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psnet.ahrq.gov/node/36927/psn-pdf
April 14, 2011 - The frequency of missed test results and associated
treatment delays in a highly computerized health system.
April 14, 2011
Wahls TL, Cram PM. The frequency of missed test results and associated treatment delays in a highly
computerized health system. BMC Fam Pract. 2007;8:32.
https://psnet.ahrq.gov/issue/frequenc…
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psnet.ahrq.gov/node/43378/psn-pdf
August 14, 2014 - Interventions to reduce pediatric medication errors: a
systematic review.
August 14, 2014
Rinke ML, Bundy DG, Velasquez CA, et al. Interventions to reduce pediatric medication errors: a
systematic review. Pediatrics. 2014;134(2):338-360. doi:10.1542/peds.2013-3531.
https://psnet.ahrq.gov/issue/interventions-reduce…
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psnet.ahrq.gov/node/45435/psn-pdf
August 24, 2016 - Pharmacist–physician communications in a highly
computerised hospital: sign-off and action of electronic
review messages.
August 24, 2016
Pontefract SK, Hodson J, Marriott JF, et al. Pharmacist-Physician Communications in a Highly
Computerised Hospital: Sign-Off and Action of Electronic Review Messages. PLoS One.
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psnet.ahrq.gov/node/45870/psn-pdf
March 25, 2017 - Improving communication with primary care physicians at
the time of hospital discharge.
March 25, 2017
Destino LA, Dixit A, Pantaleoni JL, et al. Improving Communication with Primary Care Physicians at the
Time of Hospital Discharge. Jt Comm J Qual Patient Saf. 2017;43(2):80-88. doi:10.1016/j.jcjq.2016.11.005.
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psnet.ahrq.gov/node/45471/psn-pdf
September 21, 2016 - Vital signs: epidemiology of sepsis: prevalence of health
care factors and opportunities for prevention.
September 21, 2016
Novosad SA, Sapiano MRP, Grigg C, et al. Vital Signs: Epidemiology of Sepsis: Prevalence of Health Care
Factors and Opportunities for Prevention. MMWR Morb Mortal Wkly Rep. 2016;65(33):864-869…
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psnet.ahrq.gov/node/764396/psn-pdf
March 02, 2022 - Family Input for Quality and Safety (FIQS): using mobile
technology for in-hospital reporting from families and
patients.
March 2, 2022
Bardach NS, Stotts JR, Fiore DM, et al. Family Input for Quality and Safety (FIQS): Using mobile
technology for in?hospital reporting from families and patients. J Hosp Med. 2022;…
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psnet.ahrq.gov/node/845631/psn-pdf
March 08, 2023 - Evaluation of policies limiting opioid exposure on opioid
prescribing and patient pain in opioid-naive patients
undergoing elective surgery in a large American health
system.
March 8, 2023
Rennert L, Howard KA, Walker KB, et al. Evaluation of policies limiting opioid exposure on opioid
prescribing and patient pai…
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psnet.ahrq.gov/node/45739/psn-pdf
July 02, 2017 - High-risk medications in hospitalized elderly adults: are
we making it easy to do the wrong thing?
July 2, 2017
Blachman NL, Leipzig RM, Mazumdar M, et al. High-Risk Medications in Hospitalized Elderly Adults: Are
We Making It Easy to Do the Wrong Thing? J Am Geriatr Soc. 2017;65(3):603-607. doi:10.1111/jgs.14703.
…
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psnet.ahrq.gov/node/41192/psn-pdf
November 26, 2014 - Effect of patient- and medication-related factors on
inpatient medication reconciliation errors.
November 26, 2014
Salanitro AH, Osborn CY, Schnipper JL, et al. Effect of patient- and medication-related factors on inpatient
medication reconciliation errors. J Gen Intern Med. 2012;27(8):924-932. doi:10.1007/s11606-0…
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psnet.ahrq.gov/node/44530/psn-pdf
October 21, 2015 - Patient safety and quality of care in developing countries
in Southeast Asia: a systematic literature review.
October 21, 2015
Harrison R, Cohen AWS, Walton M. Patient safety and quality of care in developing countries in Southeast
Asia: a systematic literature review. Int J Qual Health Care. 2015;27(4):240-254.
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May 01, 2015 - Promoting Patient Safety Through Effective Health
Information Technology Risk Management.
May 1, 2015
Schneider EC, Ridgely MS, Meeker D, Hunter LE, Khodyakov D, Rudin R. RAND Health. Washington, DC:
Office of the National Coordinator for Health Information Technology; May 2014. RR-654-DHHSNCH.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/42177/psn-pdf
November 23, 2016 - Failure to engage hospitalized elderly patients and their
families in advance care planning.
November 23, 2016
Heyland DK, Barwich D, Pichora D, et al. Failure to engage hospitalized elderly patients and their families
in advance care planning. JAMA Intern Med. 2013;173(9):778-787. doi:10.1001/jamainternmed.2013.18…
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psnet.ahrq.gov/node/43533/psn-pdf
August 28, 2017 - Organizational, cultural, and psychological determinants
of smart infusion pump work arounds: a study of 3 U.S.
health systems.
August 28, 2017
Dunford BB, Perrigino M, Tucker SJ, et al. Organizational, Cultural, and Psychological Determinants of
Smart Infusion Pump Work Arounds: A Study of 3 U.S. Health Systems. …
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psnet.ahrq.gov/node/43771/psn-pdf
May 01, 2015 - The Public's Views on Medical Error in Massachusetts.
May 1, 2015
Boston, MA: Harvard School of Public Health; December 2014.
https://psnet.ahrq.gov/issue/publics-views-medical-error-massachusetts
This statewide public telephone survey in Massachusetts found that more than 20% of respondents
experienced a medical …
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psnet.ahrq.gov/node/45608/psn-pdf
October 27, 2016 - Errors, omissions, and outliers in hourly vital signs
measurements in intensive care.
October 27, 2016
Maslove DM, Dubin JA, Shrivats A, et al. Errors, Omissions, and Outliers in Hourly Vital Signs
Measurements in Intensive Care. Crit Care Med. 2016;44(11):e1021-e1030.
https://psnet.ahrq.gov/issue/errors-omissions…
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psnet.ahrq.gov/node/866686/psn-pdf
September 11, 2024 - Impact of automated alerts on discharge opioid
overprescribing after general surgery.
September 11, 2024
Rizk E, Kaur N, Duong PY, et al. Impact of automated alerts on discharge opioid overprescribing after
general surgery. Am J Health Syst Pharm. 2024;81(24):1288-1296. doi:10.1093/ajhp/zxae185.
https://psnet.ahrq…
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psnet.ahrq.gov/node/45509/psn-pdf
September 28, 2016 - Computerized triggers of big data to detect delays in
follow-up of chest imaging results.
September 28, 2016
Murphy DR, Meyer AND, Bhise V, et al. Computerized Triggers of Big Data to Detect Delays in Follow-up
of Chest Imaging Results. Chest. 2016;150(3):613-20. doi:10.1016/j.chest.2016.05.001.
https://psnet.ahrq…
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psnet.ahrq.gov/node/39873/psn-pdf
January 22, 2017 - A proactive risk avoidance system using failure mode and
effects analysis for "same-name" physician orders.
January 22, 2017
Tarpey K, Schaaf E, Lakhani U, et al. A proactive risk avoidance system using failure mode and effects
analysis for "same-name" physician orders. Jt Comm J Qual Patient Saf. 2010;36(10):461-7…
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digital.ahrq.gov/sites/default/files/docs/citation/r21hs024540-ferucci-final-report-2019.pdf
January 01, 2019 - Evaluation of the Impact of Telemedicine on Management of Rheumatoid Arthritis - Final Report
FINAL PROGRESS REPORT
Title: Evaluation of the Impact of Telemedicine on Management of Rheumatoid Arthritis
Principal Investigator: Elizabeth D. Ferucci, MD, MPH
Other Key Personnel: Sara…
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psnet.ahrq.gov/web-mm/bad-writing-wrong-medication
March 01, 2015 - SPOTLIGHT CASE
Bad Writing, Wrong Medication
Citation Text:
Devine B. Bad Writing, Wrong Medication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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