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  1. Psn-Pdf (pdf file)

    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…
  2. Psn-Pdf (pdf file)

    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.…
  3. Psn-Pdf (pdf file)

    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…
  4. Psn-Pdf (pdf file)

    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…
  5. Psn-Pdf (pdf file)

    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…
  6. Psn-Pdf (pdf file)

    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…
  7. Psn-Pdf (pdf file)

    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…
  8. Psn-Pdf (pdf file)

    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…
  9. Psn-Pdf (pdf file)

    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…
  10. Psn-Pdf (pdf file)

    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…
  11. Psn-Pdf (pdf file)

    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…
  12. Psn-Pdf (pdf file)

    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…
  13. Psn-Pdf (pdf file)

    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…
  14. Psn-Pdf (pdf file)

    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…
  15. Psn-Pdf (pdf file)

    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…
  16. Psn-Pdf (pdf file)

    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…
  17. Psn-Pdf (pdf file)

    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…
  18. Psn-Pdf (pdf file)

    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. …
  19. Psn-Pdf (pdf file)

    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…
  20. Psn-Pdf (pdf file)

    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-…

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