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psnet.ahrq.gov/issue/thematic-reviews-patient-safety-incidents-tool-systems-thinking-quality-improvement-report
January 15, 2020 - Commentary
Thematic reviews of patient safety incidents as a tool for systems thinking: a quality improvement report.
Citation Text:
Machen S. Thematic reviews of patient safety incidents as a tool for systems thinking: a quality improvement report. BMJ Open Qual. 2023;12(2):e002020. doi…
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psnet.ahrq.gov/issue/workarounds-intended-use-health-information-technology-narrative-review-human-factors
July 24, 2013 - Review
Emerging Classic
Workarounds to intended use of health information technology: a narrative review of the human factors engineering literature.
Citation Text:
Patterson ES. Workarounds to Intended Use of Health Information Technology: A Narrative Review of…
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psnet.ahrq.gov/issue/optimizing-pediatric-patient-safety-emergency-care-setting
March 15, 2023 - Organizational Policy/Guidelines
Optimizing Pediatric Patient Safety in the Emergency Care Setting.
Citation Text:
Joseph MM, Mahajan P, Snow SK, et al. Optimizing Pediatric Patient Safety in the Emergency Care Setting. Pediatrics. 2022;150(5):e2022059673. doi:10.1542/peds.2022-059673.
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psnet.ahrq.gov/issue/foundational-science-learning-health-systems
June 26, 2019 - Commentary
The foundational science of learning health systems.
Citation Text:
Kilbourne AM, Borsky AE, O'Brien RW, et al. The foundational science of learning health systems. Health Serv Res. 2024;59(6):e14374. doi:10.1111/1475-6773.14374.
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/wolfstadt-ji-et-al-2008
January 01, 2008 - Wolfstadt JI et al. 2008 "The effect of computerized physician order entry with clinical decision support on the rates of adverse drug events: a systematic review."
Reference
Wolfstadt JI, Gurwitz JH, Field TS, et al. The effect of computerized physician order entry with clinical decision support on t…
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/zheng-k-et-al-2009
January 01, 2009 - Zheng K et al. 2009 "An interface-driven analysis of user interactions with an electronic health records system."
Reference
Zheng K, Padman R, Johnson MP, et al. An interface-driven analysis of user interactions with an electronic health records system. J Am Med Inform Assoc 2009;16(2):228-237.
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psnet.ahrq.gov/issue/need-closed-loop-systems-management-abnormal-test-results
May 20, 2019 - Study
The need for closed-loop systems for management of abnormal test results.
Citation Text:
Zuccotti G, Samal L, Maloney FL, et al. The Need for Closed-Loop Systems for Management of Abnormal Test Results. Ann Intern Med. 2018;168(11):820-821. doi:10.7326/M17-2425.
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psnet.ahrq.gov/issue/prevalence-errors-anaphylaxis-kids-peak-multicenter-simulation-based-study
June 15, 2022 - Study
Prevalence of Errors in Anaphylaxis in Kids (PEAK): a multicenter simulation-based study.
Citation Text:
Maa T, Scherzer DJ, Harwayne-Gidansky I, et al. Prevalence of Errors in Anaphylaxis in Kids (PEAK): a multicenter simulation-based study. J Allergy Clin Immunol Pract. 2020;8(4)…
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psnet.ahrq.gov/issue/opportunities-diagnostic-improvement-among-pediatric-hospital-readmissions
August 30, 2023 - Study
Opportunities for diagnostic improvement among pediatric hospital readmissions.
Citation Text:
Congdon M, Rauch B, Carroll B, et al. Opportunities for diagnostic improvement among pediatric hospital readmissions. Hosp Pediatr. 2023;13(7):563-571. doi:10.1542/hpeds.2023-007157.
Co…
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psnet.ahrq.gov/issue/use-standard-design-medication-room-promote-medication-safety-organizational-implications
July 27, 2022 - Study
The use of a standard design medication room to promote medication safety: organizational implications.
Citation Text:
Rozenbaum H, Gordon L, Brezis M, et al. The use of a standard design medication room to promote medication safety: organizational implications. Int J Qual Health C…
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/goetz-goldberg-d-kuzel
January 01, 2023 - Goetz Goldberg D, Kuzel AJ, Feng LB, et al. "EHRs in primary care practices: benefits, challenges, and successful strategies."
Reference
Goetz Goldberg D, Kuzel AJ, Feng LB, et al. EHRs in primary care practices: benefits, challenges, and successful strategies. Am J Manag Care 2012 Feb 1;18(2):e48-54.…
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psnet.ahrq.gov/issue/pediatric-crisis-resource-management-training-improves-emergency-medicine-trainees-perceived
March 25, 2020 - Study
Pediatric crisis resource management training improves emergency medicine trainees' perceived ability to manage emergencies and ability to identify teamwork errors.
Citation Text:
Bank I, Snell L, Bhanji F. Pediatric crisis resource management training improves emergency medicine t…
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psnet.ahrq.gov/issue/3-year-study-medication-incidents-acute-general-hospital
July 15, 2020 - Study
A 3-year study of medication incidents in an acute general hospital.
Citation Text:
Song L, Chui WCM, Lau CP, et al. A 3-year study of medication incidents in an acute general hospital. J Clin Pharm Ther. 2008;33(2):109-14. doi:10.1111/j.1365-2710.2007.00880.x.
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psnet.ahrq.gov/issue/americans-experiences-medical-errors-and-views-patient-safety
January 06, 2015 - Book/Report
Classic
Americans' Experiences With Medical Errors and Views on Patient Safety.
Citation Text:
Americans' Experiences With Medical Errors and Views on Patient Safety. Chicago, IL: NORC at the University of Chicago and IHI/NPSF Lucian Leape Institute;…
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psnet.ahrq.gov/issue/limits-safety-organizations-accidents-and-nuclear-weapons
July 28, 2013 - Book/Report
Classic
The Limits of Safety: Organizations, Accidents and Nuclear Weapons.
Citation Text:
The Limits of Safety: Organizations, Accidents and Nuclear Weapons. Sagan SD. Princeton NJ: Princeton University Press; 1993. ISBN: 9780691032214.
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psnet.ahrq.gov/issue/same-behavior-different-provider-american-medical-students-attitudes-toward-reporting-risky
May 12, 2021 - Study
Same behavior, different provider: American medical students' attitudes toward reporting risky behaviors committed by doctors, nurses, and classmates.
Citation Text:
Aggarwal S, Kheriaty A. Same behavior, different provider: American medical students' attitudes toward reporting ris…
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psnet.ahrq.gov/issue/patient-misidentification-laboratory-medicine-qualitative-analysis-227-root-cause-analysis
August 28, 2024 - Study
Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis reports in the Veterans Health Administration.
Citation Text:
Dunn EJ, Moga PJ. Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis …
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psnet.ahrq.gov/issue/incidence-and-preventability-adverse-drug-events-hospitalized-patients
May 27, 2011 - Study
Classic
Incidence and preventability of adverse drug events in hospitalized patients.
Citation Text:
Bates DW, Leape L, Petrycki S. Incidence and preventability of adverse drug events in hospitalized adults. J Gen Intern Med. 1993;8(6):289-294.
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psnet.ahrq.gov/issue/medical-malpractice-lawsuits-involving-trainees-obstetrics-and-gynecology-usa
February 15, 2023 - Study
Medical malpractice lawsuits involving trainees in obstetrics and gynecology in the USA.
Citation Text:
Ghaith S, Campbell RL, Pollock JR, et al. Medical malpractice lawsuits involving trainees in obstetrics and gynecology in the USA. Healthcare (Basel). 2022;10(7):1328. doi:10.339…
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psnet.ahrq.gov/issue/antimicrobial-stewardship-another-focus-patient-safety
May 29, 2024 - Review
Antimicrobial stewardship: another focus for patient safety?
Citation Text:
Tamma PD, Holmes A, Ashley ED. Antimicrobial stewardship: another focus for patient safety? Curr Opin Infect Dis. 2014;27(4):348-55. doi:10.1097/QCO.0000000000000077.
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