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psnet.ahrq.gov/issue/preventability-adverse-drug-events-involving-multiple-drugs-using-publicly-available-clinical
December 21, 2017 - Study
Preventability of adverse drug events involving multiple drugs using publicly available clinical decision support tools.
Citation Text:
Wright A, Feblowitz J, Phansalkar S, et al. Preventability of adverse drug events involving multiple drugs using publicly available clinical dec…
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psnet.ahrq.gov/issue/computerized-decision-support-medication-dosing-renal-insufficiency-randomized-controlled
September 30, 2009 - Study
Computerized decision support for medication dosing in renal insufficiency: a randomized, controlled trial.
Citation Text:
Terrell KM, Perkins AJ, Hui SL, et al. Computerized decision support for medication dosing in renal insufficiency: a randomized, controlled trial. Ann Emerg …
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psnet.ahrq.gov/issue/health-care-workers-second-victims-medical-errors
April 07, 2021 - Study
Health care workers as second victims of medical errors.
Citation Text:
Edrees HH, Paine LA, Feroli R, et al. Health care workers as second victims of medical errors. Pol Arch Med Wewn. 2011;121(4):101-108.
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psnet.ahrq.gov/primer/responding-patient-safety-events
October 18, 2023 - Responding to Patient Safety Events
Citation Text:
Shaikh U. Responding to Patient Safety Events. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025.
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psnet.ahrq.gov/issue/randomized-trial-effectiveness-demand-versus-computer-triggered-drug-decision-support-primary
March 11, 2011 - Study
A randomized trial of the effectiveness of on-demand versus computer-triggered drug decision support in primary care.
Citation Text:
Tamblyn R, Huang A, Taylor L, et al. A randomized trial of the effectiveness of on-demand versus computer-triggered drug decision support in primar…
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psnet.ahrq.gov/issue/unintended-adverse-consequences-clinical-decision-support-system-two-cases
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psnet.ahrq.gov/issue/physicians-needs-coping-emotional-stressors-case-peer-support
September 09, 2008 - Study
Physicians' needs in coping with emotional stressors: the case for peer support.
Citation Text:
Hu Y-Y, Fix ML, Hevelone ND, et al. Physicians' needs in coping with emotional stressors: the case for peer support. Arch Surg. 2012;147(3):212-217. doi:10.1001/archsurg.2011.312.
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psnet.ahrq.gov/issue/communication-elements-supporting-patient-safety-psychiatric-inpatient-care
July 01, 2013 - Study
Communication elements supporting patient safety in psychiatric inpatient care.
Citation Text:
Kanerva A, Kivinen T, Lammintakanen J. Communication elements supporting patient safety in psychiatric inpatient care. J Psychiatr Ment Health Nurs. 2015;22(5):298-305. doi:10.1111/jpm.12…
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psnet.ahrq.gov/issue/good-bad-and-ugly-patient-experiences-crps
February 28, 2024 - Webinar
The Good, The Bad, and The Ugly: Patient Experiences with CRPs.
Citation Text:
The Good, The Bad, and The Ugly: Patient Experiences with CRPs. Collaborative for Accountability and Improvement. October 21, 2021.
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psnet.ahrq.gov/issue/national-cost-adverse-drug-events-resulting-inappropriate-medication-related-alert-overrides
July 02, 2019 - Study
The national cost of adverse drug events resulting from inappropriate medication-related alert overrides in the United States.
Citation Text:
Slight SP, Seger DL, Franz C, et al. The national cost of adverse drug events resulting from inappropriate medication-related alert override…
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psnet.ahrq.gov/issue/forgive-divine
November 11, 2020 - Commentary
To forgive, divine.
Citation Text:
Johnson V. To forgive, divine. N Engl J Med. 2024;391(1):6-7. doi:10.1056/nejmp2402006.
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psnet.ahrq.gov/node/33586/psn-pdf
December 15, 2024 - Alert Fatigue
December 15, 2024
Alert Fatigue. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/alert-fatigue
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in 2024.
Bac…
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psnet.ahrq.gov/issue/leveraging-artificial-intelligence-reduce-diagnostic-errors-emergency-medicine-challenges
May 29, 2019 - Commentary
Leveraging artificial intelligence to reduce diagnostic errors in emergency medicine: challenges, opportunities, and future directions.
Citation Text:
Taylor RA, Sangal RB, Smith ME, et al. Leveraging artificial intelligence to reduce diagnostic errors in emergency medicine: c…
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psnet.ahrq.gov/print/pdf/node/848754
January 01, 2025 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Implementation of Patient Safety Projects
Curated Library
Foundations
Leading change: why transformation efforts fail.
Kotter JP. Harvard Bus Rev 1995;73(2);59-67.
Kotter, a professor at Harvard Business School, outlines the eight stages …
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psnet.ahrq.gov/issue/socio-technical-issues-and-challenges-implementing-safe-patient-handovers-insights
July 19, 2023 - Study
Socio-technical issues and challenges in implementing safe patient handovers: insights from ethnographic case studies.
Citation Text:
Balka E, Tolar M, Coates S, et al. Socio-technical issues and challenges in implementing safe patient handovers: insights from ethnographic case st…
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psnet.ahrq.gov/node/849330/psn-pdf
May 24, 2023 - Using sociotechnical theory to understand medication
safety work in primary care and prescribers' use of
clinical decision support: a qualitative study.
May 24, 2023
Jeffries M, Salema N-E, Laing L, et al. Using sociotechnical theory to understand medication safety work in
primary care and prescribers’ use of clin…
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psnet.ahrq.gov/issue/computerised-provider-order-entry-combined-clinical-decision-support-systems-improve
March 20, 2013 - Review
Computerised provider order entry combined with clinical decision support systems to improve medication safety: a narrative review.
Citation Text:
Ranji SR, Rennke S, Wachter R. Computerised provider order entry combined with clinical decision support systems to improve medication…
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psnet.ahrq.gov/issue/effects-workload-work-complexity-and-repeated-alerts-alert-fatigue-clinical-decision-support
March 04, 2015 - Study
Effects of workload, work complexity, and repeated alerts on alert fatigue in a clinical decision support system.
Citation Text:
Ancker JS, Edwards A, Nosal S, et al. Effects of workload, work complexity, and repeated alerts on alert fatigue in a clinical decision support system. B…
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psnet.ahrq.gov/issue/second-victim-casualties-and-how-physician-leaders-can-help
August 28, 2024 - Newspaper/Magazine Article
"Second victim" casualties and how physician leaders can help.
Citation Text:
MacLeod L. "Second victim" casualties and how physician leaders can help. Physician Exect. 2014;40(1):8-12.
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psnet.ahrq.gov/issue/second-victim-phenomenon
July 10, 2024 - Review
Second-victim phenomenon.
Citation Text:
New L, Lambeth T. Second-victim phenomenon. Nurs Clin North Am. 2024;59(1):141-152. doi:10.1016/j.cnur.2023.11.011.
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