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psnet.ahrq.gov/issue/failure-utilize-functions-electronic-prescribing-system-and-subsequent-generation-technically
February 15, 2012 - Study
Failure to utilize functions of an electronic prescribing system and the subsequent generation of 'technically preventable' computerized alerts.
Citation Text:
Baysari M, Reckmann MH, Li L, et al. Failure to utilize functions of an electronic prescribing system and the subsequent g…
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psnet.ahrq.gov/issue/association-label-drug-use-and-adverse-drug-events-adult-population
February 03, 2011 - Study
Classic
Association of off-label drug use and adverse drug events in an adult population.
Citation Text:
Eguale T, Buckeridge DL, Verma A, et al. Association of Off-label Drug Use and Adverse Drug Events in an Adult Population. JAMA Intern Med. 2016;176(1)…
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psnet.ahrq.gov/issue/evaluation-automated-surveillance-system-using-trigger-alerts-prevent-adverse-drug-events
August 30, 2017 - Study
Evaluation of an automated surveillance system using trigger alerts to prevent adverse drug events in the intensive care unit and general ward.
Citation Text:
DiPoto JP, Buckley MS, Kane-Gill SL. Evaluation of an automated surveillance system using trigger alerts to prevent adverse…
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psnet.ahrq.gov/issue/burnout-and-its-relationship-self-reported-quality-patient-care-and-adverse-events-during
August 25, 2021 - Study
Burnout and its relationship to self-reported quality of patient care and adverse events during COVID-19: a cross-sectional online survey among nurses.
Citation Text:
Kakemam E, Chegini Z, Rouhi A, et al. Burnout and its relationship to self‐reported quality of patient care and adv…
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psnet.ahrq.gov/issue/healthcare-failure-mode-and-effect-analysis-hfmea-effective-mechanism-preventing-infection
April 05, 2023 - Study
Healthcare failure mode and effect analysis (HFMEA) as an effective mechanism in preventing infection caused by accompanying caregivers during COVID-19-experience of a city medical center in Taiwan.
Citation Text:
Tiao C-H, Tsai L-C, Chen L-C, et al. Healthcare Failure Mode and Eff…
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psnet.ahrq.gov/issue/factors-associated-mental-health-outcomes-among-health-care-workers-exposed-coronavirus
March 24, 2019 - Study
Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019.
Citation Text:
Lai J, Ma S, Wang Y, et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open. 20…
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psnet.ahrq.gov/innovation/implicit-bias-and-patient-care-mitigating-bias-preventing-harm
September 22, 2021 - EMERGING INNOVATIONS
Implicit bias and patient care: mitigating bias, preventing harm.
Citation Text:
Barber Doucet H, Wilson T, Vrablik L, et al. Implicit bias and patient care: mitigating bias, preventing harm. MedEdPORTAL. 2023;19:11343. doi:10.15766/mep_2374-8265.11343.
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psnet.ahrq.gov/issue/distinguishing-high-performing-low-performing-hospitals-severe-maternal-morbidity-focus
June 01, 2022 - Study
Distinguishing high-performing from low-performing hospitals for severe maternal morbidity: a focus on quality and equity.
Citation Text:
Howell EA, Sofaer S, Balbierz A, et al. Distinguishing high-performing from low-performing hospitals for severe maternal morbidity: a focus on q…
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psnet.ahrq.gov/issue/electronic-health-record-based-real-time-analytics-program-patient-safety-surveillance-and
May 19, 2018 - Study
An electronic health record–based real-time analytics program for patient safety surveillance and improvement.
Citation Text:
Classen D, Li M, Miller S, et al. An Electronic Health Record-Based Real-Time Analytics Program For Patient Safety Surveillance And Improvement. Health Aff …
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psnet.ahrq.gov/issue/toward-zero-harm-mackenzie-healths-journey-toward-becoming-high-reliability-organization-and
September 14, 2022 - Study
Toward zero harm: Mackenzie Health's journey toward becoming a high reliability organization and eliminating avoidable harm.
Citation Text:
Wilson M-A, Sinno M, Hacker Teper M, et al. Toward zero harm: Mackenzie Health's journey toward becoming a high reliability organization and e…
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psnet.ahrq.gov/issue/nosocomial-transmission-and-outbreaks-coronavirus-disease-2019-need-protect-both-patients-and
February 07, 2022 - Review
Nosocomial transmission and outbreaks of coronavirus disease 2019: the need to protect both patients and healthcare workers.
Citation Text:
Abbas M, Robalo Nunes T, Martischang R, et al. Nosocomial transmission and outbreaks of coronavirus disease 2019: the need to protect both pa…
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psnet.ahrq.gov/issue/national-survey-assessing-number-records-allowed-open-electronic-health-records-hospitals-and
May 29, 2019 - Study
A national survey assessing the number of records allowed open in electronic health records at hospitals and ambulatory sites.
Citation Text:
Adelman JS, Berger MA, Rai A, et al. A national survey assessing the number of records allowed open in electronic health records at hospital…
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psnet.ahrq.gov/issue/good-care-slow-enough-be-able-pay-attention-primary-care-time-scarcity-and-patient-safety
August 04, 2015 - Study
"Good care is slow enough to be able to pay attention": primary care time scarcity and patient safety.
Citation Text:
Satterwhite S, Nguyen M-LT, Honcharov V, et al. "Good care is slow enough to be able to pay attention": primary care time scarcity and patient safety. J Gen Intern …
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psnet.ahrq.gov/issue/drug-drug-interactions-and-actual-harm-hospitalized-patients-multicentre-study-examining
August 26, 2020 - Study
Drug-drug interactions and actual harm to hospitalized patients: a multicentre study examining the prevalence pre- and post-electronic medication system implementation.
Citation Text:
Li L, Baker J, Quirk R, et al. Drug-drug interactions and actual harm to hospitalized patients: a …
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psnet.ahrq.gov/issue/patient-related-factors-associated-increased-risk-being-reported-case-preventable-harm-first
October 09, 2019 - Study
Patient-related factors associated with an increased risk of being a reported case of preventable harm in first-line health care: a case-control study
Citation Text:
Fernholm R, Holzmann MJ, Wachtler C, et al. Patient-related factors associated with an increased risk of being a rep…
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psnet.ahrq.gov/issue/learning-patient-safety-incidents-involving-acutely-sick-adults-hospital-assessment-units
November 11, 2020 - Study
Learning from patient safety incidents involving acutely sick adults in hospital assessment units in England and Wales: a mixed methods analysis for quality improvement.
Citation Text:
Urquhart A, Yardley S, Thomas E, et al. Learning from patient safety incidents involving acutely …
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psnet.ahrq.gov/web-mm/troubling-amine
September 01, 2003 - A Troubling Amine
Citation Text:
Flynn EA. A Troubling Amine. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/node/49422/psn-pdf
November 01, 2003 - 40 of K
November 1, 2003
Lesar TS. 40 of K. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/40-k
The Case
An 81-year-old female maintained on warfarin for a history of chronic atrial fibrillation and mitral valve
replacement developed asymptomatic runs of ventricular tachycardia while hospitalized. The unit…
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psnet.ahrq.gov/web-mm/coming-short-maintaining-safety-face-drug-shortages
November 01, 2012 - Coming Up Short: Maintaining Safety in the Face of Drug Shortages
Citation Text:
Plogsted S. Coming Up Short: Maintaining Safety in the Face of Drug Shortages. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/node/49673/psn-pdf
December 01, 2012 - A Real Heartache
December 1, 2012
Polevoi SK. A Real Heartache. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/real-heartache
The Case
A 60-year-old man presented to the emergency department (ED) with 2 hours of burning chest pain. The
pain began at rest, and it radiated to his back and left axilla. He had…