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psnet.ahrq.gov/node/50744/psn-pdf
December 18, 2019 - EMS crews brought patients to the hospital with
misplaced breathing tubes. None of them survived
December 18, 2019
Arditi L. Peoples Public Radio. December 3, 2019.
https://psnet.ahrq.gov/issue/ems-crews-brought-patients-hospital-misplaced-breathing-tubes-none-them-
survived
Emergency medical services are often p…
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psnet.ahrq.gov/node/43471/psn-pdf
September 10, 2014 - Computerized prescriber order entry in the outpatient
oncology setting: from evidence to meaningful use.
September 10, 2014
Kukreti V, Cosby R, Cheung A, et al. Computerized prescriber order entry in the outpatient oncology
setting: from evidence to meaningful use. Curr Oncol. 2014;21(4):e604-12. doi:10.3747/co.21.…
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psnet.ahrq.gov/node/43598/psn-pdf
October 08, 2014 - Clinical faculty: taking the lead in teaching quality
improvement and patient safety.
October 8, 2014
Davis NL, Davis DA, Rayburn WF. Clinical faculty: taking the lead in teaching quality improvement and
patient safety. Am J Obstet Gynecol. 2014;211(3):215-215.e1. doi:10.1016/j.ajog.2014.05.043.
https://psnet.ahrq…
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psnet.ahrq.gov/node/38063/psn-pdf
February 23, 2009 - CPOE in Iran—a viable prospect? Physicians' opinions on
using CPOE in an Iranian teaching hospital.
February 23, 2009
Kazemi A, Ellenius J, Tofighi S, et al. CPOE in Iran--a viable prospect? Physicians' opinions on using
CPOE in an Iranian teaching hospital. Int J Med Inform. 2009;78(3):199-207.
doi:10.1016/j.ijme…
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psnet.ahrq.gov/node/39124/psn-pdf
February 18, 2011 - Adverse drug event rates in six community hospitals and
the potential impact of computerized physician order
entry for prevention.
February 18, 2011
Hug BL, Witkowski DJ, Sox CM, et al. Adverse Drug Event Rates in Six Community Hospitals and the
Potential Impact of Computerized Physician Order Entry for Prevention…
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psnet.ahrq.gov/node/73469/psn-pdf
July 07, 2021 - Barriers to and facilitators of bedside nursing handover: a
systematic review and meta-synthesis.
July 7, 2021
Clari M, Conti A, Chiarini D, et al. Barriers to and facilitators of bedside nursing handover: a systematic
review and meta-synthesis. J Nurs Care Qual. 2021;36(4):e51-e58. doi:10.1097/ncq.0000000000000564…
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psnet.ahrq.gov/node/838311/psn-pdf
October 12, 2022 - How to reduce stigma and bias in clinical communication:
a narrative review.
October 12, 2022
Healy M, Richard A, Kidia K. How to reduce stigma and bias in clinical communication: a narrative review. J
Gen Intern Med. 2022;37(10):2533-2540. doi:10.1007/s11606-022-07609-y.
https://psnet.ahrq.gov/issue/how-reduce-st…
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psnet.ahrq.gov/node/39256/psn-pdf
November 14, 2011 - Improving America's Hospitals: The Joint Commission's
Annual Report on Quality and Safety 2009.
November 14, 2011
Oakbrook Terrace, IL: The Joint Commission; January 2010.
https://psnet.ahrq.gov/issue/improving-americas-hospitals-joint-commissions-annual-report-quality-and-
safety-2009
America's hospitals continu…
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psnet.ahrq.gov/node/855094/psn-pdf
November 08, 2023 - Preferred language and diagnostic errors in the pediatric
emergency department.
November 8, 2023
Lowe JT, Leonard J, Dominguez F, et al. Preferred language and diagnostic errors in the pediatric
emergency department. Diagnosis (Berl). 2024;11(1):49-53. doi:10.1515/dx-2023-0079.
https://psnet.ahrq.gov/issue/preferr…
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psnet.ahrq.gov/node/837041/psn-pdf
May 04, 2022 - APSF endorsed statement on revising recommendations
for patient monitoring during anesthesia.
May 4, 2022
The APSF Committee on Technology. APSF Newsletter. 2022;37(1):7–8.
https://psnet.ahrq.gov/issue/apsf-endorsed-statement-revising-recommendations-patient-monitoring-during-
anesthesia
Variation across sta…
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psnet.ahrq.gov/node/34998/psn-pdf
June 22, 2009 - Cause and effect analysis of closed claims in obstetrics
and gynecology.
June 22, 2009
White AA, Pichert JW, Bledsoe SH, et al. Cause and effect analysis of closed claims in obstetrics and
gynecology. Obstet Gynecol. 2005;105(5 Pt 1):1031-1038.
https://psnet.ahrq.gov/issue/cause-and-effect-analysis-closed-claims-o…
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psnet.ahrq.gov/node/837855/psn-pdf
August 17, 2022 - Patterns of error in interpretive pathology.
August 17, 2022
Packer MDC, Ravinsky E, Azordegan N. Patterns of error in interpretive pathology. Am J Clin Pathol.
2022;157(5):767-773. doi:10.1093/ajcp/aqab190.
https://psnet.ahrq.gov/issue/patterns-error-interpretive-pathology
Studies have shown diagnostic discordanc…
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psnet.ahrq.gov/node/43881/psn-pdf
February 11, 2015 - Cognitive Systems Engineering in Health Care.
February 11, 2015
Bisantz AM, Burns CM, Fairbanks RJ, eds. Boca Raton, FL: CRC Press; 2014. ISBN: 9781466587960.
https://psnet.ahrq.gov/issue/cognitive-systems-engineering-health-care
This publication provides information about the role of cognition in medical error. Th…
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psnet.ahrq.gov/node/849615/psn-pdf
May 31, 2023 - Clinical Investigation Booking Systems Failures: Written
Communications in Community Languages.
May 31, 2023
Farnborough, UK: Healthcare Safety Investigation Branch; April 2023.
https://psnet.ahrq.gov/issue/clinical-investigation-booking-systems-failures-written-communications-
community-languages
Gaps in patient…
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psnet.ahrq.gov/node/39601/psn-pdf
June 16, 2010 - Impact of computerized orders for pediatric continuous
drug infusions on detecting infusion pump programming
errors: a simulated study.
June 16, 2010
Sowan AK, Gaffoor MI, Soeken K, et al. Impact of Computerized Orders for Pediatric Continuous Drug
Infusions on Detecting Infusion Pump Programming Errors: A Simulat…
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psnet.ahrq.gov/node/867748/psn-pdf
March 12, 2025 - Adverse events involving telehealth in the Veterans
Health Administration.
March 12, 2025
Mills PD, Tomolo A, Yackel EE. Adverse events involving telehealth in the Veterans Health Administration.
Jt Comm J Qual Patient Saf. 2024;Epub Dec 20. doi:10.1016/j.jcjq.2024.12.002.
https://psnet.ahrq.gov/issue/adverse-even…
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psnet.ahrq.gov/node/46051/psn-pdf
April 12, 2017 - Automated detection of look-alike/sound-alike medication
errors.
April 12, 2017
Rash-Foanio C, Galanter W, Bryson M, et al. Automated detection of look-alike/sound-alike medication
errors. Am J Health Syst Pharm. 2017;74(7):521-527. doi:10.2146/ajhp150690.
https://psnet.ahrq.gov/issue/automated-detection-look-alik…
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psnet.ahrq.gov/node/44072/psn-pdf
August 02, 2015 - The rise of the medical scribe industry: implications for
the advancement of electronic health records.
August 2, 2015
Gellert GA, Ramirez R, Webster L. The rise of the medical scribe industry: implications for the
advancement of electronic health records. JAMA. 2015;313(13):1315-1316. doi:10.1001/jama.2014.17128.
…
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psnet.ahrq.gov/node/46266/psn-pdf
July 19, 2017 - New unintended adverse consequences of electronic
health records.
July 19, 2017
Sittig DF, Wright A, Ash J, et al. New Unintended Adverse Consequences of Electronic Health Records.
Yearb Med Inform. 2016;(1):7-12.
https://psnet.ahrq.gov/issue/new-unintended-adverse-consequences-electronic-health-records
Pressures…
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psnet.ahrq.gov/node/40006/psn-pdf
November 17, 2010 - Impact of health information technology on detection of
potential adverse drug events at the ordering stage.
November 17, 2010
Roberts LL, Ward MM, Brokel JM, et al. Impact of health information technology on detection of potential
adverse drug events at the ordering stage. Am J Health Syst Pharm. 2010;67(21):1838-…