Health Trigger Tool: Development and Testing of a Specialized Trigger Tool for Mental Health Settings. J Patient S…
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psnet.ahrq.gov/print/pdf/node/866984
January 01, 2020 - authors review a series of interventions designed through the
multidisciplinary efforts of nursing, pharmacy … authors review a series of interventions designed through the
multidisciplinary efforts of nursing, pharmacy
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psnet.ahrq.gov/node/867475/psn-pdf
February 26, 2025 - can play a role in increasing
access to naloxone for pediatric patients, with all states allowing pharmacy … Vital Signs: Pharmacy-Based Naloxone Dispensing –
United States, 2012-2018.
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psnet.ahrq.gov/web-mm/around-block
March 04, 2020 - Forcing functions might include a pharmacy-triggered warning when neuraxial anesthesia is ordered in … clinician that prior approval from the anticoagulation, pain, or anesthesia service is required, and that pharmacy
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psnet.ahrq.gov/web-mm/potent-medication-administered-not-so-viable-route
July 20, 2016 - mortality review, and a new protocol was issued that potent medications may be started only after the pharmacy … From the Same Author(s)
Reducing readmission at an academic medical center: results of a pharmacy-facilitated
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psnet.ahrq.gov/node/49678/psn-pdf
March 01, 2013 - Furthermore, because the
pharmacy likely would have received the identical "bad data" (incorrect weight … ) sent through a third-party
broker from the CPOE system to the pharmacy dispensing system, there would
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psnet.ahrq.gov/issue/prevalence-severity-and-nature-preventable-patient-harm-across-medical-care-settings
February 17, 2021 - Study
Classic
Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis.
Citation Text:
Panagioti M, Khan K, Keers RN, et al. Prevalence, severity, and nature of preventable patient harm across…
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psnet.ahrq.gov/issue/workarounds-barcode-medication-administration-systems-their-occurrences-causes-and-threats
November 30, 2011 - Study
Classic
Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety.
Citation Text:
Koppel R, Wetterneck TB, Telles JL, et al. Workarounds to barcode medication administration systems: their occurren…
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psnet.ahrq.gov/issue/methodological-variations-and-their-effects-reported-medication-administration-error-rates
January 15, 2025 - Review
Methodological variations and their effects on reported medication administration error rates.
Citation Text:
McLeod MC, Barber N, Franklin BD. Methodological variations and their effects on reported medication administration error rates. BMJ Qual Saf. 2013;22(4):278-89. doi:10.…
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psnet.ahrq.gov/issue/understanding-factors-influencing-implementation-new-national-patient-safety-policy-england
August 18, 2021 - Study
Understanding the factors influencing implementation of a new national patient safety policy in England: lessons from 'Learning from Deaths'.
Citation Text:
Lalani M, Morgan S, Basu A, et al. Understanding the factors influencing implementation of a new national patient safety pol…
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psnet.ahrq.gov/issue/parent-reported-errors-and-adverse-events-hospitalized-children
June 29, 2009 - Study
Classic
Parent-reported errors and adverse events in hospitalized children.
Citation Text:
Khan A, Furtak SL, Melvin P, et al. Parent-reported errors and adverse events in hospitalized children. JAMA Pediatr. 2016;170(4):e154608. doi:10.1001/jamapediatrics…
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psnet.ahrq.gov/issue/medication-errors-during-simulated-paediatric-resuscitations-prospective-observational-human
February 23, 2022 - Study
Medication errors during simulated paediatric resuscitations: a prospective, observational human reliability analysis.
Citation Text:
Appelbaum N, Clarke J, Feather C, et al. Medication errors during simulated paediatric resuscitations: a prospective, observational human reliabilit…
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psnet.ahrq.gov/issue/qualitative-study-what-care-workers-do-provide-patient-safety-home-through-telecare
September 08, 2021 - Study
A qualitative study of what care workers do to provide patient safety at home through telecare.
Citation Text:
Stokke R, Melby L, Isaksen J, et al. A qualitative study of what care workers do to provide patient safety at home through telecare. BMC Health Serv Res. 2021;21(1):553. d…
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psnet.ahrq.gov/issue/medication-related-clinical-decision-support-alert-overrides-inpatients
July 16, 2019 - Study
Medication-related clinical decision support alert overrides in inpatients.
Citation Text:
Nanji KC, Seger DL, Slight SP, et al. Medication-related clinical decision support alert overrides in inpatients. J Am Med Inform Assoc. 2018;25(5):476-481. doi:10.1093/jamia/ocx115.
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psnet.ahrq.gov/issue/using-automated-methods-detect-safety-problems-health-information-technology-scoping-review
April 07, 2019 - Review
Using automated methods to detect safety problems with health information technology: a scoping review.
Citation Text:
Surian D, Wang Y, Coiera E, et al. Using automated methods to detect safety problems with health information technology: a scoping review. J Am Med Inform Assoc. …
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psnet.ahrq.gov/issue/artificial-intelligence-identifying-prevention-medication-incidents-causing-serious-or
March 11, 2020 - Study
Artificial intelligence for identifying the prevention of medication incidents causing serious or moderate harm: an analysis using incident reporters' views.
Citation Text:
Härkänen M, Haatainen K, Vehviläinen-Julkunen K, et al. Artificial intelligence for identifying the preventio…