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psnet.ahrq.gov/node/35385/psn-pdf
January 02, 2017 - El Camino Hospital: using health information technology
to promote patient safety.
January 2, 2017
Bukunt S, Hunter C, Perkins S, et al. El Camino Hospital: Using Health Information Technology to Promote
Patient Safety. Jt Comm J Qual Patient Saf. 2016;31(10):561-565. doi:10.1016/s1553-7250(05)31073-7.
https://psn…
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psnet.ahrq.gov/node/38641/psn-pdf
September 02, 2009 - Assessing the value of electronic prescribing in
ambulatory care: A focus group study.
September 2, 2009
Weingart SN, Massagli M, Cyrulik A, et al. Assessing the value of electronic prescribing in ambulatory care:
a focus group study. Int J Med Inform. 2009;78(9):571-8. doi:10.1016/j.ijmedinf.2009.03.007.
https://…
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psnet.ahrq.gov/node/42128/psn-pdf
August 15, 2013 - Computerized prescriber order entry and opportunities
for medication errors: comparison to tradition paper-
based order entry.
August 15, 2013
Jozefczyk KG, Kennedy WK, Lin MJ, et al. Computerized prescriber order entry and opportunities for
medication errors: comparison to tradition paper-based order entry. J Pha…
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psnet.ahrq.gov/node/38072/psn-pdf
February 15, 2011 - Detection, classification, and correction of defective
chemotherapy orders through nursing and pharmacy
oversight.
February 15, 2011
Mertens WC, Brown DE, Parisi R, et al. Detection, Classification, and Correction of Defective
Chemotherapy Orders Through Nursing and Pharmacy Oversight. J Patient Saf. 2008;4(3):195…
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psnet.ahrq.gov/node/865680/psn-pdf
September 06, 2024 - Workforce and Patient Safety.
September 6, 2024
Dorset, UK: Health Services Safety Investigations Body; 2024.
https://psnet.ahrq.gov/issue/workforce-and-patient-safety
The complex health care work environment creates conditions that detract from staff ability to provide safe
care. This collection of reports to be …
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psnet.ahrq.gov/node/35669/psn-pdf
July 08, 2008 - Problem doctors: is there a system-level solution?
July 8, 2008
Leape L, Fromson J. Problem doctors: is there a system-level solution? Ann Intern Med. 2006;144(2):107-
15.
https://psnet.ahrq.gov/issue/problem-doctors-there-system-level-solution
This commentary discusses the current systemwide limitations in measur…
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psnet.ahrq.gov/node/39900/psn-pdf
October 06, 2010 - Computerized physician order entry of injectable
antineoplastic drugs: an epidemiologic study of
prescribing medication errors.
October 6, 2010
Nerich V, Limat S, Demarchi M, et al. Computerized physician order entry of injectable antineoplastic
drugs: an epidemiologic study of prescribing medication errors. Int J…
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psnet.ahrq.gov/node/38036/psn-pdf
January 02, 2017 - Debriefing medical teams: 12 evidence-based best
practices and tips.
January 2, 2017
Salas E, Klein C, King HB, et al. Debriefing medical teams: 12 evidence-based best practices and tips. Jt
Comm J Qual Patient Saf. 2008;34(9):518-527.
https://psnet.ahrq.gov/issue/debriefing-medical-teams-12-evidence-based-best-pr…
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psnet.ahrq.gov/node/42205/psn-pdf
April 24, 2013 - Reported medication errors after introducing an
electronic medication management system.
April 24, 2013
Redley B, Botti M. Reported medication errors after introducing an electronic medication management
system. J Clin Nurs. 2013;22(3-4):579-89. doi:10.1111/j.1365-2702.2012.04326.x.
https://psnet.ahrq.gov/issue/re…
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psnet.ahrq.gov/node/73586/psn-pdf
January 01, 2022 - 'More than words' - interpersonal communication,
cognitive bias and diagnostic errors.
August 11, 2021
Dahm MR, Williams M, Crock C. ‘More than words’ – Interpersonal communication, cognitive bias and
diagnostic errors. Patient Educ Couns. 2022;105(1):252-256. doi:10.1016/j.pec.2021.05.012.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/40356/psn-pdf
May 26, 2011 - Clinicians' satisfaction with CPOE ease of use and effect
on clinicians' workflow, efficiency and medication safety.
May 26, 2011
Khajouei R, Wierenga PC, Hasman A, et al. Clinicians satisfaction with CPOE ease of use and effect on
clinicians' workflow, efficiency and medication safety. Int J Med Inform. 2011;80(5)…
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psnet.ahrq.gov/node/39119/psn-pdf
November 25, 2009 - Effect of a weight-based prescribing method within an
electronic health record on prescribing errors.
November 25, 2009
Ginzburg R, Barr WB, Harris M, et al. Effect of a weight-based prescribing method within an electronic
health record on prescribing errors. Am J Health Syst Pharm. 2009;66(22):2037-41.
doi:10.214…
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psnet.ahrq.gov/node/35485/psn-pdf
May 27, 2011 - Navigating the information technology highway:
computer solutions to reduce errors and enhance patient
safety.
May 27, 2011
Koshy R. Navigating the information technology highway: computer solutions to reduce errors and enhance
patient safety. Transfusion (Paris). 2005;45(4 Suppl):189S-205S.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/40428/psn-pdf
May 04, 2011 - Does user-centred design affect the efficiency, usability
and safety of CPOE order sets?
May 4, 2011
Chan J, Shojania KG, Easty AC, et al. Does user-centred design affect the efficiency, usability and safety
of CPOE order sets? J Am Med Inform Assoc. 2011;18(3):276-81. doi:10.1136/amiajnl-2010-000026.
https://psne…
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psnet.ahrq.gov/node/38893/psn-pdf
August 26, 2009 - Patient safety, quality care, and service utilization with
PLATO (Physician Leadership for Accurate and Timely
Orders): a pilot study.
August 26, 2009
Brunt BA, Gifford L. Patient safety, quality care, and service utilization with PLATO (Physician Leadership
for Accurate and Timely Orders): a pilot study. J Nurses…
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psnet.ahrq.gov/node/40320/psn-pdf
March 30, 2011 - Effectiveness of an information technology intervention
to improve prophylactic antibacterial use in the
postoperative period.
March 30, 2011
Haynes K, Linkin DR, Fishman NO, et al. Effectiveness of an information technology intervention to
improve prophylactic antibacterial use in the postoperative period. Journa…
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psnet.ahrq.gov/node/36716/psn-pdf
July 26, 2011 - Medication-error reporting and pharmacy resident
experience during implementation of computerized
prescriber order entry.
July 26, 2011
Weant KA, Cook AM, Armitstead JA. Medication-error reporting and pharmacy resident experience during
implementation of computerized prescriber order entry. Am J Health Syst Pharm.…
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psnet.ahrq.gov/node/38346/psn-pdf
April 01, 2010 - Human factors engineering in healthcare systems: the
problem of human error and accident management.
April 1, 2010
Cacciabue PC, Vella G. Human factors engineering in healthcare systems: the problem of human error and
accident management. Int J Med Inform. 2010;79(4):e1-17. doi:10.1016/j.ijmedinf.2008.10.005.
http…
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psnet.ahrq.gov/node/42355/psn-pdf
February 11, 2015 - Advancing Successful Care Transitions to Improve
Outcomes.
February 11, 2015
Society of Hospital Medicine
https://psnet.ahrq.gov/issue/project-boost-mentored-implementation-program
This Web site provides resources associated with the Better Outcomes for Older adults through Safe
Transitions project, called Projec…
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psnet.ahrq.gov/node/47112/psn-pdf
May 09, 2018 - 34 ways to survive your next trip to the hospital.
May 9, 2018
Crouch M. Reader's Digest. April 2018.
https://psnet.ahrq.gov/issue/34-ways-survive-your-next-trip-hospital
Involving patients in their care can help improve safety. This magazine article provides 34 tips from leading
patient safety experts to assist p…