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psnet.ahrq.gov/node/37536/psn-pdf
February 01, 2011 - Improving patient safety by taking systems seriously.
February 1, 2011
Shortell SM, Singer SJ. … Improving patient safety by taking systems seriously. JAMA. 2008;299(4):445-447. … https://psnet.ahrq.gov/issue/improving-patient-safety-taking-systems-seriously
The authors advocate … that systems thinking needs to be applied more robustly in health care in order to
achieve lasting safety … https://psnet.ahrq.gov/issue/improving-patient-safety-taking-systems-seriously
https://psnet.ahrq.gov
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psnet.ahrq.gov/node/36131/psn-pdf
September 29, 2010 - Emergent CSCW systems: the resolution and bandwidth
of workplaces. … Emergent CSCW systems: the resolution and bandwidth of workplaces. … https://psnet.ahrq.gov/issue/emergent-cscw-systems-resolution-and-bandwidth-workplaces
The authors discuss … characteristics should be considered when developing computerized supported
collaborative work (CSCW) systems … https://psnet.ahrq.gov/issue/emergent-cscw-systems-resolution-and-bandwidth-workplaces
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digital.ahrq.gov/sites/default/files/docs/publication/uc1hs016142-sims-final-report-2008.pdf
January 01, 2008 - The underlying problem from a systems perspective, and especially with technological
systems, begins … • Data from all systems will be accurately displayed. … • Data in all systems will be accurately synchronized. … Data in all systems will be accurately synchronized. … to having the systems drive
the work.
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psnet.ahrq.gov/node/40269/psn-pdf
January 01, 2016 - Rapid response systems in the Netherlands. … Rapid Response Systems in the Netherlands. … https://psnet.ahrq.gov/issue/rapid-response-systems-netherlands
Nearly 80% of Dutch hospitals have implemented … https://psnet.ahrq.gov/issue/rapid-response-systems-netherlands
https://psnet.ahrq.gov/primer/rapid-response-systems
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psnet.ahrq.gov/node/44689/psn-pdf
February 24, 2018 - what-role-individual-accountability-patient-safety-multi-site-ethnographic-study
The concept of a just culture has become popular for balancing individual accountability with a systems … empiric data from five ethnographic case studies to illustrate the fundamental interdependence of systems … The authors argue apportioning responsibility between systems and the
individuals within them leads … Senior author Mary Dixon-Woods
elaborates on the relationship between individuals and systems in a PSNet … https://psnet.ahrq.gov/primer/systems-approach
https://psnet.ahrq.gov/perspective/conversation-mary-dixon-woods-dphil
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psnet.ahrq.gov/node/34690/psn-pdf
February 10, 2011 - Systems analysis of adverse drug events.
February 10, 2011
Leape L, Bates DW, Cullen DJ, et al. … Systems analysis of adverse drug events. ADE Prevention Study
Group. JAMA. 1995;274(1):35-43. … https://psnet.ahrq.gov/issue/systems-analysis-adverse-drug-events
The authors report a "systems analysis … Using the airline industry
as an example, the authors advocate a nonpunitive systems approach as a more … https://psnet.ahrq.gov/issue/systems-analysis-adverse-drug-events
https://psnet.ahrq.gov//#adversedrugevent
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psnet.ahrq.gov/node/38176/psn-pdf
October 29, 2008 - Human error, not communication and systems, underlies
surgical complications. … Human error, not communication and systems, underlies surgical
complications. … https://psnet.ahrq.gov/issue/human-error-not-communication-and-systems-underlies-surgical-complications … The authors highlight that their findings challenge
"popular wisdom" about the role of systems in patient … https://psnet.ahrq.gov/issue/human-error-not-communication-and-systems-underlies-surgical-complications
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psnet.ahrq.gov/node/35476/psn-pdf
February 22, 2010 - Taking the pulse of health care systems: experiences of
patients with health problems in six countries … Taking The Pulse Of Health Care Systems: Experiences Of Patients
With Health Problems In Six Countries … https://psnet.ahrq.gov/issue/taking-pulse-health-care-systems-experiences-patients-health-problems-six … https://psnet.ahrq.gov/issue/taking-pulse-health-care-systems-experiences-patients-health-problems-six-countries … https://psnet.ahrq.gov/issue/taking-pulse-health-care-systems-experiences-patients-health-problems-six-countries
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psnet.ahrq.gov/node/47105/psn-pdf
August 10, 2018 - A systems approach to identify factors influencing
adverse drug events in nursing homes. … A Systems Approach to Identify Factors Influencing Adverse Drug Events in
Nursing Homes. … https://psnet.ahrq.gov/issue/systems-approach-identify-factors-influencing-adverse-drug-events-nursing … Using the
Systems Engineering Initiative for Patient Safety model, they identified numerous resident … https://psnet.ahrq.gov/issue/systems-approach-identify-factors-influencing-adverse-drug-events-nursing-homes
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psnet.ahrq.gov/node/41556/psn-pdf
January 03, 2017 - Patient safety reporting systems: sustained quality
improvement using a multidisciplinary team and " … Patient Safety Reporting Systems: Sustained Quality Improvement Using
a Multidisciplinary Team and “ … https://psnet.ahrq.gov/issue/patient-safety-reporting-systems-sustained-quality-improvement-using-
multidisciplinary-team … A major limitation of voluntary error reporting systems is that many hospitals do not reliably feed … https://psnet.ahrq.gov/issue/patient-safety-reporting-systems-sustained-quality-improvement-using-multidisciplinary-team
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psnet.ahrq.gov/node/36456/psn-pdf
May 27, 2011 - Evaluation and certification of computerized physician
order entry systems. … Evaluation and certification of computerized provider order entry systems. … https://psnet.ahrq.gov/issue/evaluation-and-certification-computerized-physician-order-entry-systems … The authors reviewed studies on implementation and use of computerized physician order entry systems … https://psnet.ahrq.gov/issue/evaluation-and-certification-computerized-physician-order-entry-systems
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psnet.ahrq.gov/node/36844/psn-pdf
January 22, 2017 - Errors prevented by and associated with bar-code
medication administration systems. … Errors prevented by and associated with bar-code medication
administration systems. … https://psnet.ahrq.gov/issue/errors-prevented-and-associated-bar-code-medication-administration-systems … The authors share case reports that demonstrate how bar-code medication administration (BCMA)
systems … https://psnet.ahrq.gov/issue/errors-prevented-and-associated-bar-code-medication-administration-systems
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psnet.ahrq.gov/node/40696/psn-pdf
December 01, 2011 - Rapid response systems: a prospective study of
response times. … Rapid response systems: a prospective study of response times. … https://psnet.ahrq.gov/issue/rapid-response-systems-prospective-study-response-times
Introduction of … https://psnet.ahrq.gov/issue/rapid-response-systems-prospective-study-response-times
https://psnet.ahrq.gov … /primer/rapid-response-systems
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digital.ahrq.gov/sites/default/files/docs/page/2006WardWakefieldLi_051111comp.pdf
January 01, 2005 - Iowa hospitals had more computerized systems but
used IT technologies to a lesser extent than Canada … Iowa rural hospitals had low levels of clinical
information systems (Ward et al., in press). … to
determine the level of systems in each hospital
Sample for 2005 Survey
number of
hospitals … clinical information systems. … systems, network influence, or
wanting to stay current with other hospitals
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psnet.ahrq.gov/node/49409/psn-pdf
July 01, 2003 - Stretching the search for the “why” of error: the systems approach. … Identifying error provoking factors: the systems approach. … The systems approach analysis of error. … The Systems Approach: Artichoke Model
The leaves of the systems approach artichoke are the constituent … systems of the context of care, and the
basic care-providing systems are the heart of the artichoke
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psnet.ahrq.gov/node/38452/psn-pdf
December 30, 2014 - The safety of intravenous drug delivery systems: update
on current issues since the 1999 Consensus Development … https://psnet.ahrq.gov/issue/safety-intravenous-drug-delivery-systems-update-current-issues-1999-
consensus-development … This review charts the evolution of intravenous drug delivery systems and policies between 1999 and … https://psnet.ahrq.gov/issue/safety-intravenous-drug-delivery-systems-update-current-issues-1999-consensus-development … https://psnet.ahrq.gov/issue/safety-intravenous-drug-delivery-systems-update-current-issues-1999-consensus-development
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psnet.ahrq.gov/node/40019/psn-pdf
November 17, 2010 - Patient safety systems in the primary health care of
diabetes—a story of missed opportunities? … Patient safety systems in the primary health care of diabetes—a story of
missed opportunities? … https://psnet.ahrq.gov/issue/patient-safety-systems-primary-health-care-diabetes-story-missed-
opportunities … https://psnet.ahrq.gov/issue/patient-safety-systems-primary-health-care-diabetes-story-missed-opportunities … https://psnet.ahrq.gov/issue/patient-safety-systems-primary-health-care-diabetes-story-missed-opportunities
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psnet.ahrq.gov/node/35999/psn-pdf
May 09, 2014 - Internally-developed online adverse drug reaction and
medication error reporting systems. … Internally-Developed Online Adverse Drug Reaction and
Medication Error Reporting Systems. … psnet.ahrq.gov/issue/internally-developed-online-adverse-drug-reaction-and-medication-error-
reporting-systems … psnet.ahrq.gov/issue/internally-developed-online-adverse-drug-reaction-and-medication-error-reporting-systems … psnet.ahrq.gov/issue/internally-developed-online-adverse-drug-reaction-and-medication-error-reporting-systems
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psnet.ahrq.gov/node/35279/psn-pdf
June 30, 2009 - Results of a survey on medical error reporting systems in
Korean hospitals. … Results of a survey on medical error reporting systems in Korean hospitals. … https://psnet.ahrq.gov/issue/results-survey-medical-error-reporting-systems-korean-hospitals
The authors … studied the use of hospital information systems to report adverse events in Korean hospitals. … https://psnet.ahrq.gov/issue/results-survey-medical-error-reporting-systems-korean-hospitals
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psnet.ahrq.gov/node/37080/psn-pdf
October 03, 2011 - Pharmacists' perceptions of computerized prescriber-
order-entry systems. … Pharmacists' perceptions of computerized prescriber-
order-entry systems. … https://psnet.ahrq.gov/issue/pharmacists-perceptions-computerized-prescriber-order-entry-systems
This … pharmacists found only moderate satisfaction with existing computerized provider
order entry (CPOE) systems … https://psnet.ahrq.gov/issue/pharmacists-perceptions-computerized-prescriber-order-entry-systems
https