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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.
Solving alarm fatigue with smartphone technology.
Short K, Chung YJ Jr. Nursing. 2019;49:52-57.
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 Mar 29; [Epub ahead of print].
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.
Assessing frequency and risk of weight entry errors in pediatrics.
Hagedorn PA, Kirkendall ES, Kouril M, et al. JAMA Pediatr. 2017;171:392-393
Estimating deaths due to medical error: the ongoing controversy and why it matters.
Shojania KG, Dixon-Woods M. BMJ Qual Saf. 2017;26:423-428.
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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