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psnet.ahrq.gov/node/39525/psn-pdf
March 13, 2019 - Effect of bar-code technology on the safety of medication
administration.
March 13, 2019
Poon EG, Keohane C, Yoon CS, et al. Effect of bar-code technology on the safety of medication
administration. New Engl J Med. 2010;362(18):1698-1707. doi:10.1056/NEJMsa0907115.
https://psnet.ahrq.gov/issue/effect-bar-code-tech…
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psnet.ahrq.gov/node/39729/psn-pdf
September 20, 2011 - Contextual errors and failures in individualizing patient
care: a multicenter study.
September 20, 2011
Weiner SJ, Schwartz A, Weaver FM, et al. Contextual errors and failures in individualizing patient care: a
multicenter study. Ann Intern Med. 2010;153(2):69-75. doi:10.7326/0003-4819-153-2-201007200-00002.
https…
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psnet.ahrq.gov/node/43436/psn-pdf
August 13, 2014 - Decreasing handoff-related care failures in children's
hospitals.
August 13, 2014
Bigham MT, Logsdon TR, Manicone PE, et al. Decreasing handoff-related care failures in children's
hospitals. Pediatrics. 2014;134(2):e572-e579. doi:10.1542/peds.2013-1844.
https://psnet.ahrq.gov/issue/decreasing-handoff-related-care-…
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psnet.ahrq.gov/node/39497/psn-pdf
February 10, 2015 - The value from investments in health information
technology at the U.S. Department of Veterans Affairs.
February 10, 2015
Byrne CM, Mercincavage LM, Pan EC, et al. The value from investments in health information technology
at the U.S. Department of Veterans Affairs. Health Aff (Millwood). 2010;29(4):629-638.
doi:…
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psnet.ahrq.gov/node/45944/psn-pdf
August 15, 2018 - Orders on file but no labs drawn: investigation of machine
and human errors caused by an interface idiosyncrasy.
August 15, 2018
Schreiber R, Sittig DF, Ash JS, et al. Orders on file but no labs drawn: investigation of machine and human
errors caused by an interface idiosyncrasy. J Am Med Inform Assoc. 2017;24(5):9…
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psnet.ahrq.gov/node/844787/psn-pdf
September 11, 2019 - TRIAD XII: are patients aware of and agree with DNR or
POLST orders in their medical records.
September 11, 2019
Mirarchi FL, Juhasz K, Cooney TE, et al. TRIAD XII: Are Patients Aware of and Agree With DNR or POLST
Orders in Their Medical Records. J Patient Saf. 2019;15(3):230-237. doi:10.1097/PTS.0000000000000631.…
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psnet.ahrq.gov/node/40306/psn-pdf
May 07, 2015 - The benefits of health information technology: a review of
the recent literature shows predominantly positive
results.
May 7, 2015
Buntin MB, Burke MF, Hoaglin MC, et al. The Benefits Of Health Information Technology: A Review Of The
Recent Literature Shows Predominantly Positive Results. Health Aff. 2011;30(3):46…
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psnet.ahrq.gov/node/866646/psn-pdf
September 04, 2024 - Adverse events and perceived abandonment: learning
from patients' accounts of medical mishaps.
September 4, 2024
Schlesinger M, Dhingra I, Fain BA, et al. Adverse events and perceived abandonment: learning from
patients’ accounts of medical mishaps. BMJ Open Qual. 2024;13(3):e002848. doi:10.1136/bmjoq-2024-
002848…
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psnet.ahrq.gov/node/855097/psn-pdf
November 08, 2023 - Use of the Second Victim Experience and Support Tool
(SVEST) to assess the impact of a departmental peer
support program on anesthesia professionals' second
victim experiences (SVEs) and perceptions of support two
years after implementation.
November 8, 2023
Pelikan M, Finney RE, Jacob A. AANA J. 2023;91(5):…
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psnet.ahrq.gov/node/38877/psn-pdf
April 08, 2011 - Computerized order entry with limited decision support to
prevent prescription errors in a PICU.
April 8, 2011
Kadmon G, Bron-Harlev E, Nahum E, et al. Computerized order entry with limited decision support to
prevent prescription errors in a PICU. Pediatrics. 2009;124(3):935-940. doi:10.1542/peds.2008-2737.
https…
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psnet.ahrq.gov/node/862608/psn-pdf
February 14, 2024 - Communication and birth experiences among Black
birthing people who experienced preterm birth.
February 14, 2024
Gregory EF, Johnson GT, Barreto A, et al. Communication and birth experiences among Black birthing
people who experienced preterm birth. Ann Fam Med. 2024;22(1):31-36. doi:10.1370/afm.3048.
https://psne…
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psnet.ahrq.gov/node/40993/psn-pdf
December 14, 2011 - Anticoagulation-associated adverse drug events.
December 14, 2011
Piazza G, Nguyen TN, Cios D, et al. Anticoagulation-associated Adverse Drug Events. Am J Med.
2011;124(12). doi:10.1016/j.amjmed.2011.06.009.
https://psnet.ahrq.gov/issue/anticoagulation-associated-adverse-drug-events
Warfarin and other anticoagulan…
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psnet.ahrq.gov/node/34714/psn-pdf
February 18, 2011 - Relation between malpractice claims and adverse events
due to negligence. Results of the Harvard Medical
Practice Study III.
February 18, 2011
Localio AR, Lawthers AG, Brennan TA, et al. Relation between Malpractice Claims and Adverse Events
Due to Negligence. New England Journal of Medicine. 2010;325(4). doi:10.1…
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psnet.ahrq.gov/node/41898/psn-pdf
December 05, 2012 - Pharmacy dispensing of electronically discontinued
medications.
December 5, 2012
Allen AS, Sequist TD. Pharmacy dispensing of electronically discontinued medications. Ann Intern Med.
2012;157(10):700-705. doi:10.7326/0003-4819-157-10-201211200-00006.
https://psnet.ahrq.gov/issue/pharmacy-dispensing-electronically-…
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psnet.ahrq.gov/node/60523/psn-pdf
May 27, 2020 - "We're not ready, but I don't think you're ever ready."
Clinician perspectives on implementation of crisis
standards of care.
May 27, 2020
Chuang E, Cuartas PA, Powell T, et al. "We're not ready, but I don't think you're ever ready." Clinician
perspectives on implementation of crisis standards of care. AJOB Empir …
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psnet.ahrq.gov/node/42229/psn-pdf
July 03, 2014 - Relationship between occurrence of surgical
complications and hospital finances.
July 3, 2014
Eappen S, Lane BH, Rosenberg B, et al. Relationship between occurrence of surgical complications and
hospital finances. JAMA. 2013;309(15):1599-606. doi:10.1001/jama.2013.2773.
https://psnet.ahrq.gov/issue/relationship-be…
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psnet.ahrq.gov/issue/patient-safety-group
March 27, 2024 - Multi-use Website
The Patient Safety Group.
Save
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August 9, 2006
Development of The Patient Safety Group was motivated by the death of…
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psnet.ahrq.gov/node/35978/psn-pdf
May 27, 2011 - The impact of prescribing safety alerts for elderly persons
in an electronic medical record: an interrupted time series
evaluation.
May 27, 2011
Smith DH, Perrin N, Feldstein AC, et al. The impact of prescribing safety alerts for elderly persons in an
electronic medical record: an interrupted time series evaluatio…
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psnet.ahrq.gov/node/42710/psn-pdf
December 29, 2014 - Impact of electronic chemotherapy order forms on
prescribing errors at an urban medical center: results
from an interrupted time-series analysis.
December 29, 2014
Elsaid K, Truong T, Monckeberg M, et al. Impact of electronic chemotherapy order forms on prescribing
errors at an urban medical center: results from a…
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psnet.ahrq.gov/node/43072/psn-pdf
November 21, 2016 - Physician attitudes toward family-activated medical
emergency teams for hospitalized children.
November 21, 2016
Paciotti B, Roberts KE, Tibbetts KM, et al. Physician attitudes toward family-activated medical emergency
teams for hospitalized children. Jt Comm J Qual Patient Saf. 2014;40(4):187-192.
https://psnet.a…