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Introduction of a rapid response system at a United States Veterans Affairs hospital reduced cardiac arrests. | PSNet

psnet.ahrq.gov/issue/introduction-rapid-response-system-united-states-veterans-affairs-hospital-reduced-cardiac

January 02, 2017 - Study Introduction of a rapid response system at a United States Veterans Affairs … Introduction of a rapid response system at a United States veterans affairs hospital reduced cardiac … add to the existing literature by showing its potential value in the Veterans Affairs health care system … Introduction of a rapid response system at a United States veterans affairs hospital reduced cardiac … Citation Related Resources From the Same Author(s) Using the rapid response system

Attitudes toward the large-scale implementation of an incident reporting system. | PSNet

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March 23, 2011 - Study Attitudes toward the large-scale implementation of an incident reporting system … Attitudes toward the large-scale implementation of an incident reporting system. … likely to report a positive impression of the system. … Attitudes toward the large-scale implementation of an incident reporting system. … June 23, 2010 Review of the Australian Incident Monitoring System.

Failure to utilize functions of an electronic prescribing system and the subsequent generation of 'technically preventable' computerized alerts. | PSNet

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 … Failure to utilize functions of an electronic prescribing system and the subsequent generation of 'technically … This Australian study found that many clinicians did not use CPOE system features that were intended … likely contributing to alert fatigue and probably diminishing the overall safety performance of the system … August 28, 2024 Short- and long-term effects of an electronic medication management system

Evaluating the medication process in the context of CPOE use: the significance of working around the system. | PSNet

psnet.ahrq.gov/issue/evaluating-medication-process-context-cpoe-use-significance-working-around-system

February 23, 2009 - Evaluating the medication process in the context of CPOE use: the significance of working around the system … Evaluating the medication process in the context of CPOE use: the significance of working around the system … and unintended consequences associated with implementation of a computerized provider order entry system … Download Citation Related Resources From the Same Author(s) Same system … July 27, 2011 Can an electronic prescribing system detect doctors who are more likely

Field test results of a new ambulatory care Medication Error and Adverse Drug Event Reporting System—MEADERS. | PSNet

psnet.ahrq.gov/issue/field-test-results-new-ambulatory-care-medication-error-and-adverse-drug-event-reporting

September 27, 2010 - Field test results of a new ambulatory care Medication Error and Adverse Drug Event Reporting System—MEADERS … Field test results of a new ambulatory care Medication Error and Adverse Drug Event Reporting System- … This study reports on the initial experience with an Internet-based voluntary reporting system for … The system was relatively easy to use, but some participants raised concerns about error reporting leading … Field test results of a new ambulatory care Medication Error and Adverse Drug Event Reporting System-

Impact of a pharmacotherapy alerting system on medication errors. | PSNet

psnet.ahrq.gov/issue/impact-pharmacotherapy-alerting-system-medication-errors

November 10, 2015 - Impact of a pharmacotherapy alerting system on medication errors. … American Journal of Health-System Pharmacy. 2012;70(1). doi:10.2146/ajhp120126. … American Journal of Health-System Pharmacy . 2012; 70 (1) . … Impact of a pharmacotherapy alerting system on medication errors. … American Journal of Health-System Pharmacy. 2012;70(1). doi:10.2146/ajhp120126.

Disuse of system is cited in gaps in soldiers' care. | PSNet

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September 28, 2005 - Newspaper/Magazine Article Disuse of system is cited in gaps in soldiers' care. … Citation Text: Disuse of system is cited in gaps in soldiers' care. Urbina I; Nixon R. … This article reports on the inconsistent use of the Department of Defense electronic medical records system … Copy URL Cite Citation Citation Text: Disuse of system … 2023 Senators threaten consequences after VA confirms 4 deaths tied to computer system

Improving administration and documentation of enteral nutrition support therapy in a Veteran Affairs health care system: use of medication administration record and bar code scanning technology. | PSNet

psnet.ahrq.gov/issue/improving-administration-and-documentation-enteral-nutrition-support-therapy-veteran-affairs

September 09, 2020 - administration and documentation of enteral nutrition support therapy in a Veteran Affairs health care system … administration and documentation of enteral nutrition support therapy in a Veteran Affairs health care system … discovering significant issues with ordering, administration, and documentation of EN, this health system … EN therapies were added to the electronic medication administration record (MAR) and the barcoding system … Author(s) Improving transfusion safety in the operating room with a barcode scanning system

Using an enhanced oral chemotherapy computerized provider order entry system to reduce prescribing errors and improve safety. | PSNet

psnet.ahrq.gov/issue/using-enhanced-oral-chemotherapy-computerized-provider-order-entry-system-reduce-prescribing

October 20, 2014 - Study Using an enhanced oral chemotherapy computerized provider order entry system … Using an enhanced oral chemotherapy computerized provider order entry system to reduce prescribing errors … This study describes how implementation of a computerized provider order entry system reduced errors … Using an enhanced oral chemotherapy computerized provider order entry system to reduce prescribing errors … December 29, 2014 Effects of an integrated clinical information system on medication

We are not there yet: a qualitative system probing study of a hospital rapid response system. | PSNet

psnet.ahrq.gov/issue/we-are-not-there-yet-qualitative-system-probing-study-hospital-rapid-response-system

March 15, 2023 - Study We are not there yet: a qualitative system probing study of a hospital rapid … response system. … We are not there yet: a qualitative system probing study of a hospital rapid response system. … We are not there yet: a qualitative system probing study of a hospital rapid response system. … July 20, 2022 Mature rapid response system and potentially avoidable cardiopulmonary

Reducing medication errors and improving systems reliability using an electronic medication reconciliation system. | PSNet

psnet.ahrq.gov/issue/reducing-medication-errors-and-improving-systems-reliability-using-electronic-medication

January 09, 2013 - Reducing medication errors and improving systems reliability using an electronic medication reconciliation system … Reducing Medication Errors and Improving Systems Reliability Using an Electronic Medication Reconciliation System … Implementation of a medication reconciliation system reduced preventable medication errors at the time … 2023 Assessing the accuracy of drug profiles in an electronic medical record system … June 16, 2010 Effects of an adverse-drug-event alert system on cost and quality outcomes

Learning Health Systems for Patient Safety | PSNet

psnet.ahrq.gov/perspective/learning-health-systems-patient-safety

February 26, 2025 - Background A learning health system is a health system (i.e., a group of one or more healthcare organizations … Health technology, quality and safety in a learning health system. … There is a lot of waste in the system. … other health system partners went there to observe what they did. … During that time, the health system probably has a new problem.

Impact of a computerized physician order entry system on nurse-physician collaboration in the medication process. | PSNet

psnet.ahrq.gov/issue/impact-computerized-physician-order-entry-system-nurse-physician-collaboration-medication

February 23, 2009 - Study Impact of a computerized physician order entry system on nurse-physician collaboration … Impact of a computerized physician order entry system on nurse-physician collaboration in the medication … This study found that implementation of a computerized physician order entry system appeared to impair … Impact of a computerized physician order entry system on nurse-physician collaboration in the medication … June 13, 2011 Can an electronic prescribing system detect doctors who are more likely

A system-wide initiative to prevent retained vaginal sponges. | PSNet

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November 07, 2012 - Commentary A system-wide initiative to prevent retained vaginal sponges. … A system-wide initiative to prevent retained vaginal sponges. … This commentary describes how a 32-hospital system implemented a surgical sponge management program in … A system-wide initiative to prevent retained vaginal sponges. … , 2020 Results and lessons from a hospital-wide initiative incentivised by delivery system

Integrating incident reporting into an electronic patient record system. | PSNet

psnet.ahrq.gov/issue/integrating-incident-reporting-electronic-patient-record-system

June 08, 2010 - Study Integrating incident reporting into an electronic patient record system. … Integrating incident reporting into an electronic patient record system. … study, conducted in an Australian hospital, reports on the implementation of an incident reporting system … Acceptance of the system was high, and the vast majority of reported adverse events were confirmed by … Integrating incident reporting into an electronic patient record system.

Framework for Effective Board Governance of Health System Quality. | PSNet

psnet.ahrq.gov/issue/framework-effective-board-governance-health-system-quality

January 20, 2016 - Book/Report Framework for Effective Board Governance of Health System Quality. … Citation Text: Framework for Effective Board Governance of Health System Quality. … Institute of Medicine six elements of quality to clarify responsibilities of trustees and health system … Cite Citation Citation Text: Framework for Effective Board Governance of Health System

Computerized physician order entry, a factor in medication errors: descriptive analysis of events in the intensive care unit safety reporting system. | PSNet

psnet.ahrq.gov/issue/computerized-physician-order-entry-factor-medication-errors-descriptive-analysis-events

July 14, 2010 - factor in medication errors: descriptive analysis of events in the intensive care unit safety reporting system … factor in medication errors: descriptive analysis of events in the intensive care unit safety reporting system … Related Resources From the Same Author(s) Development of the ICU safety reporting system … July 14, 2010 Pediatric safety incidents from an intensive care reporting system. … March 23, 2011 Creating the web-based intensive care unit safety reporting system.

Does the implementation of an electronic prescribing system create unintended medication errors? A study of the sociotechnical context through the analysis of reported medication incidents. | PSNet

psnet.ahrq.gov/issue/does-implementation-electronic-prescribing-system-create-unintended-medication-errors-study

August 24, 2016 - Study Does the implementation of an electronic prescribing system create unintended … Does the implementation of an electronic prescribing system create unintended medication errors? … Does the implementation of an electronic prescribing system create unintended medication errors? … July 8, 2020 Can an electronic prescribing system detect doctors who are more likely … June 13, 2011 Can an electronic prescribing system detect doctors who are more likely

Pediatric safety incidents from an intensive care reporting system. | PSNet

psnet.ahrq.gov/issue/pediatric-safety-incidents-intensive-care-reporting-system

May 27, 2011 - Study Pediatric safety incidents from an intensive care reporting system. … Citation Text: Pediatric safety incidents from an intensive care reporting system. … The Intensive Care Unit Safety Reporting System (ICUSRS) is a model incident reporting system that has … January 7, 2008 Development of the ICU safety reporting system. … October 13, 2010 Effectiveness of a barcode medication administration system in reducing

Developing an adverse event reporting system using administrative data. | PSNet

psnet.ahrq.gov/issue/developing-adverse-event-reporting-system-using-administrative-data

September 23, 2009 - Study Developing an adverse event reporting system using administrative data. … Citation Text: Developing an adverse event reporting system using administrative data. … The AHRQ Patient Safety Indicators were used as the basis for developing a system for identifying errors … Cite Citation Citation Text: Developing an adverse event reporting system … September 6, 2017 Mature rapid response system and potentially avoidable cardiopulmonary

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