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psnet.ahrq.gov/node/41519/psn-pdf
September 01, 2016 - Failure to utilize functions of an electronic prescribing
system and the subsequent generation of 'technically
preventable' computerized alerts.
September 1, 2016
Baysari M, Reckmann MH, Li L, et al. Failure to utilize functions of an electronic prescribing system and the
subsequent generation of 'technically prev…
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psnet.ahrq.gov/node/47602/psn-pdf
January 27, 2019 - Association of nurse workload with missed nursing care
in the neonatal intensive care unit.
January 27, 2019
Tubbs-Cooley HL, Mara CA, Carle AC, et al. Association of Nurse Workload With Missed Nursing Care in
the Neonatal Intensive Care Unit. JAMA Pediatr. 2019;173(1):44-51.
doi:10.1001/jamapediatrics.2018.3619.
…
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psnet.ahrq.gov/node/46995/psn-pdf
January 01, 2021 - Qualitative content analysis of coworkers' safety reports
of unprofessional behavior by physicians and advanced
practice professionals.
April 18, 2018
Martinez W, Pichert JW, Hickson GB, et al. Qualitative Content Analysis of Coworkers' Safety Reports of
Unprofessional Behavior by Physicians and Advanced Practice …
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psnet.ahrq.gov/issue/vha-national-patient-safety-improvement-handbook
April 12, 2019 - Organizational Policy/Guidelines
VHA National Patient Safety Improvement Handbook.
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January 17, 2012
A handbook developed by the …
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psnet.ahrq.gov/node/45536/psn-pdf
October 05, 2016 - Clinician-identified problems and solutions for delayed
diagnosis in primary care: a PRIORITIZE study.
October 5, 2016
Car LT, Papachristou N, Bull A, et al. Clinician-identified problems and solutions for delayed diagnosis in
primary care: a PRIORITIZE study. BMC Fam Pract. 2016;17(1):131. doi:10.1186/s12875-016-0…
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psnet.ahrq.gov/node/45380/psn-pdf
November 11, 2016 - Innovative patient safety curriculum using iPad game
(PASSED) improved patient safety concepts in
undergraduate medical students.
November 11, 2016
Kow AWC, Ang BLS, Chong CS, et al. Innovative Patient Safety Curriculum Using iPAD Game (PASSED)
Improved Patient Safety Concepts in Undergraduate Medical Students. Wo…
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psnet.ahrq.gov/node/39282/psn-pdf
September 20, 2011 - Weekend mortality for emergency admissions. A large,
multicentre study.
September 20, 2011
Aylin PP, Yunus A, Bottle A, et al. Weekend mortality for emergency admissions. A large, multicentre
study. Qual Saf Health Care. 2010;19(3):213-7. doi:10.1136/qshc.2008.028639.
https://psnet.ahrq.gov/issue/weekend-mortality…
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psnet.ahrq.gov/node/41455/psn-pdf
June 13, 2012 - Medication errors during medical emergencies in a large,
tertiary care, academic medical center.
June 13, 2012
Gokhman R, Seybert AL, Phrampus P, et al. Medication errors during medical emergencies in a large,
tertiary care, academic medical center. Resuscitation. 2012;83(4):482-7.
doi:10.1016/j.resuscitation.2011…
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psnet.ahrq.gov/node/46932/psn-pdf
April 22, 2018 - Hospital Survey on Patient Safety Culture: 2018 User
Database Report.
April 22, 2018
Famolaro T, Yount N, Hare, R, et al. Rockville, MD: Agency for Healthcare Research and Quality; March
2018. AHRQ Publication No. 18-0025-EF.
https://psnet.ahrq.gov/issue/hospital-survey-patient-safety-culture-2018-user-database-re…
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psnet.ahrq.gov/node/42900/psn-pdf
September 19, 2016 - Suicide attempts and completions on medical-surgical
and intensive care units.
September 19, 2016
Mills PD, Watts V, Hemphill RR. Suicide attempts and completions on medical-surgical and intensive care
units. J Hosp Med. 2014;9(3):182-5. doi:10.1002/jhm.2141.
https://psnet.ahrq.gov/issue/suicide-attempts-and-compl…
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psnet.ahrq.gov/node/40167/psn-pdf
January 22, 2017 - Trainees' perceptions of patient safety practices:
recounting failures of supervision.
January 22, 2017
Ross PT, McMyler ET, Anderson SG, et al. Trainees' perceptions of patient safety practices: recounting
failures of supervision. Jt Comm J Qual Patient Saf. 2011;37(2):88-95.
https://psnet.ahrq.gov/issue/trainees…
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psnet.ahrq.gov/node/45207/psn-pdf
August 17, 2016 - Unit-based incident reporting and root cause analysis:
variation at three hospital unit types.
August 17, 2016
Wagner C, Merten H, Zwaan L, et al. Unit-based incident reporting and root cause analysis: variation at
three hospital unit types. BMJ Open. 2016;6(6):e011277. doi:10.1136/bmjopen-2016-011277.
https://psn…
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psnet.ahrq.gov/node/44353/psn-pdf
November 03, 2015 - Evaluation of symptom checkers for self diagnosis and
triage: audit study.
November 3, 2015
Semigran HL, Linder JA, Gidengil C, et al. Evaluation of symptom checkers for self diagnosis and triage:
audit study. BMJ. 2015;351:h3480. doi:10.1136/bmj.h3480.
https://psnet.ahrq.gov/issue/evaluation-symptom-checkers-self…
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psnet.ahrq.gov/node/39365/psn-pdf
May 25, 2010 - Electronic prescribing improves medication safety in
community-based office practices.
May 25, 2010
Kaushal R, Kern LM, Barrón Y, et al. Electronic Prescribing Improves Medication Safety in Community-
Based Office Practices. J Gen Intern Med. 2010;25(6). doi:10.1007/s11606-009-1238-8.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/43486/psn-pdf
September 01, 2016 - Indication alerts intercept drug name confusion errors
during computerized entry of medication orders.
September 1, 2016
Galanter W, Bryson M, Falck S, et al. Indication alerts intercept drug name confusion errors during
computerized entry of medication orders. PLoS One. 2014;9(7):e101977.
doi:10.1371/journal.pone…
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psnet.ahrq.gov/node/42788/psn-pdf
January 19, 2014 - Demonstrating high reliability on accountability measures
at The Johns Hopkins Hospital.
January 19, 2014
Pronovost P, Demski R, Callender T, et al. Demonstrating high reliability on accountability measures at the
Johns Hopkins Hospital. Jt Comm J Qual Patient Saf. 2013;39(12):531-544.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/44208/psn-pdf
July 16, 2015 - Preventability of voluntarily reported or trigger
tool–identified medication errors in a pediatric institution
by information technology: a retrospective cohort study.
July 16, 2015
Stultz JS, Nahata MC. Preventability of Voluntarily Reported or Trigger Tool-Identified Medication Errors in
a Pediatric Institution …
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psnet.ahrq.gov/node/45323/psn-pdf
June 28, 2017 - Effects of health information technology on patient
outcomes: a systematic review.
June 28, 2017
Brenner SK, Kaushal R, Grinspan Z, et al. Effects of health information technology on patient outcomes: a
systematic review. J Am Med Inform Assoc. 2016;23(5):1016-36. doi:10.1093/jamia/ocv138.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/42711/psn-pdf
October 31, 2014 - Characterising the complexity of medication safety using
a human factors approach: an observational study in two
intensive care units.
October 31, 2014
Carayon P, Wetterneck TB, Cartmill R, et al. Characterising the complexity of medication safety using a
human factors approach: an observational study in two inten…
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psnet.ahrq.gov/node/44004/psn-pdf
September 01, 2016 - Impact of computerized physician order entry alerts on
prescribing in older patients.
September 1, 2016
Lester PE, Rios-Rojas L, Islam S, et al. Impact of computerized physician order entry alerts on prescribing
in older patients. Drugs Aging. 2015;32(3):227-33. doi:10.1007/s40266-015-0244-2.
https://psnet.ahrq.go…