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psnet.ahrq.gov/issue/unrealized-potential-and-residual-consequences-electronic-prescribing-pharmacy-workflow
December 31, 2014 - Study
Unrealized potential and residual consequences of electronic prescribing on pharmacy workflow in the outpatient pharmacy.
Citation Text:
Nanji KC, Rothschild JM, Boehne JJ, et al. Unrealized potential and residual consequences of electronic prescribing on pharmacy workflow in the o…
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psnet.ahrq.gov/issue/exploring-sociotechnical-intersection-patient-safety-and-electronic-health-record
May 01, 2015 - Study
Classic
Exploring the sociotechnical intersection of patient safety and electronic health record implementation.
Citation Text:
Meeks DW, Takian A, Sittig DF, et al. Exploring the sociotechnical intersection of patient safety and electronic health record i…
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psnet.ahrq.gov/issue/incidence-and-variables-associated-inconsistencies-opioid-prescribing-hospital-discharge-and
April 29, 2018 - Study
Incidence and variables associated with inconsistencies in opioid prescribing at hospital discharge and its associated adverse drug outcomes.
Citation Text:
Kurteva S, Habib B, Moraga T, et al. Incidence and variables associated with inconsistencies in opioid prescribing at hospita…
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psnet.ahrq.gov/issue/laboratory-medicine-handoff-gaps-experienced-primary-care-practices-report-shared-networks
September 01, 2012 - Study
Laboratory medicine handoff gaps experienced by primary care practices: a report from the Shared Networks of Collaborative Ambulatory Practices and Partners (SNOCAP).
Citation Text:
West DR, James KA, Fernald DH, et al. Laboratory medicine handoff gaps experienced by primary care p…
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psnet.ahrq.gov/issue/qualitative-analysis-physician-perspectives-missed-and-delayed-outpatient-diagnosis-focus
October 19, 2012 - Study
A qualitative analysis of physician perspectives on missed and delayed outpatient diagnosis: the focus on system-related factors.
Citation Text:
Sarkar U, Simchowitz B, Bonacum D, et al. A Qualitative Analysis of Physician Perspectives on Missed and Delayed Outpatient Diagnosis: Th…
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psnet.ahrq.gov/issue/prevalence-potentially-inappropriate-prescribing-older-people-primary-care-and-its
September 28, 2016 - Study
Emerging Classic
Prevalence of potentially inappropriate prescribing in older people in primary care and its association with hospital admission: longitudinal study.
Citation Text:
Pérez T, Moriarty F, Wallace E, et al. Prevalence of potentially inappropri…
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psnet.ahrq.gov/issue/identification-priorities-improvement-medication-safety-primary-care-prioritize-study
October 05, 2016 - Study
Identification of priorities for improvement of medication safety in primary care: a PRIORITIZE study.
Citation Text:
Car LT, Papachristou N, Gallagher J, et al. Identification of priorities for improvement of medication safety in primary care: a PRIORITIZE study. BMC Fam Pract. 20…
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psnet.ahrq.gov/issue/examining-variations-prescribing-safety-uk-general-practice-cross-sectional-study-using
July 22, 2015 - Study
Examining variations in prescribing safety in UK general practice: cross sectional study using the Clinical Practice Research Datalink.
Citation Text:
Stocks J, Kontopantelis E, Akbarov A, et al. Examining variations in prescribing safety in UK general practice: cross sectional stu…
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psnet.ahrq.gov/issue/patient-feedback-reporting-tool-opennotes-implications-patient-clinician-safety-and-quality
June 06, 2018 - Study
A patient feedback reporting tool for OpenNotes: implications for patient–clinician safety and quality partnerships.
Citation Text:
Bell SK, Gerard M, Fossa A, et al. A patient feedback reporting tool for OpenNotes: implications for patient-clinician safety and quality partnerships…
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psnet.ahrq.gov/issue/routine-failures-process-blood-testing-and-communication-results-patients-primary-care-uk
November 20, 2015 - Study
Routine failures in the process for blood testing and the communication of results to patients in primary care in the UK: a qualitative
exploration of patient and provider perspectives.
Citation Text:
Litchfield I, Bentham L, Hill A, et al. Routine failures in the process for bloo…
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psnet.ahrq.gov/issue/developing-and-evaluating-success-family-activated-medical-emergency-team-quality-improvement
December 02, 2014 - Study
Developing and evaluating the success of a family activated medical emergency team: a quality improvement report.
Citation Text:
Brady PW, Zix J, Brilli RJ, et al. Developing and evaluating the success of a family activated medical emergency team: a quality improvement report. BMJ …
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psnet.ahrq.gov/issue/look-back-and-talk-openly-responding-and-communicating-about-risk-large-scale-error-pathology
November 16, 2016 - Study
Look back and talk openly: responding to and communicating about the risk of large-scale error in pathology diagnoses.
Citation Text:
Aldrich R, Finlayson P, Hill K, et al. Look back and talk openly: responding to and communicating about the risk of large-scale error in pathology d…
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psnet.ahrq.gov/issue/repeat-prescribing-medications-system-centred-risk-management-model-primary-care
January 20, 2016 - Study
Repeat prescribing of medications: a system-centred risk management model for primary care organisations.
Citation Text:
Price J, Man SL, Bartlett S, et al. Repeat prescribing of medications: A system-centred risk management model for primary care organisations. J Eval Clin Pract. …
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psnet.ahrq.gov/issue/impact-computerized-provider-order-entry-systems-medical-imaging-services-systematic-review
June 14, 2017 - Study
The impact of computerized provider order entry systems on medical-imaging services: a systematic review.
Citation Text:
Georgiou A, Prgomet M, Markewycz A, et al. The impact of computerized provider order entry systems on medical-imaging services: a systematic review. J Am Med I…
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psnet.ahrq.gov/issue/exploring-new-avenues-assess-sharp-end-patient-safety-analysis-nationally-aggregated-peer
December 21, 2014 - Study
Exploring new avenues to assess the sharp end of patient safety: an analysis of nationally aggregated peer review data.
Citation Text:
Meeks DW, Meyer AND, Rose B, et al. Exploring new avenues to assess the sharp end of patient safety: an analysis of nationally aggregated peer revi…
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psnet.ahrq.gov/issue/implementation-trigger-review-method-scottish-general-practices-patient-safety-outcomes-and
November 07, 2011 - Study
Implementation of the trigger review method in Scottish general practices: patient safety outcomes and potential for quality improvement.
Citation Text:
de Wet C, Black C, Luty S, et al. Implementation of the trigger review method in Scottish general practices: patient safety outco…
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psnet.ahrq.gov/issue/role-informal-dimensions-safety-high-volume-organisational-routines-ethnographic-study-test
August 01, 2018 - Study
The role of informal dimensions of safety in high-volume organisational routines: an ethnographic study of test results handling in UK general practice.
Citation Text:
Grant S, Checkland K, Bowie P, et al. The role of informal dimensions of safety in high-volume organisational rout…
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psnet.ahrq.gov/issue/understanding-and-responding-when-things-go-wrong-key-principles-primary-care-educators
January 23, 2017 - Study
Understanding and responding when things go wrong: key principles for primary care educators.
Citation Text:
McNab D, Bowie P, Ross A, et al. Understanding and responding when things go wrong: key principles for primary care educators. Educ Prim Care. 2016;27(4):258-66. doi:10.1080…
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psnet.ahrq.gov/node/49456/psn-pdf
July 12, 2004 - Glucose Roller Coaster
July 1, 2004
Sharpe B. Glucose Roller Coaster. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/glucose-roller-coaster
The Case
A 71-year-old woman with congestive heart failure was admitted to the hospital. Her medical history was
significant for dialysis-dependent, end-stage kidney d…
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psnet.ahrq.gov/node/33684/psn-pdf
May 01, 2009 - Patient Safety: A Perspective from Office Practice
May 1, 2009
Baron RJ. Patient Safety: A Perspective from Office Practice. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/patient-safety-perspective-office-practice
Perspective
Most patient interactions with the health care system occur in the outpatien…