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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39084/psn-pdf
    March 05, 2010 - The impact of Rapid Response System on delayed emergency team activation patient characteristics and … The impact of Rapid Response System on delayed emergency team activation patient characteristics and … https://psnet.ahrq.gov/issue/impact-rapid-response-system-delayed-emergency-team-activation-patient- … https://psnet.ahrq.gov/issue/impact-rapid-response-system-delayed-emergency-team-activation-patient-characteristics-and … https://psnet.ahrq.gov/issue/impact-rapid-response-system-delayed-emergency-team-activation-patient-characteristics-and
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34930/psn-pdf
    April 06, 2011 - "Going solid": a model of system dynamics and consequences for patient safety. … "Going solid": a model of system dynamics and consequences for patient safety. … https://psnet.ahrq.gov/issue/going-solid-model-system-dynamics-and-consequences-patient-safety Health … care systems continue to evolve with greater complexity and attention to system-based improvement efforts … https://psnet.ahrq.gov/issue/going-solid-model-system-dynamics-and-consequences-patient-safety
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36105/psn-pdf
    May 27, 2011 - found an increase in mortality among PICU patients in another hospital that implemented the same CPOE system … Prior to implementing the CPOE system in this study, leaders from both hospitals collaborated to identify … standardized order sets and other means of decreasing the time needed to enter orders, preserving a system … of obtaining medications outside the CPOE system in emergencies, and emphasizing the need for face-to-face … contrast to the earlier study, the authors found no change in PICU mortality in 13 months after the CPOE system
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43067/psn-pdf
    November 23, 2014 - Characterization of adverse events detected in a large health care delivery system using an enhanced … Characterization of adverse events detected in a large health care delivery system using an enhanced … https://psnet.ahrq.gov/issue/characterization-adverse-events-detected-large-health-care-delivery-system … Improvement's Global Trigger Tool, this retrospective study analyzed adverse events at a large health care system … https://psnet.ahrq.gov/issue/characterization-adverse-events-detected-large-health-care-delivery-system-using-enhanced
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44506/psn-pdf
    October 21, 2015 - A prospective controlled trial of an electronic hand hygiene reminder system. … A Prospective Controlled Trial of an Electronic Hand Hygiene Reminder System. … https://psnet.ahrq.gov/issue/prospective-controlled-trial-electronic-hand-hygiene-reminder-system Hand … Once the reminder system was turned off, compliance rates returned to the previous baseline. … https://psnet.ahrq.gov/issue/prospective-controlled-trial-electronic-hand-hygiene-reminder-system https
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38816/psn-pdf
    July 29, 2009 - Uncovering system errors using a rapid response team: cross-coverage caught in the crossfire. … Uncovering System Errors Using a Rapid Response Team: Cross-Coverage Caught in the Crossfire. … https://psnet.ahrq.gov/issue/uncovering-system-errors-using-rapid-response-team-cross-coverage-caught … https://psnet.ahrq.gov/issue/uncovering-system-errors-using-rapid-response-team-cross-coverage-caught-crossfire … psnet.ahrq.gov/issue/randomized-controlled-trial-evaluating-impact-computerized-rounding-and-sign-out-system
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43419/psn-pdf
    October 20, 2014 - Impact of a reengineered electronic error-reporting system on medication event reporting and care process … Impact of a reengineered electronic error-reporting system on medication event reporting and care process … https://psnet.ahrq.gov/issue/impact-reengineered-electronic-error-reporting-system-medication-event- … Researchers implemented a Web-based electronic medication error reporting system in concert with a novel … https://psnet.ahrq.gov/issue/impact-reengineered-electronic-error-reporting-system-medication-event-reporting-and-care
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40163/psn-pdf
    December 21, 2014 - Integration of a formalized handoff system into the surgical curriculum: resident perspectives and early … Integration of a Formalized Handoff System Into the Surgical Curriculum. … https://psnet.ahrq.gov/issue/integration-formalized-handoff-system-surgical-curriculum-resident- perspectives-and-early … https://psnet.ahrq.gov/issue/integration-formalized-handoff-system-surgical-curriculum-resident-perspectives-and-early … https://psnet.ahrq.gov/issue/integration-formalized-handoff-system-surgical-curriculum-resident-perspectives-and-early
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45970/psn-pdf
    March 22, 2017 - A learning health care system using computer-aided diagnosis. March 22, 2017 Cahan A, Cimino JJ. … A Learning Health Care System Using Computer-Aided Diagnosis. … https://psnet.ahrq.gov/issue/learning-health-care-system-using-computer-aided-diagnosis Although advanced … The authors encourage drawing from crowdsourced data to guide improvements at a system level to address … https://psnet.ahrq.gov/issue/learning-health-care-system-using-computer-aided-diagnosis https://psnet.ahrq.gov
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47265/psn-pdf
    February 22, 2019 - Introduction of a mobile adverse event reporting system is associated with participation in adverse … Introduction of a Mobile Adverse Event Reporting System Is Associated With Participation in Adverse … https://psnet.ahrq.gov/issue/introduction-mobile-adverse-event-reporting-system-associated-participation … https://psnet.ahrq.gov/issue/introduction-mobile-adverse-event-reporting-system-associated-participation-adverse-event … https://psnet.ahrq.gov/issue/introduction-mobile-adverse-event-reporting-system-associated-participation-adverse-event
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40242/psn-pdf
    February 23, 2011 - An anesthesiology department leads culture change at a hospital system level to improve quality and … An anesthesiology department leads culture change at a hospital system level to improve quality and … https://psnet.ahrq.gov/issue/anesthesiology-department-leads-culture-change-hospital-system-level- improve-quality-and … https://psnet.ahrq.gov/issue/anesthesiology-department-leads-culture-change-hospital-system-level-improve-quality-and … https://psnet.ahrq.gov/issue/anesthesiology-department-leads-culture-change-hospital-system-level-improve-quality-and
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40097/psn-pdf
    January 19, 2011 - Use of an electronic information system to identify adverse events resulting in an emergency department … Use of an electronic information system to identify adverse events resulting in an emergency department … https://psnet.ahrq.gov/issue/use-electronic-information-system-identify-adverse-events-resulting- emergency-department … https://psnet.ahrq.gov/issue/use-electronic-information-system-identify-adverse-events-resulting-emergency-department … https://psnet.ahrq.gov/issue/use-electronic-information-system-identify-adverse-events-resulting-emergency-department
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47126/psn-pdf
    May 16, 2018 - Unintended adverse consequences of a clinical decision support system: two cases. … Unintended adverse consequences of a clinical decision support system: two cases. … https://psnet.ahrq.gov/issue/unintended-adverse-consequences-clinical-decision-support-system-two-cases … https://psnet.ahrq.gov/issue/unintended-adverse-consequences-clinical-decision-support-system-two-cases … clinical-decision-support-and-malpractice-risk https://psnet.ahrq.gov/issue/analysis-clinical-decision-support-system-malfunctions-case-series-and-survey
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38585/psn-pdf
    April 30, 2014 - Development of an online morbidity, mortality, and near- miss reporting system to identify patterns … Development of an online morbidity, mortality, and near-miss reporting system to identify patterns of … https://psnet.ahrq.gov/issue/development-online-morbidity-mortality-and-near-miss-reporting-system- … This study describes the development of a Web-based system to capture physician- reported AEs, including … https://psnet.ahrq.gov/issue/development-online-morbidity-mortality-and-near-miss-reporting-system-identify-patterns
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45983/psn-pdf
    June 27, 2018 - Educating for the 21st-century health care system: an interdependent framework of basic, clinical, and … Educating for the 21st-Century Health Care System: An Interdependent Framework of Basic, Clinical, and … https://psnet.ahrq.gov/issue/educating-21st-century-health-care-system-interdependent-framework-basic … https://psnet.ahrq.gov/issue/educating-21st-century-health-care-system-interdependent-framework-basic-clinical-and-systems … https://psnet.ahrq.gov/issue/educating-21st-century-health-care-system-interdependent-framework-basic-clinical-and-systems
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38784/psn-pdf
    July 13, 2010 - A survey of nurses' beliefs about the medical emergency team system in a Canadian tertiary hospital. … A survey of nurses' beliefs about the medical emergency team system in a canadian tertiary hospital. … https://psnet.ahrq.gov/issue/survey-nurses-beliefs-about-medical-emergency-team-system-canadian- tertiary-hospital … https://psnet.ahrq.gov/issue/survey-nurses-beliefs-about-medical-emergency-team-system-canadian-tertiary-hospital … https://psnet.ahrq.gov/issue/survey-nurses-beliefs-about-medical-emergency-team-system-canadian-tertiary-hospital
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33874/psn-pdf
    February 01, 2019 - of an organization without transforming our prevailing system of education. … They are the same system.(1) Edwards Deming The Burning Platform for Change The Institute of Medicine's … 1999 (IOM) report, To Err Is Human: Building a Safer Health System, revealed that more people die each … We are all one system, one learning environment. … To Err Is Human: Building a Safer Health System.
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46072/psn-pdf
    November 08, 2017 - Repeat prescribing of medications: a system-centred risk management model for primary care organisations … Repeat prescribing of medications: A system-centred risk management model for primary care organisations … https://psnet.ahrq.gov/issue/repeat-prescribing-medications-system-centred-risk-management-model- primary-care … https://psnet.ahrq.gov/issue/repeat-prescribing-medications-system-centred-risk-management-model-primary-care … https://psnet.ahrq.gov/issue/repeat-prescribing-medications-system-centred-risk-management-model-primary-care
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33842/psn-pdf
    January 01, 2018 - related to large-scale ransomware attacks (13), lack of contingency planning, routine EHR upgrades, system-to-system … designed and developed to withstand unanticipated user and system actions. … Analysis of clinical decision support system malfunctions: a case series and survey. … Computer crash--lessons from a system failure. N Engl J Med. 2003;348:881-882. … Effect of a computerized prescriber- order-entry system on reported medication errors.
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36238/psn-pdf
    October 21, 2010 - Claiming behaviour in a no-fault system of medical injury: a descriptive analysis of claimants and non-claimants … Claiming behaviour in a no-fault system of medical injury: a descriptive analysis of claimants and non-claimants … https://psnet.ahrq.gov/issue/claiming-behaviour-no-fault-system-medical-injury-descriptive-analysis- … https://psnet.ahrq.gov/issue/claiming-behaviour-no-fault-system-medical-injury-descriptive-analysis-claimants-and-non … https://psnet.ahrq.gov/issue/claiming-behaviour-no-fault-system-medical-injury-descriptive-analysis-claimants-and-non

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