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Kowalczyk L. Boston Globe. February 13–14, 2011.
Revealing cases in which the constant din of hospital alarms led to fatal errors, this two-part newspaper article reports on the dangers of "alarm fatigue" and describes potential technological and human factors solutions.
A clinical case of electronic health record drug alert fatigue: consequences for patient outcome.
Carspecken CW, Sharek PJ, Longhurst C, Pageler NM. Pediatrics. 2013;131:e1970-e1973.
A review of current and emerging approaches to address failure-to-rescue.
Taenzer AH, Pyke JB, McGrath SP. Anesthesiology. 2011;115:421-431.
Reducing alarm hazards: selection and implementation of alarm notification systems.
Gee T, Moorman BA. Patient Saf Qual Healthc. March/April 2011;8:14-17.
Preventing maternal death.
Sentinel Event Alert. January 26, 2010;(44):1-4.
The wolf is crying in the operating room: patient monitor and anesthesia workstation alarming patterns during cardiac surgery.
Schmid F, Goepfert MS, Kuhnt D, et al. Anesth Analg. 2011;112:78-83.
Impact of non-interruptive medication laboratory monitoring alerts in ambulatory care.
Lo HG, Matheny ME, Seger DL, Bates DW, Gandhi TK. J Am Med Inform Assoc. 2009;16:66-71.
Evaluation of an electronic health record structured discharge summary to provide real time adverse event reporting in thoracic surgery.
Graham AJ, Ocampo W, Southern DA, et al. BMJ Qual Saf. 2019;28:310-316
Solving alarm fatigue with smartphone technology.
Short K, Chung YJ Jr. Nursing. 2019;49:52-57.
Using electronic health records to identify adverse drug events in ambulatory care: a systematic review.
Feng C, Le D, McCoy AB. Appl Clin Inform. 2019;10:123-128.
An electronic health record–based real-time analytics program for patient safety surveillance and improvement.
Classen D, Li M, Miller S, Ladner D. Health Aff (Millwood). 2018;37:1805-1812.
Application of electronic trigger tools to identify targets for improving diagnostic safety.
Murphy DR, Meyer AN, Sittig DF, Meeks DW, Thomas EJ, Singh H. BMJ Qual Saf. 2019;28:151-159.
Managing alarm systems for quality and safety in the hospital setting.
Bach TA, Berglund L, Turk E. BMJ Open Qual. 2018;7:e000202.
Smart pump custom concentrations without hard "low concentration" alerts can lead to patient harm.
ISMP Medication Safety Alert! Acute Care Edition. May 31, 2018;23:1-4.
Mixed-methods evaluation of real-time safety reporting by hospitalized patients and their care partners: the MySafeCare application.
Collins SA, Couture B, Smith AD, et al. J Patient Saf. 2018 Apr 27; [Epub ahead of print].
An electronic intervention to improve safety for pain patients co-prescribed chronic opioids and benzodiazepines.
Zaman T, Rife TL, Batki SL, Pennington DL. Subst Abus. 2018;39:441-448.
Designing and evaluating an automated system for real-time medication administration error detection in a neonatal intensive care unit.
Ni Y, Lingren T, Hall ES, Leonard M, Melton K, Kirkendall ES. J Am Med Inform Assoc. 2018;25:555-563.
The accuracy of trigger tools to detect preventable adverse events in primary care: a systematic review.
Davis J, Harrington N, Bittner Fagan H, Henry B, Savoy M. J Am Board Fam Med. 2018;31:113-125.
Electronic triggers to identify delays in follow-up of mammography: harnessing the power of big data in health care.
Murphy DR, Meyer AND, Vaghani V, et al. J Am Coll Radiol. 2018;15:287-295.
An electronic trigger based on care escalation to identify preventable adverse events in hospitalised patients.
Bhise V, Sittig DF, Vaghani V, Wei L, Baldwin J, Singh H. BMJ Qual Saf. 2018;27:241-246.
Video analysis of factors associated with response time to physiologic monitor alarms in a children's hospital.
Bonafide CP, Localio AR, Holmes JH, et al. JAMA Pediatr. 2017;171:524-531.
How redesigning the abrasive alarms of hospital soundscapes can save lives.
Couch C. Fast Company. April 3, 2017.
Developing and evaluating an automated all-cause harm trigger system.
Sammer C, Miller S, Jones C, et al. Jt Comm J Qual Patient Saf. 2017;43:155-165.
Data-driven implementation of alarm reduction interventions in a cardiovascular surgical ICU.
Allan SH, Doyle PA, Sapirstein A, Cvach M. Jt Comm J Qual Patient Saf. 2017;43:62-70.
Screening for medication errors using an outlier detection system.
Schiff GD, Volk LA, Volodarskaya M, et al. J Am Med Inform Assoc. 2017;24:281-287.
PSNET: Patient Safety Network
PSNet is produced for the Agency for Healthcare Research and Quality by a team of editors at the University of California, San Francisco with guidance from a prominent Technical Expert/Advisory Panel. The AHRQ PSNet site was designed and implemented by Silverchair.
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