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psnet.ahrq.gov/node/72854/psn-pdf
March 17, 2021 - Enabling sustained communication with patients for safe
and effective management of oral chemotherapy: a
longitudinal ethnography.
March 17, 2021
Mitchell G, Porter S, Manias E. Enabling sustained communication with patients for safe and effective
management of oral chemotherapy: a longitudinal ethnography. J Adv …
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psnet.ahrq.gov/taxonomy/term/3504
June 24, 2025 - Workaround
From the perspective of frontline personnel trying to accomplish their work, the design of equipment or the policies governing work tasks can seem counterproductive. When frontline personnel adopt consistent patterns of work or ways of bypassing safety features of medical equipment, these patterns and acti…
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psnet.ahrq.gov/node/73478/psn-pdf
July 07, 2021 - Medical malpractice claims by members of the uniformed
services.
July 7, 2021
Department of Defense Office of General Counsel. 32 CFR Part 45. Fed Register. 86(115); June 17,
2021:32194-32215.
https://psnet.ahrq.gov/issue/medical-malpractice-claims-members-uniformed-services
Organizations with safety culture…
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psnet.ahrq.gov/node/60296/psn-pdf
May 06, 2020 - Ensuring access to medications in the US during the
COVID-19 pandemic.
May 6, 2020
Alexander GC, Qato DM. Ensuring access to medications in the US during the COVID-19 pandemic.
JAMA. 2020;324(1):31-32. doi:10.1001/jama.2020.6016.
https://psnet.ahrq.gov/issue/ensuring-access-medications-us-during-covid-19-pandemic
…
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psnet.ahrq.gov/node/865874/psn-pdf
May 15, 2024 - Perceptions of U.S. and U.K. incident reporting systems:
a scoping review.
May 15, 2024
Gampetro PJ, Nickum A, Schultz CM. Perceptions of U.S. and U.K. incident reporting systems: a scoping
review. J Patient Saf. 2024;20(5):360-365. doi:10.1097/pts.0000000000001231.
https://psnet.ahrq.gov/issue/perceptions-us-and-…
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psnet.ahrq.gov/node/72528/psn-pdf
December 02, 2020 - Impact of remote consultations on antibiotic prescribing
in primary healthcare: systematic review.
December 2, 2020
Han SM, Greenfield G, Majeed A, et al. Impact of remote consultations on antibiotic prescribing in primary
healthcare: systematic review. J Med Internet Res. 2020;22(11):e23482. doi:10.2196/23482.
ht…
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psnet.ahrq.gov/node/43645/psn-pdf
November 12, 2014 - Health IT and Clinical Decision Support Systems.
November 12, 2014
Ohno-Machado L, ed. J Am Med Inform Assoc. 2014;21:e180-e375.
https://psnet.ahrq.gov/issue/health-it-and-clinical-decision-support-systems
A universal agreement on how to calculate the return on investment for health information technology (IT)
and…
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psnet.ahrq.gov/node/36529/psn-pdf
August 09, 2011 - 5 Million Lives Campaign.
August 9, 2011
Institute for Healthcare Improvement; IHI
https://psnet.ahrq.gov/issue/5-million-lives-campaign
The Institute for Healthcare Improvement's 100,000 Lives Campaign successfully engaged more than
3,000 US hospitals in a coordinated effort to reduce preventable inpatient deaths…
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psnet.ahrq.gov/node/838029/psn-pdf
September 07, 2022 - Emergency preparedness: be ready for unanticipated
electronic health record (EHR) downtime.
September 7, 2022
ISMP Medication Safety Alert! Acute care edition! August 25, 2022:27(17)1-6.
https://psnet.ahrq.gov/issue/emergency-preparedness-be-ready-unanticipated-electronic-health-record-ehr-
downtime
Unanticipated…
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psnet.ahrq.gov/node/72735/psn-pdf
February 10, 2021 - Deficiencies in Inpatient Mental Health Care Coordination
and Processes Prior to a Patient's Death by Suicide, Harry
S. Truman Memorial Veterans' Hospital in Columbia,
Missouri.
February 10, 2021
Washington, DC: Department of Veterans Affairs, Office of Inspector General. January 5, 2021. Report No.
20-01521-48. …
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psnet.ahrq.gov/node/43261/psn-pdf
June 18, 2014 - Activation of a medical emergency team using an
electronic medical recording–based screening system.
June 18, 2014
Huh JW, Lim C-M, Koh Y, et al. Activation of a medical emergency team using an electronic medical
recording-based screening system*. Crit Care Med. 2014;42(4):801-8.
doi:10.1097/CCM.0000000000000031.
…
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psnet.ahrq.gov/node/38534/psn-pdf
January 31, 2013 - Health care information technology vendors' "hold
harmless" clause: implications for patients and clinicians.
January 31, 2013
Koppel R, Kreda D. Health care information technology vendors' "hold harmless" clause: implications for
patients and clinicians. JAMA. 2009;301(12):1276-8. doi:10.1001/jama.2009.398.
https…
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psnet.ahrq.gov/node/47297/psn-pdf
October 31, 2018 - Reducing treatment errors through point-of-care
glucometer configuration.
October 31, 2018
Estock JL, Pham I-T, Curinga HK, et al. Reducing Treatment Errors Through Point-of-Care Glucometer
Configuration. Jt Comm J Qual Patient Saf. 2018;44(11):683-694. doi:10.1016/j.jcjq.2018.03.014.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/44842/psn-pdf
March 02, 2016 - Organizational ambidexterity and the hybrid middle
manager: the case of patient safety in UK hospitals.
March 2, 2016
Burgess N, Strauss K, Currie G, et al. Organizational Ambidexterity and the Hybrid Middle Manager: The
Case of Patient Safety in UK Hospitals. Hum Resour Manage. 2015;54(S1). doi:10.1002/hrm.21725.
…
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psnet.ahrq.gov/node/44345/psn-pdf
October 05, 2015 - Apologies following an adverse medical event: the
importance of focusing on the consumer's needs.
October 5, 2015
Allan A, McKillop D, Dooley J, et al. Apologies following an adverse medical event: The importance of
focusing on the consumer's needs. Patient Educ Couns. 2015;98(9):1058-62.
doi:10.1016/j.pec.2015.06…
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psnet.ahrq.gov/node/37444/psn-pdf
January 02, 2008 - My brother's keeper: must a physician disclose another's
medical error and potential negligence?
January 2, 2008
Liang BA, Smith C by DS. My brother's keeper: must a physician disclose another's medical error and
potential negligence? J Clin Anesth. 2007;19(7):558-562. doi:10.1016/j.jclinane.2007.05.005.
https://p…
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psnet.ahrq.gov/node/35044/psn-pdf
September 27, 2017 - Decisions about critical events in device-related
scenarios as a function of expertise.
September 27, 2017
Laxmisan A, Malhotra S, Keselman A, et al. Decisions about critical events in device-related scenarios as a
function of expertise. J Biomed Inform. 2005;38(3):200-12.
https://psnet.ahrq.gov/issue/decisions-ab…
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psnet.ahrq.gov/node/35112/psn-pdf
June 22, 2009 - Medication safety in older adults: home-based practice
patterns.
June 22, 2009
Metlay JP, Cohen A, Polsky D, et al. Medication safety in older adults: home-based practice patterns. J Am
Geriatr Soc. 2005;53(6):976-982.
https://psnet.ahrq.gov/issue/medication-safety-older-adults-home-based-practice-patterns
This s…
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psnet.ahrq.gov/node/37981/psn-pdf
June 16, 2011 - Nurses' perceptions of error communication and
reporting in the intensive care unit.
June 16, 2011
Elder NC, Brungs SM, Nagy M, et al. Nurses' Perceptions of Error Communication and Reporting in the
Intensive Care Unit. J Patient Saf. 2008;4(3). doi:10.1097/pts.0b013e3181839b48.
https://psnet.ahrq.gov/issue/nurses…
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psnet.ahrq.gov/node/42994/psn-pdf
March 26, 2014 - Conditions that influence the impact of malpractice
litigation risk on physicians' behavior regarding patient
safety.
March 26, 2014
Renkema E, Broekhuis M, Ahaus K. Conditions that influence the impact of malpractice litigation risk on
physicians' behavior regarding patient safety. BMC Health Serv Res. 2014;14:38…