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psnet.ahrq.gov/node/836852/psn-pdf
April 06, 2022 - Frequency and nature of communication and handoff
failures in medical malpractice claims.
April 6, 2022
Humphrey KE, Sundberg M, Milliren CE, et al. Frequency and nature of communication and handoff
failures in medical malpractice claims. J Patient Saf. 2022;18(2):130-137.
doi:10.1097/pts.0000000000000937.
https:…
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psnet.ahrq.gov/node/43805/psn-pdf
February 11, 2015 - Understanding the nature of medication errors in an ICU
with a computerized physician order entry system.
February 11, 2015
Cho IS, Park H, Choi YJ, et al. Understanding the nature of medication errors in an ICU with a
computerized physician order entry system. PLoS One. 2014;9(12):e114243.
doi:10.1371/journal.pon…
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psnet.ahrq.gov/node/43885/psn-pdf
January 30, 2018 - Health Information Technology.
January 30, 2018
Am J Manag Care. 2014;20(spec 17):492-554,e1-e31.
https://psnet.ahrq.gov/issue/health-information-technology
Efforts to implement health information technology, particularly electronic health records and computerized
provider order entry systems, continue at a rapid …
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psnet.ahrq.gov/node/44579/psn-pdf
September 01, 2016 - Increased appropriateness of customized alert
acknowledgement reasons for overridden medication
alerts in a computerized provider order entry system.
September 1, 2016
Dekarske BM, Zimmerman CR, Chang R, et al. Increased appropriateness of customized alert
acknowledgement reasons for overridden medication alerts i…
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psnet.ahrq.gov/node/50569/psn-pdf
October 23, 2019 - Design and implementation of a tool for pharmacists to
register potential errors in prescribed medication.
October 23, 2019
Frid S, Zapico V, Mansilla A, et al. Design and Implementation of a Tool for Pharmacists to Register
Potential Errors in Prescribed Medication. Stud Health Technol Inform. 2019;264:581-585.
d…
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psnet.ahrq.gov/node/841475/psn-pdf
January 01, 2023 - The second victim of unanticipated adverse events.
December 14, 2022
Chen S, Skidmore S, Ferrigno BN, et al. The second victim of unanticipated adverse events. J Thorac
Cardiovasc Surg. 2023;166(3):890-894. doi:10.1016/j.jtcvs.2022.09.010.
https://psnet.ahrq.gov/issue/second-victim-unanticipated-adverse-events
“Se…
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psnet.ahrq.gov/node/49624/psn-pdf
May 01, 2011 - Duty to Disclose Someone Else's Error?
May 1, 2011
Gallagher TH. Duty to Disclose Someone Else's Error? PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/duty-disclose-someone-elses-error
Case Objectives
State the rationale for disclosing medical errors.
Describe key principles in effective error disclosure.
…
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psnet.ahrq.gov/node/49855/psn-pdf
March 01, 2019 - Which Line: Ordering Provider or Proceduralist?
March 1, 2019
Blackmore CC. Which Line: Ordering Provider or Proceduralist? PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
Case Objectives
Review the role of mistake-proofing to block errors from leading to adverse…
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psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination
September 27, 2023 - Verbal Orders and Medication Overrides: A Dangerous Combination
Citation Text:
Mueller C, MacDowell P, Bourgeois JA. Verbal Orders and Medication Overrides: A Dangerous Combination. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024…
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psnet.ahrq.gov/issue/family-participation-during-intensive-care-unit-rounds-goals-and-expectations-parents-and
June 12, 2019 - Study
Family participation during intensive care unit rounds: goals and expectations of parents and health care providers in a tertiary pediatric intensive care unit.
Citation Text:
Stickney CA, Ziniel SI, Brett MS, et al. Family participation during intensive care unit rounds: goals and…
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psnet.ahrq.gov/issue/provider-bias-prescribing-opioid-analgesics-study-electronic-medical-records-hospital
September 30, 2020 - Study
Provider bias in prescribing opioid analgesics: a study of electronic medical records at a hospital emergency department.
Citation Text:
Keister LA, Stecher C, Aronson B, et al. Provider bias in prescribing opioid analgesics: a study of electronic medical records at a hospital emer…
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psnet.ahrq.gov/issue/using-ecological-systems-theory-understand-blackwhite-disparities-maternal-morbidity-and
February 08, 2023 - Study
Emerging Classic
Using the ecological systems theory to understand black/white disparities in maternal morbidity and mortality in the United States.
Citation Text:
Noursi S, Saluja B, Richey L. Using the ecological systems theory to understand black/white …
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psnet.ahrq.gov/issue/effects-computerized-physician-order-entry-and-clinical-decision-support-systems-medication
May 27, 2011 - Review
Classic
Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review.
Citation Text:
Kaushal R, Shojania KG, Bates DW. Effects of computerized physician order entry and clinical decision s…
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psnet.ahrq.gov/issue/prevalence-second-victim-syndrome-and-emotional-distress-pediatric-intensive-care-providers
April 24, 2018 - Study
The prevalence of second victim syndrome and emotional distress in pediatric intensive care providers.
Citation Text:
Wolf MS, Smith K, Basu M, et al. The prevalence of second victim syndrome and emotional distress in pediatric intensive care providers. J Pediatr Intensive Care. 20…
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psnet.ahrq.gov/issue/factors-contributing-medication-errors-made-when-using-computerized-order-entry-pediatrics
May 08, 2017 - Review
Factors contributing to medication errors made when using computerized order entry in pediatrics: a systematic review.
Citation Text:
Tolley CL, Forde NE, Coffey KL, et al. Factors contributing to medication errors made when using computerized order entry in pediatrics: a systemat…
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psnet.ahrq.gov/issue/how-providers-can-optimize-effective-and-safe-scribe-use-qualitative-study
November 18, 2020 - Study
How providers can optimize effective and safe scribe use: a qualitative study.
Citation Text:
Corby S, Ash JS, Florig ST, et al. How providers can optimize effective and safe scribe use: a qualitative study. J Gen Intern Med. 2023;38(9):2052-2058. doi:10.1007/s11606-022-07942-2.
…
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psnet.ahrq.gov/issue/deficiencies-provider-reported-interpreter-use-clinical-trial-comparing-telephonic-and-video
August 12, 2020 - Study
Deficiencies in provider-reported interpreter use in a clinical trial comparing telephonic and video interpretation in a pediatric emergency department.
Citation Text:
Gutman CK, Klein EJ, Follmer K, et al. Deficiencies in provider-reported interpreter use in a clinical trial compa…
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psnet.ahrq.gov/issue/views-children-parents-and-health-care-providers-pediatric-disclosure-medical-errors
April 08, 2020 - Study
Views of children, parents, and health-care providers on pediatric disclosure of medical errors.
Citation Text:
Koller D, Espin S. Views of children, parents, and health-care providers on pediatric disclosure of medical errors. J Child Health Care. 2018;22(4):577-590. doi:10.1177/1…
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psnet.ahrq.gov/issue/patient-provider-and-system-factors-contributing-patient-safety-events-during-medical-and
November 18, 2016 - Study
Patient, provider, and system factors contributing to patient safety events during medical and surgical hospitalizations for persons with serious mental illness.
Citation Text:
McGinty EE, Thompson DA, Pronovost P, et al. Patient, provider, and system factors contributing to patien…
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psnet.ahrq.gov/issue/opportunity-engage-obstetrics-and-gynecology-patients-through-shared-visit-notes
July 01, 2020 - Study
An opportunity to engage obstetrics and gynecology patients through shared visit notes.
Citation Text:
Herlihy M, Harcourt K, Fossa A, et al. An Opportunity to Engage Obstetrics and Gynecology Patients Through Shared Visit Notes. Obstet Gynecol. 2019;134(1):128-137. doi:10.1097/AOG…