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psnet.ahrq.gov/issue/review-medication-error-sources-associated-inpatient-subcutaneous-insulin-recommendations
June 17, 2020 - Review
Review of medication error sources associated with inpatient subcutaneous insulin: recommendations for safe and cost-effective dispensing practices.
Citation Text:
McKay C, Schenkat D, Murphy K, et al. Review of medication error sources associated with inpatient subcutaneous insul…
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psnet.ahrq.gov/issue/patient-and-physician-perspectives-deprescribing-potentially-inappropriate-medications-older
March 09, 2022 - Study
Patient and physician perspectives of deprescribing potentially inappropriate medications in older adults with a history of falls: a qualitative study.
Citation Text:
Hahn EE, Munoz-Plaza CE, Lee EA, et al. Patient and physician perspectives of deprescribing potentially inappropria…
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psnet.ahrq.gov/issue/interventions-reliability-seeking-health-care-organizations-systematic-review-their-goals-and
October 19, 2022 - Review
Interventions into reliability-seeking health care organizations: a systematic review of their goals and measuring methods.
Citation Text:
Auschra C, Asaad E, Sydow J, et al. Interventions into reliability-seeking health care organizations: a systematic review of their goals and m…
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psnet.ahrq.gov/issue/comparative-economic-analyses-patient-safety-improvement-strategies-acute-care-systematic
November 07, 2012 - Review
Comparative economic analyses of patient safety improvement strategies in acute care: a systematic review.
Citation Text:
Etchells E, Koo M, Daneman N, et al. Comparative economic analyses of patient safety improvement strategies in acute care: a systematic review. BMJ Qual Saf.…
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psnet.ahrq.gov/issue/health-care-associated-infections-meta-analysis-costs-and-financial-impact-us-health-care
July 31, 2013 - Study
Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system.
Citation Text:
Zimlichman E, Henderson D, Tamir O, et al. Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system. JA…
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psnet.ahrq.gov/issue/eliminating-central-line-associated-bloodstream-infections-national-patient-safety-imperative
March 21, 2012 - Study
Eliminating central line-associated bloodstream infections: a national patient safety imperative.
Citation Text:
Berenholtz SM, Lubomski LH, Weeks K, et al. Eliminating central line-associated bloodstream infections: a national patient safety imperative. Infect Control Hosp Epidem…
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psnet.ahrq.gov/issue/changes-medical-errors-after-implementation-handoff-program
April 24, 2018 - Study
Classic
Changes in medical errors after implementation of a handoff program.
Citation Text:
Starmer AJ, Spector ND, Srivastava R, et al. Changes in medical errors after implementation of a handoff program. New Engl J Med. 2014;371(19):1803-1812. doi:10.105…
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psnet.ahrq.gov/issue/culture-change-infection-control-applying-psychological-principles-improve-hand-hygiene
November 21, 2021 - Study
Culture change in infection control: applying psychological principles to improve hand hygiene.
Citation Text:
Cumbler E, Castillo L, Satorie L, et al. Culture change in infection control: applying psychological principles to improve hand hygiene. J Nurs Care Qual. 2013;28(4):304…
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psnet.ahrq.gov/issue/inadequate-hand-communication
April 02, 2015 - Sentinel Event Alerts
Inadequate hand-off communication.
Citation Text:
Inadequate hand-off communication. Sentinel event alert. 2017;58(58):1-6.
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psnet.ahrq.gov/issue/knowledge-retention-after-simulated-crisis-importance-independent-practice-and-simulated
September 13, 2017 - Study
Knowledge retention after simulated crisis: importance of independent practice and simulated mortality.
Citation Text:
Burnett G, Goldberg A, DeMaria S, et al. Knowledge retention after simulated crisis: importance of independent practice and simulated mortality. Br J Anaesth. 2019…
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psnet.ahrq.gov/issue/rates-serious-surgical-errors-california-and-plans-prevent-recurrence
March 09, 2022 - Study
Rates of serious surgical errors in California and plans to prevent recurrence.
Citation Text:
Cohen AJ, Lui H, Zheng M, et al. Rates of serious surgical errors in California and plans to prevent recurrence. JAMA Netw Open. 2021;4(5):e217058. doi:10.1001/jamanetworkopen.2021.7058. …
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psnet.ahrq.gov/issue/ten-principles-more-conservative-care-full-diagnosis
August 04, 2021 - Commentary
Emerging Classic
Ten principles for more conservative, care-full diagnosis.
Citation Text:
Schiff G, Martin SA, Eidelman DH, et al. Ten Principles for More Conservative, Care-Full Diagnosis. Ann Intern Med. 2018;169(9):643-645. doi:10.7326/M18-1468.
…
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psnet.ahrq.gov/issue/national-trends-patient-safety-four-common-conditions-2005-2011
August 03, 2016 - Study
Classic
National trends in patient safety for four common conditions, 2005–2011.
Citation Text:
Wang Y, Eldridge N, Metersky M, et al. National trends in patient safety for four common conditions, 2005-2011. N Engl J Med. 2014;370(4):341-51. doi:10.1056/NE…
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psnet.ahrq.gov/issue/program-provide-clinicians-feedback-their-diagnostic-performance-learning-health-system
October 12, 2022 - Study
A program to provide clinicians with feedback on their diagnostic performance in a learning health system.
Citation Text:
Meyer AND, Upadhyay DK, Collins CA, et al. A program to provide clinicians with feedback on their diagnostic performance in a learning health system. Jt Comm J …
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psnet.ahrq.gov/issue/nature-and-timing-incidents-intercepted-surpass-checklist-surgical-patients
September 20, 2011 - Study
Nature and timing of incidents intercepted by the SURPASS checklist in surgical patients.
Citation Text:
de Vries EN, Prins HA, Bennink C, et al. Nature and timing of incidents intercepted by the SURPASS checklist in surgical patients. BMJ Qual Saf. 2012;21(6):503-8. doi:10.1136/…
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psnet.ahrq.gov/node/853080/psn-pdf
August 30, 2023 - Virtual Nursing: Improving Patient Care and Meeting
Workforce Challenges
August 30, 2023
Sanford K, Schuelke S, Lee M, et al. Virtual Nursing: Improving Patient Care and Meeting Workforce
Challenges. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/virtual-nursing-improving-patient-care-and-meeting-workf…
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psnet.ahrq.gov/node/865697/psn-pdf
April 24, 2024 - In Conversation with...Katie Boston-Leary about Patient
Safety Amid Nursing Workforce Challenges
April 24, 2024
Leary KB. In Conversation with..Katie Boston-Leary about Patient Safety Amid Nursing Workforce
Challenges. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/conversation-withkatie-boston-leary-a…
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psnet.ahrq.gov/node/49836/psn-pdf
July 01, 2018 - Primary Workaround, Secondary Complication
July 1, 2018
Debono D, Levett-Jones T. Primary Workaround, Secondary Complication. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/primary-workaround-secondary-complication
The Case
A young adult with a progressive neurological disorder presented to a hospital emerg…
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psnet.ahrq.gov/node/49802/psn-pdf
August 01, 2017 - Add-on Case and the Missing Checklist
August 1, 2017
Catchpole K. Add-on Case and the Missing Checklist. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/add-case-and-missing-checklist
The Case
A 65-year-old woman was admitted for evaluation of abdominal pain and weight loss. Based on diagnostic
data and ima…
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psnet.ahrq.gov/innovation/transition-coachesr-reduce-readmissions-medicare-patients-complex-postdischarge-needs
March 27, 2024 - Achieving positive ROI via targeted care coordination programs. The SCAN Foundation September 2014.