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psnet.ahrq.gov/node/49851/psn-pdf
January 01, 2019 - The entire care team paused in real time to review the events. … We argue that errors and situations identified as prone to
error should be reported to case review committees … Adherence to guidelines and systematic approaches to improve drug administration
procedures can reduce … Complications and discomfort of
bronchoscopy: a systematic review.
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psnet.ahrq.gov/primer/medication-administration-errors
December 15, 2024 - In a review of 91 direct observation studies of medication errors in hospitals and long-term care facilities … Medication administration errors and the pediatric population: a systematic search of the literature. … April 26, 2023
Frequency of medication administration timing error in hospitals: a systematic review … March 15, 2017
Shift-to-shift handoff effects on patient safety and outcomes: a systematic … review.
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psnet.ahrq.gov/web-mm/point-care-mixup-1-shot-turns-3
February 14, 2024 - In the postincident review, the nurse described being rushed and because of that, she did not properly … The schedules, exceptions, and catch-up strategies are sufficiently complex so as to require systematic … Whether as part of student training, or as a matter of periodic review, learning programs covering all … Brief clinical report: a systematic review and meta-analysis of pain memory-reframing interventions for
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psnet.ahrq.gov/perspective/physical-environment-often-unconsidered-patient-safety-tool
November 21, 2018 - A review of the research literature on evidence-based healthcare design. … Systematic review of studies on compliance with hand hygiene guidelines in hospital care. … multi-systemic fall prevention model, incorporating the physical environment, the care process and technology: a systematic … review. … Safety, performance, and satisfaction outcomes in the operating room: a literature review
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psnet.ahrq.gov/node/33886/psn-pdf
August 01, 2019 - processes, including log-in procedures; scope of documentation assistance; requirements
for provider review … It is particularly important for providers to supervise and review their scribes' work. … The use of medical scribes in health care settings: a systematic review and
future directions. … Effect of scribes on patient
throughput, revenue, and patient and provider satisfaction: a systematic … review and meta-analysis.
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psnet.ahrq.gov/web-mm/hip-fractures-older-patients-case-geriatrics-comanagement
July 01, 2004 - In a review of 3517 patients from the Danish Fracture Database, there was a stepwise increase in 30-day … For example, in the preoperative use of echocardiograms, a retrospective review of hip fracture patients … Impact of timing of surgery in elderly hip fracture patients: a systematic review and meta-analysis. … Orthogeriatric care models and outcomes in hip fracture patients: a systematic review and meta-analysis
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psnet.ahrq.gov/web-mm/copy-and-paste-notes-and-autopopulated-text-electronic-health-record
May 26, 2021 - Upon further review, the physician found that this history had been recorded in the patient’s record … During a thorough review of the electronic health records, clinic staff found that the patient’s wife … However, the time and cognitive effort required to review a block of pasted text may exceed the time … Little systematic data allow us to compare the quality of note content before and after the CMS policy … ChatGPT utility in healthcare education, research, and practice: systematic review on the promising perspectives
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psnet.ahrq.gov/perspective/patient-safety-and-evolution-webmm-and-psnet
April 01, 2008 - order entry combined with clinical decision support systems to improve medication safety: a narrative review … Hospital-initiated transitional care interventions as a patient safety strategy: a systematic … review. … A systematic review.
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psnet.ahrq.gov/web-mm/it-safe-be-direct
September 30, 2015 - A recent systematic review revealed the frequent failure of information transfer that occurs during hospital … this case had an EKG performed in the office, it was not available for the admitting hospitalist to review … May 19, 2021
A systematic review of the effects of resident duty hour restrictions in
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psnet.ahrq.gov/web-mm/dont-wait-collect-accurate-weight-case-subtherapeutic-insulin-therapy
July 01, 2008 - Management of diabetic ketoacidosis in adults: a narrative review. … bypassed pharmacist review. … August 30, 2023
The neglected barrier to medication use: a systematic review of difficulties … impacts of prefilled syringes versus conventional medication administration methods: results from a systematic … literature review.
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psnet.ahrq.gov/web-mm/slow-down-right-drug-wrong-formulation
October 13, 2018 - As part of the clinical review process, the case was discussed in a morbidity and mortality conference … The review revealed the patient's home medication was metoprolol succinate 300 mg. … order entry at reducing preventable adverse drug events and medication errors in hospital settings: a systematic … review and meta-analysis. … Health information technology: an updated systematic review with a focus on meaningful use.
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psnet.ahrq.gov/node/33739/psn-pdf
October 01, 2012 - A review of the research literature on evidence-based healthcare
design. … Systematic review of studies on compliance with hand hygiene
guidelines in hospital care. … fall
prevention model, incorporating the physical environment, the care process and technology: a systematic … review.
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psnet.ahrq.gov/node/49669/psn-pdf
November 01, 2012 - Incorporating recent, emerging evidence and this systematic review, the AABB (formerly, the American … A systematic review evaluated 19 studies that examined various behavioral interventions aimed
at reducing … Reducing the amount of blood transfused: a systematic
review of behavioral interventions to change physicians
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psnet.ahrq.gov/innovation/i-readi-quality-and-safety-framework-strong-communications-channels-and-effective
February 26, 2025 - crises. 1
The I-READI acronym outlines the steps (i.e., Integration, Root-Cause Analysis, Evidence Review … innovation also requires that team members have skills and experience with aggregate root-cause analysis to review … systems to monitor care delivery, quality, and safety metrics in real time
Daily board rounds with review … of real-time patient data and systematic patient safety checklists
Ability to convene emergency meetings … Strategies for monitoring and updating clinical practice guidelines: a systematic review.
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psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem
May 01, 2017 - The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National … review. … review. … review. … review for a National Institutes of Health Pathways to Prevention Workshop.
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psnet.ahrq.gov/web-mm/dressed-failure
September 01, 2011 - Dermatology was consulted to evaluate her desquamating rash and, on full chart review, they noted a previous … user groups' perspectives of barriers and facilitators to implementing electronic health records: a systematic … review. … August 1, 2009
Effects of health information technology on patient outcomes: a systematic … review.
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psnet.ahrq.gov/perspective/updates-role-health-it-patient-safety
January 31, 2020 - The results of a systematic review concluded that the use of CPOE reduces the overall medication error … CPOE and continued pharmacist review are both essential for more comprehensive error prevention. … notifications, alerts and reminders, condition-specific order sets, clinical summaries, and templates. 3 One systematic … review demonstrated that the use of CDS in oncology care increased clinical practice guideline use … Health information technology in healthcare quality and patient safety: Literature review.
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psnet.ahrq.gov/node/60249/psn-pdf
April 22, 2020 - Overall, the review found limited evidence demonstrating the benefit of inpatient EHR
interventions
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psnet.ahrq.gov/node/847934/psn-pdf
April 26, 2023 - structure-process-outcome taxonomy as well as
measurement strategies, such as retrospective medical record review … A 2016 systematic review commissioned by the World Health Organization (WHO) identified missed
and delayed … More recently, a study of 2010-2019 data based on
medical chart review demonstrated a significant decline … pneumonia, and major surgical procedures (and for
https://psnet.ahrq.gov/issue/how-safe-primary-care-systematic-review … validity-agency-healthcare-research-and-quality-patient-safety-indicators-and-centers
https://psnet.ahrq.gov/issue/review-patient-safety-measures-based-routinely-collected-hospital-data
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psnet.ahrq.gov/issue/implementation-custom-alert-prevent-medication-timing-errors-associated-computerized
April 25, 2016 - July 19, 2023
Prevalence of harmful diagnostic errors in hospitalised adults: a systematic … review and meta-analysis.