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psnet.ahrq.gov/node/37353/psn-pdf
March 28, 2012 - Medication Use: A Systems Approach to Reducing Errors,
Second Edition.
March 28, 2012
Porche? … https://psnet.ahrq.gov/issue/medication-use-systems-approach-reducing-errors-second-edition
Co-authored … by a host of medication safety experts, this book offers practical information, case studies,
and systems-oriented … https://psnet.ahrq.gov/issue/medication-use-systems-approach-reducing-errors-second-edition
https://psnet.ahrq.gov … /primer/systems-approach
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psnet.ahrq.gov/node/38653/psn-pdf
May 20, 2009 - The frustrating case of incident-reporting systems.
May 20, 2009
Shojania KG. … The frustrating case of incident-reporting systems. Qual Saf Health Care. 2008;17(6):400-2. … https://psnet.ahrq.gov/issue/frustrating-case-incident-reporting-systems
This commentary discusses the … limitations of incident reporting systems and provides suggestions for how
data gathered from incident … https://psnet.ahrq.gov/issue/frustrating-case-incident-reporting-systems
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psnet.ahrq.gov/node/37860/psn-pdf
January 15, 2009 - Economic evaluations of maintaining patient safety
systems in teaching hospitals. … Economic evaluations of maintaining patient safety systems in
teaching hospitals. … https://psnet.ahrq.gov/issue/economic-evaluations-maintaining-patient-safety-systems-teaching-hospitals … Teaching hospitals in Japan incurred significant costs during implementation of patient safety systems … https://psnet.ahrq.gov/issue/economic-evaluations-maintaining-patient-safety-systems-teaching-hospitals
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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/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/35918/psn-pdf
July 23, 2010 - Spinal surgery and patient safety: a systems approach.
July 23, 2010
Wong DA. … Spinal surgery and patient safety: a systems approach. J Am Acad Orthop Surg.
2006;14(4):226-32. … https://psnet.ahrq.gov/issue/spinal-surgery-and-patient-safety-systems-approach
The author reviews the … epidemiology of surgical adverse events from major epidemiologic studies and
discusses the need for a systems … https://psnet.ahrq.gov/issue/spinal-surgery-and-patient-safety-systems-approach
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psnet.ahrq.gov/node/38879/psn-pdf
March 02, 2011 - The competent surgeon: individual accountability in the
era of "systems" failure. … The competent surgeon: individual accountability in the era of "systems" failure. … https://psnet.ahrq.gov/issue/competent-surgeon-individual-accountability-era-systems-failure
Discussing … safe care in the context of both systems failures and individual responsibility, this commentary
advocates … https://psnet.ahrq.gov/issue/competent-surgeon-individual-accountability-era-systems-failure
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psnet.ahrq.gov/node/41090/psn-pdf
January 25, 2012 - Early warning systems: the next level of rapid response. … Early warning systems: the next level of rapid response. … https://psnet.ahrq.gov/issue/early-warning-systems-next-level-rapid-response
This commentary describes … https://psnet.ahrq.gov/issue/early-warning-systems-next-level-rapid-response
https://psnet.ahrq.gov/primer … /rapid-response-systems
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psnet.ahrq.gov/node/34937/psn-pdf
June 23, 2009 - Theorizing about systems: an ecological task for patient
safety research. … Theorizing About Systems. Clin Nurs Res. 2005;14(2). doi:10.1177/1054773804274255. … https://psnet.ahrq.gov/issue/theorizing-about-systems-ecological-task-patient-safety-research
The author … vulnerable living system, and suggests applying principles from ecological
restoration to strengthen systems … https://psnet.ahrq.gov/issue/theorizing-about-systems-ecological-task-patient-safety-research
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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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psnet.ahrq.gov/node/33800/psn-pdf
January 01, 2015 - Investigators then observed physicians entering these orders into various CPOE systems in a simulation … prominent commercial systems as well as homegrown ones. … In 95% of observations, the CPOE systems failed to
generate a warning. … Moreover, the methods
of this study can serve as a blueprint of how vendors should test CPOE systems … In 2015, the FDA released a white paper on the safety of CPOE systems.
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psnet.ahrq.gov/node/33669/psn-pdf
May 01, 2018 - Integrating Multiple Medication Decision Support
Systems: How Will We Make It All Work? … Integrating Multiple Medication Decision Support Systems: How Will We Make It All Work? … https://psnet.ahrq.gov/perspective/integrating-multiple-medication-decision-support-systems-how-will-we … Systems that deploy extensive drug decision support have developed a mixed reputation: while
they are … More deliberate methods to create enduring and well-accepted CDSS systems
are needed.
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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/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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digital.ahrq.gov/sites/default/files/docs/publication/r18hs017151-fischer-final-report-2011.pdf
January 01, 2011 - Those with integrated systems were more likely than those
with stand-alone systems to be primary care … systems to report doing this. … Physicians with integrated systems were significantly more likely than
those with stand-alone systems … Physicians with integrated systems were significantly more likely than those with stand-
alone systems … systems.