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psnet.ahrq.gov/node/46719/psn-pdf
December 20, 2017 - Frustrated with your EHR? Don't blame your
vendor—safety is a shared responsibility.
December 20, 2017
Singh H, Sittig DF. NEJM Catalyst. December 7, 2017.
https://psnet.ahrq.gov/issue/frustrated-your-ehr-dont-blame-your-vendor-safety-shared-responsibility
The promise of health information technology has yet to be…
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psnet.ahrq.gov/node/45763/psn-pdf
December 19, 2017 - Expanded pharmacy technician roles: accepting verbal
prescriptions and communicating prescription transfers.
December 19, 2017
Frost TP, Adams AJ. Expanded pharmacy technician roles: Accepting verbal prescriptions and
communicating prescription transfers. Res Social Adm Pharm. 2017;13(6):1191-1195.
doi:10.1016/j.s…
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psnet.ahrq.gov/node/60198/psn-pdf
April 08, 2020 - Hierarchy and medical error: speaking up when
witnessing an error.
April 8, 2020
Peadon R (R), Hurley J, Hutchinson M. Hierarchy and medical error: speaking up when witnessing an
error. Safety Sci. 2020;125:104648. doi:10.1016/j.ssci.2020.104648.
https://psnet.ahrq.gov/issue/hierarchy-and-medical-error-speaking-wh…
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psnet.ahrq.gov/node/34907/psn-pdf
August 03, 2009 - Physicians' views of interventions to reduce medical
errors: does evidence of effectiveness matter?
August 3, 2009
Rosen AB, Blendon RJ, DesRoches CM, et al. Physicians' views of interventions to reduce medical errors:
does evidence of effectiveness matter? Acad Med. 2005;80(2):189-92.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/34639/psn-pdf
March 02, 2011 - Preventable deaths: who, how often, and why?
March 2, 2011
Dubois RW, Brook RH. Preventable deaths: who, how often, and why? Ann Intern Med. 1988;109(7):582-9.
https://psnet.ahrq.gov/issue/preventable-deaths-who-how-often-and-why
One of the first studies to examine the link between quality of care and hospital deat…
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psnet.ahrq.gov/node/38091/psn-pdf
February 18, 2011 - Questionable hospital chart documentation practices by
physicians.
February 18, 2011
Sharma R, Kostis WJ, Wilson AC, et al. Questionable hospital chart documentation practices by
physicians. J Gen Intern Med. 2008;23(11):1865-70. doi:10.1007/s11606-008-0750-6.
https://psnet.ahrq.gov/issue/questionable-hospital-cha…
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psnet.ahrq.gov/node/34810/psn-pdf
February 18, 2011 - Should operations be regionalized? The empirical relation
between surgical volume and mortality.
February 18, 2011
Luft HS, Bunker JP, Enthoven AC. Should operations be regionalized? The empirical relation between
surgical volume and mortality. N Engl J Med. 1979;301(25):1364-9.
https://psnet.ahrq.gov/issue/should…
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psnet.ahrq.gov/node/43867/psn-pdf
March 11, 2015 - Applying fault tree analysis to the prevention of wrong-
site surgery.
March 11, 2015
Abecassis ZA, McElroy LM, Patel RM, et al. Applying fault tree analysis to the prevention of wrong-site
surgery. J Surg Res. 2015;193(1):88-94. doi:10.1016/j.jss.2014.08.062.
https://psnet.ahrq.gov/issue/applying-fault-tree-analy…
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psnet.ahrq.gov/node/35588/psn-pdf
February 03, 2011 - Creating a safer health care system: finding the
constraint.
February 3, 2011
Pauker SG, Zane EM, Salem D. Creating a safer health care system: finding the constraint. JAMA.
2005;294(22):2906-8.
https://psnet.ahrq.gov/issue/creating-safer-health-care-system-finding-constraint
This editorial builds on the discussi…
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psnet.ahrq.gov/node/44292/psn-pdf
September 01, 2016 - Recommendations to improve the usability of drug–drug
interaction clinical decision support alerts.
September 1, 2016
Payne TH, Hines LE, Chan RC, et al. Recommendations to improve the usability of drug-drug interaction
clinical decision support alerts. J Am Med Inform Assoc. 2015;22(6):1243-50. doi:10.1093/jamia/o…
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psnet.ahrq.gov/node/46879/psn-pdf
September 24, 2018 - Epidemiology of and risk factors for harmful anti-infective
medication errors in a pediatric hospital.
September 24, 2018
Modi A, Germain E, Soma V, et al. Epidemiology of and Risk Factors for Harmful Anti-Infective Medication
Errors in a Pediatric Hospital. Jt Comm J Qual Patient Saf. 2018;44(10):599-604.
doi:10.…
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psnet.ahrq.gov/node/45879/psn-pdf
July 02, 2017 - A hybrid methodology for modeling risk of adverse
events in complex health-care settings.
July 2, 2017
Kazemi R, Mosleh A, Dierks M. A Hybrid Methodology for Modeling Risk of Adverse Events in Complex
Health-Care Settings. Risk Anal. 2017;37(3):421-440. doi:10.1111/risa.12702.
https://psnet.ahrq.gov/issue/hybrid-m…
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psnet.ahrq.gov/node/44726/psn-pdf
January 07, 2016 - The impact of resident duty hour and supervision
changes: a review.
January 7, 2016
Greenberg WE, Borus JF. The Impact of Resident Duty Hour and Supervision Changes: A Review. Harv
Rev Psychiatry. 2016;24(1):69-76. doi:10.1097/HRP.0000000000000061.
https://psnet.ahrq.gov/issue/impact-resident-duty-hour-and-supervi…
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psnet.ahrq.gov/node/48116/psn-pdf
July 17, 2019 - Patient safety superheroes in training: using a comic
book to teach patient safety to residents.
July 17, 2019
Maatman TC, Prigmore H, Williams JS, et al. Patient safety superheroes in training: using a comic book to
teach patient safety to residents. BMJ Qual Saf. 2019;28(11):934-938. doi:10.1136/bmjqs-2018-009094…
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psnet.ahrq.gov/node/47263/psn-pdf
January 01, 2021 - Dissecting communication barriers in healthcare: a path
to enhancing communication resiliency, reliability, and
patient safety.
November 28, 2018
Guttman OT, Lazzara EH, Keebler JR, et al. Dissecting Communication Barriers in Healthcare: A Path to
Enhancing Communication Resiliency, Reliability, and Patient Safety…
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psnet.ahrq.gov/node/45346/psn-pdf
November 18, 2016 - How do simulated error experiences impact attitudes
related to error prevention?
November 18, 2016
Breitkreuz KR, Dougal RL, Wright MC. How Do Simulated Error Experiences Impact Attitudes Related to
Error Prevention? Simul Healthc. 2016;11(5):323-333.
https://psnet.ahrq.gov/issue/how-do-simulated-error-experiences…
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psnet.ahrq.gov/node/47365/psn-pdf
January 01, 2019 - How well do incident reporting systems work on inpatient
psychiatric units?
December 21, 2018
Reilly CA, Cullen SW, Watts B, et al. How Well Do Incident Reporting Systems Work on Inpatient
Psychiatric Units? Jt Comm J Qual Patient Saf. 2019;45(1):63-69. doi:10.1016/j.jcjq.2018.05.002.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/45653/psn-pdf
January 25, 2017 - Opioid prescribing after surgical extraction of teeth in
Medicaid patients, 2000–2010.
January 25, 2017
Baker JA, Avorn J, Levin R, et al. Opioid Prescribing After Surgical Extraction of Teeth in Medicaid
Patients, 2000-2010. JAMA. 2016;315(15):1653-4. doi:10.1001/jama.2015.19058.
https://psnet.ahrq.gov/issue/opio…
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psnet.ahrq.gov/node/35089/psn-pdf
August 05, 2009 - Teaching medical students about medical errors and
patient safety: evaluation of a required curriculum.
August 5, 2009
Halbach JL, Sullivan LL. Teaching medical students about medical errors and patient safety: evaluation of
a required curriculum. Acad Med. 2005;80(6):600-6.
https://psnet.ahrq.gov/issue/teaching-m…
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psnet.ahrq.gov/node/45791/psn-pdf
September 01, 2018 - Changes in physician practice patterns after
implementation of a communication-and-resolution
program.
September 1, 2018
Helmchen LA, Lambert BL, McDonald TB. Changes in Physician Practice Patterns after Implementation of
a Communication-and-Resolution Program. Health Serv Res. 2016;51(Suppl 3):2516-2536.
doi:10.…