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psnet.ahrq.gov/issue/resolving-human-conflicts-when-questions-about-safety-medical-orders-arise
June 05, 2018 - Newspaper/Magazine Article
Resolving human conflicts when questions about the safety of medical orders arise.
Citation Text:
Resolving human conflicts when questions about the safety of medical orders arise. ISMP Medication Safety Alert! Acute care edition. March 13, 2008.
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psnet.ahrq.gov/issue/key-vulnerabilities-surgical-environment-container-mix-ups-and-syringe-swaps
June 10, 2018 - Newspaper/Magazine Article
Key vulnerabilities in the surgical environment: container mix-ups and syringe swaps.
Citation Text:
Key vulnerabilities in the surgical environment: container mix-ups and syringe swaps. ISMP Medication Safety Alert! Acute Care Edition. November 5, 2015;20:1-5.…
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psnet.ahrq.gov/issue/34-ways-survive-your-next-trip-hospital
May 02, 2018 - Newspaper/Magazine Article
34 ways to survive your next trip to the hospital.
Citation Text:
34 ways to survive your next trip to the hospital. Crouch M. Reader's Digest. April 2018.
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psnet.ahrq.gov/issue/disclosure-what-works-now-and-what-can-work-even-better-part-3-3
January 13, 2016 - Book/Report
Disclosure: what works now and what can work even better (part 3 of 3).
Citation Text:
Disclosure: what works now and what can work even better (part 3 of 3). Chicago, IL: American Society of Healthcare Risk Management;
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psnet.ahrq.gov/issue/informed-patient-institute
July 14, 2010 - Multi-use Website
Informed Patient Institute.
Citation Text:
Informed Patient Institute. Annapolis, MD.
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psnet.ahrq.gov/issue/all-right-reasons
March 06, 2005 - Newspaper/Magazine Article
For all the right reasons.
Citation Text:
For all the right reasons. Hagland M.
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psnet.ahrq.gov/issue/national-quality-forum
March 17, 2011 - Multi-use Website
National Quality Forum.
Citation Text:
National Quality Forum. 1099 14th Street NW, Suite 500, Washington DC 20005.
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psnet.ahrq.gov/issue/patient-specific-electronic-decision-support-reduces-prescription-excessive-doses
November 02, 2010 - Study
Patient-specific electronic decision support reduces prescription of excessive doses.
Citation Text:
Seidling HM, Schmitt SPW, Bruckner T, et al. Patient-specific electronic decision support reduces prescription of excessive doses. Qual Saf Health Care. 2010;19(5):e15. doi:10.113…
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psnet.ahrq.gov/issue/physician-intent-pharmacy-label-prevalence-and-description-discrepancies-cross-sectional
July 22, 2020 - Study
From physician intent to the pharmacy label: prevalence and description of discrepancies from a cross-sectional evaluation of electronic prescriptions.
Citation Text:
Cochran GL, Klepser DG, Morien M, et al. From physician intent to the pharmacy label: prevalence and description o…
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psnet.ahrq.gov/issue/pharmacist-physician-communications-highly-computerised-hospital-sign-and-action-electronic
February 27, 2019 - Study
Pharmacist–physician communications in a highly computerised hospital: sign-off and action of electronic review messages.
Citation Text:
Pontefract SK, Hodson J, Marriott JF, et al. Pharmacist-Physician Communications in a Highly Computerised Hospital: Sign-Off and Action of Electr…
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psnet.ahrq.gov/issue/failure-utilize-functions-electronic-prescribing-system-and-subsequent-generation-technically
February 15, 2012 - Study
Failure to utilize functions of an electronic prescribing system and the subsequent generation of 'technically preventable' computerized alerts.
Citation Text:
Baysari M, Reckmann MH, Li L, et al. Failure to utilize functions of an electronic prescribing system and the subsequent g…
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psnet.ahrq.gov/issue/sustained-user-engagement-health-information-technology-long-road-implementation-system
December 21, 2022 - Study
Sustained user engagement in health information technology: the long road from implementation to system optimization of computerized physician order entry and clinical decision support systems for prescribing in hospitals in England.
Citation Text:
Cresswell K, Lee L, Mozaffar H, e…
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psnet.ahrq.gov/node/33575/psn-pdf
March 15, 2025 - Patient Engagement and Safety
March 15, 2025
Patient Engagement and Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/patient-engagement-and-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the pati…
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psnet.ahrq.gov/node/46759/psn-pdf
January 31, 2018 - Health Literacy Toolkit.
January 31, 2018
Leeds, UK: Health Education England, Public Health England, NHS England and Community Health and
Learning Foundation; December 11, 2017.
https://psnet.ahrq.gov/issue/health-literacy-toolkit
Limits in patients' ability to understand health instructions and information affec…
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psnet.ahrq.gov/node/45590/psn-pdf
August 02, 2017 - Improving Diagnostic Accuracy Project 2016–2017.
August 2, 2017
Washington, DC: National Quality Forum; October 2016.
https://psnet.ahrq.gov/issue/improving-diagnostic-accuracy-project-2016-2017
The Improving Diagnosis in Health Care report provided recommendations to help achieve safe, reliable
diagnosis. This we…
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psnet.ahrq.gov/node/44286/psn-pdf
July 18, 2024 - Rapid response systems.
July 18, 2024
Stevens JP. UpToDate. July 18, 2024.
https://psnet.ahrq.gov/issue/rapid-response-systems-0
Although rapid response programs have been advocated as promising patient safety strategies, the
evidence regarding their benefits is mixed. This review provides an overview of rapid res…
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psnet.ahrq.gov/node/34912/psn-pdf
February 03, 2010 - Disruptive behavior and clinical outcomes: perceptions of
nurses and physicians.
February 3, 2010
Rosenstein AH, O'Daniel M. Disruptive behavior and clinical outcomes: perceptions of nurses and
physicians. Am J Nurs. 2005;105(1):54-64; quiz 64-5.
https://psnet.ahrq.gov/issue/disruptive-behavior-and-clinical-outcom…
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psnet.ahrq.gov/node/46417/psn-pdf
October 11, 2017 - Center for Health Care Human Factors.
October 11, 2017
Armstrong Institute for Patient Safety and Quality.
https://psnet.ahrq.gov/issue/center-health-care-human-factors
Human factors engineering has provided unique insights into designing solutions to address human error
and system weaknesses that facilitate mista…
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psnet.ahrq.gov/node/35482/psn-pdf
May 27, 2011 - The introduction of computerized physician order entry
and change management in a tertiary pediatric hospital.
May 27, 2011
Upperman JS, Staley P, Friend K, et al. The introduction of computerized physician order entry and change
management in a tertiary pediatric hospital. Pediatrics. 2005;116(5):e634-42.
https:/…
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psnet.ahrq.gov/node/42371/psn-pdf
November 06, 2013 - Adverse drug events in surgical patients: an
observational multicentre study.
November 6, 2013
de Boer M, Boeker EB, Ramrattan MA, et al. Adverse drug events in surgical patients: an observational
multicentre study. Int J Clin Pharm. 2013;35(5):744-52. doi:10.1007/s11096-013-9797-5.
https://psnet.ahrq.gov/issue/ad…