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psnet.ahrq.gov/node/73220/psn-pdf
May 05, 2021 - Identifying barriers to and opportunities for telehealth
implementation amidst the COVID-19 pandemic by using
a human factors approach: a leap into the future of health
care delivery?
May 5, 2021
Zhang T, Mosier J, Subbian V. Identifying barriers to and opportunities for telehealth implementation amidst
the COVID…
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psnet.ahrq.gov/node/844038/psn-pdf
January 01, 2024 - The effectiveness of tele-triage during the COVID-19
pandemic: a systematic review and narrative synthesis.
February 8, 2023
Farzandipour M, Nabovati E, Sharif R. The effectiveness of tele-triage during the COVID-19 pandemic: a
systematic review and narrative synthesis. J Telemed Telecare. 2024;30(9):1367-1375.
do…
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psnet.ahrq.gov/node/47376/psn-pdf
November 02, 2018 - Assessing information sources to elucidate diagnostic
process errors in radiologic imaging—a human factors
framework.
November 2, 2018
Cochon L, Lacson R, Wang A, et al. Assessing information sources to elucidate diagnostic process errors
in radiologic imaging - a human factors framework. J Am Med Info Asso. 2018;…
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psnet.ahrq.gov/node/72847/psn-pdf
March 17, 2021 - Barriers to accessing nighttime supervisors: a national
survey of internal medicine residents.
March 17, 2021
Catalanotti JS, O’Connor AB, Kisielewski M, et al. Barriers to accessing nighttime supervisors: a national
survey of internal medicine residents. J Gen Intern Med. 2021;36(7):1974-1979. doi:10.1007/s11606-0…
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psnet.ahrq.gov/node/40172/psn-pdf
January 26, 2011 - Risk of adverse drug events in neonates treated with
opioids and the effect of a bar-code–assisted medication
administration system.
January 26, 2011
Morriss FH, Abramowitz PW, Nelson S, et al. Risk of adverse drug events in neonates treated with opioids
and the effect of a bar-code-assisted medication administrat…
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psnet.ahrq.gov/node/73440/psn-pdf
June 30, 2021 - Bridging the feedback gap: a sociotechnical approach to
informing clinicians of patients' subsequent clinical
course and outcomes.
June 30, 2021
Cifra CL, Sittig DF, Singh H. Bridging the feedback gap: a sociotechnical approach to informing clinicians of
patients’ subsequent clinical course and outcomes. BMJ Qual …
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psnet.ahrq.gov/node/851645/psn-pdf
July 26, 2023 - Anticoagulation-associated adverse drug events in
hospitalized patients across two time periods.
July 26, 2023
Fanikos J, Tawfik Y, Almheiri D, et al. Anticoagulation-associated adverse drug events in hospitalized
patients across two time periods. Am J Med. 2023;136(9):927-936. doi:10.1016/j.amjmed.2023.05.013.
ht…
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psnet.ahrq.gov/node/39872/psn-pdf
February 25, 2013 - The Essential Guide for Patient Safety Officers, Second
Edition.
February 25, 2013
Leonard M, Frankel A, Federico F, et al, eds. Oakbrook Terrace, IL: Joint Commission Resources, Institute
for Healthcare Improvement; 2013. ISBN: 9781599407036.
https://psnet.ahrq.gov/issue/essential-guide-patient-safety-officers-se…
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psnet.ahrq.gov/node/47591/psn-pdf
January 01, 2021 - Advancing patient safety through the clinical application
of a framework focused on communication.
December 19, 2018
Manojlovich M, Hofer TP, Krein SL. Advancing Patient Safety Through the Clinical Application of a
Framework Focused on Communication. J Patient Saf. 2021;17(8):e732-e737.
doi:10.1097/PTS.00000000000…
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psnet.ahrq.gov/node/837031/psn-pdf
May 04, 2022 - Indicators for implementation outcome monitoring of
reporting and learning systems in hospitals: an
underestimated need for patient safety.
May 4, 2022
Kuske S, Willmeroth T, Schneider J, et al. Indicators for implementation outcome monitoring of reporting
and learning systems in hospitals: an underestimated need …
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psnet.ahrq.gov/node/851350/psn-pdf
July 12, 2023 - A scoping review of legibility of hand-written
prescriptions and drug-orders: the writing on the wall.
July 12, 2023
Ariaga A, Balzan D, Falzon S, et al. A scoping review of legibility of hand-written prescriptions and drug-
orders: the writing on the wall. Expert Rev Clin Pharmacol. 2023;16(7):617-621.
doi:10.108…
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psnet.ahrq.gov/node/41920/psn-pdf
October 08, 2013 - Review of computerized physician handoff tools for
improving the quality of patient care.
October 8, 2013
Li P, Ali S, Tang C, et al. Review of computerized physician handoff tools for improving the quality of
patient care. J Hosp Med. 2013;8(8):456-63. doi:10.1002/jhm.1988.
https://psnet.ahrq.gov/issue/review-com…
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psnet.ahrq.gov/node/47755/psn-pdf
July 24, 2019 - Animated stories of medical error as a means of teaching
undergraduates patient safety: an evaluation study.
July 24, 2019
Cooper K, Hatfield E, Yeomans J. Animated stories of medical error as a means of teaching
undergraduates patient safety: an evaluation study. Perspect Med Edu. 2019;8(2):118-122.
doi:10.1007/s…
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psnet.ahrq.gov/node/34916/psn-pdf
March 09, 2009 - Using a claims data-based sentinel system to improve
compliance with clinical guidelines: results of a
randomized prospective study.
March 9, 2009
Javitt JC, Steinberg G, Locke T, et al. Using a claims data-based sentinel system to improve compliance
with clinical guidelines: results of a randomized prospective st…
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psnet.ahrq.gov/node/43799/psn-pdf
January 07, 2015 - Omission of high-alert medications: a hidden danger.
January 7, 2015
Grissinger M, Alghamdi D. PA-PSRS Patient Saf Advis. December 2014;11:149-155.
https://psnet.ahrq.gov/issue/omission-high-alert-medications-hidden-danger
Analyzing incidents reported over a 4-month period, this article reveals that 21% of 2700 med…
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psnet.ahrq.gov/node/46347/psn-pdf
December 22, 2018 - Medication errors in pediatric anesthesia: a report from
the Wake Up Safe quality improvement initiative.
December 22, 2018
M Y Lobaugh L, Martin LD, Schleelein LE, et al. Medication errors in pediatric anesthesia: a report from the
Wake Up Safe quality improvement initiative. Anesth Analg. 2017;125(3):936-942.
do…
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psnet.ahrq.gov/node/35571/psn-pdf
April 06, 2011 - Overestimation of clinical diagnostic performance caused
by low necropsy rates.
April 6, 2011
Shojania KG, Burton EC, McDonald KM, et al. Overestimation of clinical diagnostic performance caused by
low necropsy rates. Qual Saf Health Care. 2005;14(6):408-13.
https://psnet.ahrq.gov/issue/overestimation-clinical-dia…
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psnet.ahrq.gov/node/46993/psn-pdf
July 18, 2018 - The nature, magnitude, and reporting compliance of
device-related events for intravenous patient-controlled
analgesia in the FDA Manufacturer and User Facility
Device Experience (MAUDE) database.
July 18, 2018
Lawal OD, Mohanty M, Elder H, et al. The nature, magnitude, and reporting compliance of device-related
e…
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psnet.ahrq.gov/node/43899/psn-pdf
February 18, 2015 - Development and validation of a taxonomy of adverse
handover events in hospital settings.
February 18, 2015
Andersen HB, Siemsen IMD, Petersen LF, et al. Development and validation of a taxonomy of adverse
handover events in hospital settings. Cognition, Technology & Work. 2014;17(1). doi:10.1007/s10111-014-
0303-…
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psnet.ahrq.gov/node/45296/psn-pdf
September 21, 2016 - Comparison of medication safety systems in critical
access hospitals: combined analysis of two studies.
September 21, 2016
Cochran GL, Barrett RS, Horn SD. Comparison of medication safety systems in critical access hospitals:
Combined analysis of two studies. Am J Health Syst Pharm. 2016;73(15):1167-73.
doi:10.214…