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psnet.ahrq.gov/node/850160/psn-pdf
June 07, 2023 - The Ohio Maternal Safety Quality Improvement Project:
initial results of a statewide perinatal hypertension quality
improvement initiative implemented during the COVID-19
pandemic.
June 7, 2023
Schneider P, Lorenz A, Menegay MC, et al. The Ohio Maternal Safety Quality Improvement Project: initial
results of a sta…
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psnet.ahrq.gov/node/37019/psn-pdf
September 15, 2011 - Just what the doctor ordered. Review of the evidence of
the impact of computerized physician order entry system
on medication errors.
September 15, 2011
Shamliyan TA, Duval S, Du J, et al. Just what the doctor ordered. Review of the evidence of the impact of
computerized physician order entry system on medication …
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psnet.ahrq.gov/node/43859/psn-pdf
May 28, 2015 - Point prevalence of surgical checklist use in Europe:
relationship with hospital mortality.
May 28, 2015
Jammer I, Ahmad T, Aldecoa C, et al. Point prevalence of surgical checklist use in Europe: relationship
with hospital mortality. Br J Anaesth. 2015;114(5):801-807. doi:10.1093/bja/aeu460.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/46807/psn-pdf
July 02, 2019 - Communication failure: analysis of prescribers' use of an
internal free-text field on electronic prescriptions.
July 2, 2019
Ai A, Wong A, Amato MG, et al. Communication failure: analysis of prescribers’ use of an internal free-text
field on electronic prescriptions. J Am Med Inform Assoc. 2018;25(6):709-714. doi:1…
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psnet.ahrq.gov/node/39852/psn-pdf
February 10, 2015 - National costs of the medical liability system.
February 10, 2015
Mello MM, Chandra A, Gawande AA, et al. National costs of the medical liability system. Health Aff
(Millwood). 2010;29(9):1569-1577. doi:10.1377/hlthaff.2009.0807.
https://psnet.ahrq.gov/issue/national-costs-medical-liability-system
The role of medi…
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psnet.ahrq.gov/node/41795/psn-pdf
September 07, 2016 - Drug shortage-associated increase in catheter-related
blood stream infection in children.
September 7, 2016
Ralls MW, Blackwood A, Arnold MA, et al. Drug shortage-associated increase in catheter-related blood
stream infection in children. Pediatrics. 2012;130(5):e1369-73. doi:10.1542/peds.2011-3894.
https://psnet.…
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psnet.ahrq.gov/node/866699/psn-pdf
September 11, 2024 - AHRQ-Funded Patient Safety Project Highlights:
Improving Patient Safety by Enhancing Medication Safety.
September 11, 2024
Ahrq-Funded Patient Safety Project Highlights: Improving Patient Safety By Enhancing Medication Safety.
Rockville, MD: Agency for Healthcare Research and Quality; 2024. AHRQ Publication No. 24-…
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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/39354/psn-pdf
September 20, 2011 - Sustaining reductions in catheter related bloodstream
infections in Michigan intensive care units: observational
study.
September 20, 2011
Pronovost P, Goeschel CA, Colantuoni E, et al. Sustaining reductions in catheter related bloodstream
infections in Michigan intensive care units: observational study. BMJ. 2010…
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psnet.ahrq.gov/node/44302/psn-pdf
August 04, 2015 - The Global Comparators project: international
comparison of 30-day in-hospital mortality by day of the
week.
August 4, 2015
Ruiz M, Bottle A, Aylin PP. The Global Comparators project: international comparison of 30-day in-hospital
mortality by day of the week. BMJ Qual Saf. 2015;24(8):492-504. doi:10.1136/bmjqs-20…
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psnet.ahrq.gov/node/37308/psn-pdf
January 05, 2012 - Effect of a rapid response system for patients in shock on
time to treatment and mortality during 5 years.
January 5, 2012
Sebat F, Musthafa AA, Johnson D, et al. Effect of a rapid response system for patients in shock on time to
treatment and mortality during 5 years. Crit Care Med. 2007;35(11):2568-75.
https://p…
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psnet.ahrq.gov/node/46910/psn-pdf
January 23, 2019 - Taking the heat or taking the temperature? A qualitative
study of a large-scale exercise in seeking to measure for
improvement, not blame.
January 23, 2019
Armstrong N, Brewster L, Tarrant C, et al. Taking the heat or taking the temperature? A qualitative study of
a large-scale exercise in seeking to measure for i…
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psnet.ahrq.gov/node/37032/psn-pdf
May 27, 2011 - Effects of computerized physician order entry and clinical
decision support systems on medication safety: a
systematic review.
May 27, 2011
Kaushal R, Shojania KG, Bates DW. Effects of computerized physician order entry and clinical decision
support systems on medication safety: a systematic review. Arch Intern Me…
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psnet.ahrq.gov/node/40526/psn-pdf
June 15, 2011 - Critical drug–drug interactions for use in electronic health
records systems with computerized physician order
entry: review of leading approaches.
June 15, 2011
Classen DC, Phansalkar S, Bates DW. Critical Drug-Drug Interactions for Use in Electronic Health Records
Systems With Computerized Physician Order Entry.…
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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/41317/psn-pdf
January 31, 2013 - Variation in 17 obstetric care pathways: potential danger
for health professionals and patient safety?
January 31, 2013
Sarrechia M, Van Gerven E, Hermans L, et al. Variation in 17 obstetric care pathways: potential danger for
health professionals and patient safety? J Adv Nurs. 2013;69(2):278-85. doi:10.1111/j.136…
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psnet.ahrq.gov/node/40072/psn-pdf
April 04, 2011 - Perceptions of hospital safety climate and incidence of
readmission.
April 4, 2011
Hansen LO, Williams M, Singer SJ. Perceptions of hospital safety climate and incidence of readmission.
Health Serv Res. 2011;46(2):596-616. doi:10.1111/j.1475-6773.2010.01204.x.
https://psnet.ahrq.gov/issue/perceptions-hospital-safe…
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psnet.ahrq.gov/node/849124/psn-pdf
May 17, 2023 - Human factors and safety analysis methods used in the
design and redesign of electronic medication
management systems: a systematic review.
May 17, 2023
Awad S, Amon K, Baillie A, et al. Human factors and safety analysis methods used in the design and
redesign of electronic medication management systems: a systema…
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psnet.ahrq.gov/node/45889/psn-pdf
August 16, 2017 - New persistent opioid use after minor and major surgical
procedures in US adults.
August 16, 2017
Brummett CM, Waljee JF, Goesling J, et al. New Persistent Opioid Use After Minor and Major Surgical
Procedures in US Adults. JAMA Surg. 2017;152(6):e170504. doi:10.1001/jamasurg.2017.0504.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/46439/psn-pdf
August 20, 2018 - Hospital-readmission risk--isolating hospital effects from
patient effects.
August 20, 2018
Krumholz HM, Wang K, Lin Z, et al. Hospital-Readmission Risk - Isolating Hospital Effects from Patient
Effects. N Engl J Med. 2017;377(11):1055-1064. doi:10.1056/NEJMsa1702321.
https://psnet.ahrq.gov/issue/hospital-readmiss…