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Design and implementation of an analgesia, sedation, and paralysis order set to enhance compliance of pro re nata medication orders with Joint Commission medication management standards in a pediatric ICU. | PSNet

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February 09, 2022 - Study Design and implementation of an analgesia, sedation, and paralysis order set to enhance compliance of pro re nata medication orders with Joint Commission medication management standards in a pediatric ICU. Citation Text: Procaccini D, Rapaport R, Petty BG, et al. Design and Impleme…

The extent and importance of unintended consequences related to computerized provider order entry. | PSNet

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May 27, 2011 - Study Classic The extent and importance of unintended consequences related to computerized provider order entry. Citation Text: Ash JS, Sittig DF, Poon EG, et al. The extent and importance of unintended consequences related to computerized provider order entry…

The effect of structured medication review followed by face-to-face feedback to prescribers on adverse drug events recognition and prevention in older inpatients - a multicenter interrupted time series study. | PSNet

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January 18, 2013 - Study The effect of structured medication review followed by face-to-face feedback to prescribers on adverse drug events recognition and prevention in older inpatients - a multicenter interrupted time series study. Citation Text: Klopotowska JE, Kuks PFM, Wierenga PC, et al. The effect o…

Electronic medical record-based interventions to encourage opioid prescribing best practices in the emergency department. | PSNet

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September 01, 2021 - Study Electronic medical record-based interventions to encourage opioid prescribing best practices in the emergency department. Citation Text: Smalley CM, Willner MA, Muir MKR, et al. Electronic medical record-based interventions to encourage opioid prescribing best practices in the emer…

Implementing a robust process improvement program in the neonatal intensive care unit to reduce harm. | PSNet

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March 23, 2022 - Study Implementing a robust process improvement program in the neonatal intensive care unit to reduce harm. Citation Text: Nether KG, Thomas EJ, Khan A, et al. Implementing a robust process improvement program in the neonatal intensive care unit to reduce harm. J Healthc Qual. 2022;44(1)…

Improving the specificity of drug-drug interaction alerts: can it be done? | PSNet

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September 07, 2022 - Study Improving the specificity of drug-drug interaction alerts: can it be done? Citation Text: Reese T, Wright A, Liu S, et al. Improving the specificity of drug-drug interaction alerts: Can it be done? Am J Health Syst Pharm. 2022;79(13):1086-1095. doi:10.1093/ajhp/zxac045. Copy Cita…

Outpatient insulin-related adverse events due to mix-up errors: findings from two national surveillance systems, United States, 2012-2017. | PSNet

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March 10, 2021 - Study Outpatient insulin-related adverse events due to mix-up errors: findings from two national surveillance systems, United States, 2012-2017. Citation Text: Geller AI, Conrad AO, Weidle NJ, et al. Outpatient insulin‐related adverse events due to mix‐up errors: Findings from two nation…

Observational evidence of the prevalence and association of polypharmacy and drug administration errors in hospitalized adult patients. | PSNet

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August 11, 2021 - Study Observational evidence of the prevalence and association of polypharmacy and drug administration errors in hospitalized adult patients. Citation Text: Savva G, Papastavrou E, Charalambous A, et al. Observational evidence of the prevalence and association of polypharmacy and drug ad…

Transforming the medication regimen review process using telemedicine to prevent adverse events. | PSNet

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November 11, 2015 - Study Transforming the medication regimen review process using telemedicine to prevent adverse events. Citation Text: Kane‐Gill SL, Wong A, Culley CM, et al. Transforming the medication regimen review process using telemedicine to prevent adverse events. J Am Geriatr Soc. 2020;69(2):530-…

Medication overdoses leading to emergency department visits among children. | PSNet

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March 05, 2008 - Study Medication overdoses leading to emergency department visits among children. Citation Text: Schillie SF, Shehab N, Thomas KE, et al. Medication overdoses leading to emergency department visits among children. Am J Prev Med. 2009;37(3):181-7. doi:10.1016/j.amepre.2009.05.018. Cop…

Obtaining the best possible medication history at hospital admission: description of a pharmacy technician-driven program to identify medication discrepancies. | PSNet

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October 31, 2023 - Study Obtaining the best possible medication history at hospital admission: description of a pharmacy technician-driven program to identify medication discrepancies. Citation Text: Kabir R, Liaw S, Cerise J, et al. Obtaining the best possible medication history at hospital admission: des…

Insights into the problem of alarm fatigue with physiologic monitor devices: a comprehensive observational study of consecutive intensive care unit patients. | PSNet

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July 17, 2013 - Study Classic Insights into the problem of alarm fatigue with physiologic monitor devices: a comprehensive observational study of consecutive intensive care unit patients. Citation Text: Drew BJ, Harris P, Zègre-Hemsey JK, et al. Insights into the problem of ala…

A cluster randomized trial of two implementation strategies to deliver audit and feedback in the EQUIPPED medication safety program. | PSNet

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September 01, 2018 - Study A cluster randomized trial of two implementation strategies to deliver audit and feedback in the EQUIPPED medication safety program. Citation Text: Vaughan CP, Burningham Z, Kelleher JL, et al. A cluster‐randomized trial of two implementation strategies to deliver audit and feedbac…

Preventability and causes of readmissions in a national cohort of general medicine patients. | PSNet

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January 25, 2017 - Study Classic Preventability and causes of readmissions in a national cohort of general medicine patients. Citation Text: Auerbach AD, Kripalani S, Vasilevskis EE, et al. Preventability and Causes of Readmissions in a National Cohort of General Medicine Patients…

Evaluating alert fatigue over time to EHR-based clinical trial alerts: findings from a randomized controlled study. | PSNet

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April 29, 2018 - Study Evaluating alert fatigue over time to EHR-based clinical trial alerts: findings from a randomized controlled study. Citation Text: Embi P, Leonard AC. Evaluating alert fatigue over time to EHR-based clinical trial alerts: findings from a randomized controlled study. J Am Med Inform…

An initiative to reduce insulin-related adverse drug events in a children's hospital. | PSNet

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March 24, 2021 - Study An initiative to reduce insulin-related adverse drug events in a children's hospital. Citation Text: Lawson SA, Hornung LN, Lawrence M, et al. An initiative to reduce insulin-related adverse drug events in a children's hospital. Pediatrics. 2022;149(1):e2020004937. doi:10.1542/peds…

Does root cause analysis improve patient safety? A systematic review at the Department of Veterans Affairs. | PSNet

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March 24, 2021 - Review Does root cause analysis improve patient safety? A systematic review at the Department of Veterans Affairs. Citation Text: Shah F, Falconer EA, Cimiotti JP. Does root cause analysis improve patient safety? A systematic review at the Department of Veterans Affairs. Qual Manag Healt…

SBAR improves communication and safety climate and decreases incident reports due to communication errors in an anaesthetic clinic: a prospective intervention study. | PSNet

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June 01, 2016 - Study SBAR improves communication and safety climate and decreases incident reports due to communication errors in an anaesthetic clinic: a prospective intervention study. Citation Text: Randmaa M, Mårtensson G, Swenne CL, et al. SBAR improves communication and safety climate and decreas…

The Veterans Affairs root cause analysis system in action. | PSNet

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June 22, 2022 - Study Classic The Veterans Affairs root cause analysis system in action. Citation Text: Bagian JP, Gosbee JW, Lee CZ, et al. The Veterans Affairs Root Cause Analysis System in Action. Jt Comm J Qual Improv. 2016;28(10):531-545. doi:10.1016/s1070-3241(02)28057-8.…

Decisions and repercussions of second victim experiences for mothers in medicine (SAVE DR MoM). | PSNet

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May 18, 2022 - Study Decisions and repercussions of second victim experiences for mothers in medicine (SAVE DR MoM). Citation Text: Gupta K, Lisker S, Rivadeneira NA, et al. Decisions and repercussions of second victim experiences for mothers in medicine (SAVE DR MoM). BMJ Qual Saf. 2019;28(7):564-573.…

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