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psnet.ahrq.gov/node/47729/psn-pdf
April 10, 2019 - Reclaiming the systems approach to paediatric safety.
April 10, 2019
Cheung R, Roland D, Lachman P. Reclaiming the systems approach to paediatric safety. Arch Dis Child.
2019;104(12):1130-1133. doi:10.1136/archdischild-2018-316401.
https://psnet.ahrq.gov/issue/reclaiming-systems-approach-paediatric-safety
Children…
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psnet.ahrq.gov/node/73675/psn-pdf
September 08, 2021 - A system-wide hospital child maltreatment patient safety
program.
September 8, 2021
Hansen J, Terreros A, Sherman A, et al. A system-wide hospital child maltreatment patient safety program.
Pediatrics. 2021;148(3):e2021050555. doi:10.1542/peds.2021-050555.
https://psnet.ahrq.gov/issue/system-wide-hospital-child-ma…
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psnet.ahrq.gov/node/50687/psn-pdf
November 20, 2019 - Discrimination, abuse, harassment, and burnout in
surgical residency training.
November 20, 2019
Hu Y-Y, Ellis RJ, Hewitt B, et al. Discrimination, Abuse, Harassment, and Burnout in Surgical Residency
Training. New Engl J Med. 2019;381(18):1741-1752. doi:10.1056/NEJMsa1903759.
https://psnet.ahrq.gov/issue/discrimi…
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psnet.ahrq.gov/node/866447/psn-pdf
August 07, 2024 - Older adults are often misdiagnosed. Specialized ERs and
trained clinicians can help.
August 7, 2024
Milne-Tyte A. Older adults are often misdiagnosed. Specialized ERs and trained clinicians can help. Health
Shots. National Public Radio. July 30, 2024;
https://psnet.ahrq.gov/issue/older-adults-are-often-misdiagnos…
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psnet.ahrq.gov/node/44742/psn-pdf
January 06, 2016 - A piece of my mind. From shame to guilt to love.
January 6, 2016
Pronovost P, Bienvenu J. A piece of my mind. From shame to guilt to love. JAMA. 2015;314(23):2507-
2508. doi:10.1001/jama.2015.11521.
https://psnet.ahrq.gov/issue/piece-my-mind-shame-guilt-love
While numerous studies have examined the psychological i…
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/poster-4x6-delirium.pdf
June 01, 2021 - Identifying Delirium: ABCs of Identification_4x6
AHRQ Pub. No. 17(21)-0029
June 2021
IDENTIFYING DELIRIUM
ABCs OF IDENTIFICATION
Acute/subacute
• Altered mental status from baseline
Behavioral disturbance
• Restless, agitated, combative
Changes in consciousness
• Jittery, drowsy, difficult to aro…
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psnet.ahrq.gov/node/46575/psn-pdf
December 13, 2017 - Economic evaluation of pharmacist-led medication
reviews in residential aged care facilities.
December 13, 2017
Hasan SS, Thiruchelvam K, Kow CS, et al. Economic evaluation of pharmacist-led medication reviews in
residential aged care facilities. Expert Rev Pharmacoecon Outcomes Res. 2017;17(5):431-439.
doi:10.108…
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psnet.ahrq.gov/node/852451/psn-pdf
August 16, 2023 - The impact of transition to a digital hospital on
medication errors (TIME study).
August 16, 2023
Engstrom T, McCourt E, Canning M, et al. The impact of transition to a digital hospital on medication errors
(TIME study). NPJ Digit Med. 2023;6(1):133. doi:10.1038/s41746-023-00877-w.
https://psnet.ahrq.gov/issue/imp…
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psnet.ahrq.gov/node/45563/psn-pdf
October 19, 2016 - Using a change model to reduce the risk of surgical site
infection.
October 19, 2016
Burden M. Using a change model to reduce the risk of surgical site infection. Br J Nurs. 2016;25(17):949-
955.
https://psnet.ahrq.gov/issue/using-change-model-reduce-risk-surgical-site-infection
Surgical site infections can resul…
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psnet.ahrq.gov/node/45974/psn-pdf
May 03, 2017 - Effects of workload, work complexity, and repeated alerts
on alert fatigue in a clinical decision support system.
May 3, 2017
Ancker JS, Edwards A, Nosal S, et al. Effects of workload, work complexity, and repeated alerts on alert
fatigue in a clinical decision support system. BMC Med Inform Decis Mak. 2017;17(1):3…
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psnet.ahrq.gov/node/847725/psn-pdf
April 19, 2023 - A scoping review of the hidden curriculum in pharmacy
education.
April 19, 2023
Park SK, Chen AMH, Daugherty KK, et al. A scoping review of the hidden curriculum in pharmacy
education. Am J Pharm Educ. 2023;87(3):ajpe8999. doi:10.5688/ajpe8999.
https://psnet.ahrq.gov/issue/scoping-review-hidden-curriculum-pharmacy…
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psnet.ahrq.gov/node/45636/psn-pdf
September 26, 2018 - Pharmacist outpatient prescription review in the
emergency department: a pediatric tertiary hospital
experience.
September 26, 2018
Shah D, Manzi S. Pharmacist Outpatient Prescription Review in the Emergency Department: A Pediatric
Tertiary Hospital Experience. Pediatr Emerg Care. 2018;34(7):497-500.
doi:10.1097/…
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psnet.ahrq.gov/node/45559/psn-pdf
November 09, 2016 - Differentiating between detrimental and beneficial
interruptions: a mixed-methods study.
November 9, 2016
Myers RA, McCarthy MC, Whitlatch A, et al. Differentiating between detrimental and beneficial
interruptions: a mixed-methods study. BMJ Qual Saf. 2016;25(11):881-888. doi:10.1136/bmjqs-2015-
004401.
https://p…
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psnet.ahrq.gov/node/45044/psn-pdf
May 11, 2016 - Creating a nurse-led culture to minimize horizontal
violence in the acute care setting: a multi-interventional
approach.
May 11, 2016
Parker KM, Harrington A, Smith CM, et al. Creating a Nurse-Led Culture to Minimize Horizontal Violence in
the Acute Care Setting: A Multi-Interventional Approach. J Nurses Prof Dev.…
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psnet.ahrq.gov/node/45824/psn-pdf
January 25, 2017 - The detection, analysis, and significance of physician
clustering in medical malpractice lawsuit payouts.
January 25, 2017
Oshel RE, Levitt P. The Detection, Analysis, and Significance of Physician Clustering in Medical
Malpractice Lawsuit Payouts. J Patient Saf. 2016;16(4):274-278. doi:10.1097/PTS.0000000000000326…
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psnet.ahrq.gov/node/36698/psn-pdf
February 24, 2011 - The impact of duty hours on resident self reports of
errors.
February 24, 2011
Vidyarthi A, Auerbach AD, Wachter R, et al. The impact of duty hours on resident self reports of errors. J
Gen Intern Med. 2007;22(2):205-9.
https://psnet.ahrq.gov/issue/impact-duty-hours-resident-self-reports-errors
Residency programs…
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psnet.ahrq.gov/node/47823/psn-pdf
March 13, 2019 - Greater Focus on Credentialing Needed to Prevent
Disqualified Providers From Delivering Patient Care.
March 13, 2019
Washington, DC: United States Government Accountability Office; February 2019. Publication GAO-19-6.
https://psnet.ahrq.gov/issue/greater-focus-credentialing-needed-prevent-disqualified-providers-del…
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psnet.ahrq.gov/node/853059/psn-pdf
August 30, 2023 - Anesthesia Risk Alert program: a proactive safety
initiative.
August 30, 2023
Lee B, Marhalik-Helms J, Penzi L. Anesthesia Risk Alert program: a proactive safety initiative. Jt Comm J
Qual Patient Saf. 2023;49(9):441-449. doi:10.1016/j.jcjq.2023.06.005.
https://psnet.ahrq.gov/issue/anesthesia-risk-alert-program-pr…
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psnet.ahrq.gov/node/46061/psn-pdf
August 03, 2017 - An organizational framework to reduce professional
burnout and bring back joy in practice.
August 3, 2017
Swensen S, Shanafelt TD. An Organizational Framework to Reduce Professional Burnout and Bring Back
Joy in Practice. Jt Comm J Qual Patient Saf. 2017;43(6):308-313. doi:10.1016/j.jcjq.2017.01.007.
https://psnet…
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psnet.ahrq.gov/node/44120/psn-pdf
November 06, 2015 - Designing highly reliable adverse-event detection
systems to predict subsequent claims.
November 6, 2015
Helmchen LA, Burke ME, Wojtusiak J. Designing highly reliable adverse-event detection systems to predict
subsequent claims. J Healthc Risk Manag. 2015;34(4):7-17. doi:10.1002/jhrm.21167.
https://psnet.ahrq.gov/…