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psnet.ahrq.gov/node/33681/psn-pdf
March 01, 2009 - The Role of Health Literacy in Patient Safety
March 1, 2009
Wolf MS, Bailey SC. The Role of Health Literacy in Patient Safety. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/role-health-literacy-patient-safety
Perspective
Clear health communication is increasingly recognized as essential for promoting …
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psnet.ahrq.gov/node/49623/psn-pdf
March 01, 2011 - Are We Pushing Graduate Nurses Too Fast?
March 1, 2011
Spector ND. Are We Pushing Graduate Nurses Too Fast? . PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/are-we-pushing-graduate-nurses-too-fast
The Case
A middle-aged man was admitted to the surgical intensive care unit (SICU) following a complex surgical…
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psnet.ahrq.gov/web-mm/feeling-no-pain
August 30, 2023 - means to an end—she would have been more likely to heed what the patient was saying and be alert to the adverse … drug reaction.
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psnet.ahrq.gov/issue/hospice-diagnosis-polypharmacy-teachable-moment
April 24, 2018 - Commentary
Hospice diagnosis: polypharmacy—a teachable moment.
Citation Text:
Larson CK, Kao H. Hospice Diagnosis: Polypharmacy: A Teachable Moment. JAMA Intern Med. 2015;175(11):1750-1751. doi:10.1001/jamainternmed.2015.5253.
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psnet.ahrq.gov/issue/health-services-under-pressure-scoping-review-and-development-taxonomy-adaptive-strategies
January 22, 2020 - Commentary
Health services under pressure: a scoping review and development of a taxonomy of adaptive strategies.
Citation Text:
Page B, Irving D, Amalberti R, et al. Health services under pressure: a scoping review and development of a taxonomy of adaptive strategies. BMJ Qual Saf. 2023…
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psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis
October 28, 2020 - Hospital-Acquired Diabetic Ketoacidosis.
Citation Text:
Zuidema D, Bagley B, Tan CL. Hospital-Acquired Diabetic Ketoacidosis.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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Google Scholar Bi…
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psnet.ahrq.gov/issue/evidence-based-red-cell-transfusion-critically-ill-quality-improvement-using-computerized
February 15, 2017 - Study
Evidence-based red cell transfusion in the critically ill: quality improvement using computerized physician order entry.
Citation Text:
Rana R, Afessa B, Keegan MT, et al. Evidence-based red cell transfusion in the critically ill: quality improvement using computerized physician …
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psnet.ahrq.gov/issue/strategies-improve-patient-safety-outcome-indicator-preventing-or-reducing-falls
March 24, 2021 - Commentary
Strategies to improve the patient safety outcome indicator: preventing or reducing falls.
Citation Text:
Bright L. Strategies to improve the patient safety outcome indicator: preventing or reducing falls. Home Healthc Nurse. 2005;23(1):29-36.
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…
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psnet.ahrq.gov/node/33745/psn-pdf
February 01, 2013 - Patient Engagement and Patient Safety
February 1, 2013
Weingart SN. Patient Engagement and Patient Safety. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/patient-engagement-and-patient-safety
Perspective
Patient engagement has arrived at the station. A Google search of this phrase identified 335,000 hi…
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psnet.ahrq.gov/issue/what-happens-medication-regimens-older-adults-during-and-after-acute-hospitalization
May 19, 2021 - Study
What happens to the medication regimens of older adults during and after an acute hospitalization?
Citation Text:
Harris CM, Sridharan A, Landis R, et al. What happens to the medication regimens of older adults during and after an acute hospitalization? J Patient Saf. 2013;9(3):15…
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psnet.ahrq.gov/issue/what-driving-hospitals-patient-safety-efforts
February 10, 2015 - Commentary
What is driving hospitals' patient-safety efforts?
Citation Text:
Devers KJ, Pham HH, Liu G. What is driving hospitals' patient-safety efforts? Health Aff (Millwood). 2004;23(2):103-15.
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psnet.ahrq.gov/issue/improving-team-information-sharing-structured-call-out-anaesthetic-emergencies-randomized
November 17, 2014 - Study
Improving team information sharing with a structured call-out in anaesthetic emergencies: a randomized controlled trial.
Citation Text:
Weller JM, Torrie J, Boyd M, et al. Improving team information sharing with a structured call-out in anaesthetic emergencies: a randomized control…
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psnet.ahrq.gov/issue/devil-detail-how-closed-loop-documentation-system-iv-infusion-administration-contributes-and
February 12, 2020 - Study
The devil is in the detail: how a closed-loop documentation system for IV infusion administration contributes to and compromises patient safety.
Citation Text:
Furniss D, Dean Franklin B, Blandford A. The devil is in the detail: how a closed-loop documentation system for IV infusi…
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psnet.ahrq.gov/issue/facilitated-self-reported-anaesthetic-medication-errors-and-after-implementation-safety
February 09, 2011 - Study
Facilitated self-reported anaesthetic medication errors before and after implementation of a safety bundle and barcode-based safety system.
Citation Text:
Bowdle TA, Jelacic S, Nair B, et al. Facilitated self-reported anaesthetic medication errors before and after implementation of…
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psnet.ahrq.gov/issue/wolf-crying-operating-room-patient-monitor-and-anesthesia-workstation-alarming-patterns
April 17, 2013 - Study
The wolf is crying in the operating room: patient monitor and anesthesia workstation alarming patterns during cardiac surgery.
Citation Text:
Schmid F, Goepfert MS, Kuhnt D, et al. The wolf is crying in the operating room: patient monitor and anesthesia workstation alarming patte…
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psnet.ahrq.gov/issue/worldwide-incidence-surgical-site-infections-general-surgical-patients-systematic-review-and
August 11, 2021 - Review
Worldwide incidence of surgical site infections in general surgical patients: a systematic review and meta-analysis of 488,594 patients.
Citation Text:
Gillespie BM, Harbeck EL, Rattray M, et al. Worldwide incidence of surgical site infections in general surgical patients: a syste…
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psnet.ahrq.gov/issue/my-five-moments-hand-hygiene-user-centred-design-approach-understand-train-monitor-and-report
September 09, 2020 - Commentary
'My five moments for hand hygiene': a user-centred design approach to understand, train, monitor and report hand hygiene.
Citation Text:
Sax H, Allegranzi B, Uçkay I, et al. 'My five moments for hand hygiene': a user-centred design approach to understand, train, monitor and …
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psnet.ahrq.gov/issue/crew-resource-management-improved-perception-patient-safety-operating-room
April 27, 2010 - Study
Crew resource management improved perception of patient safety in the operating room.
Citation Text:
Gore DC, Powell JM, Baer JG, et al. Crew resource management improved perception of patient safety in the operating room. Am J Med Qual. 2010;25(1):60-3. doi:10.1177/1062860609351…
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psnet.ahrq.gov/web-mm/dont-push
March 02, 2011 - Don't Push
Citation Text:
Meltzer HY. Don't Push. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Downl…
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psnet.ahrq.gov/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
March 15, 2023 - August 5, 2020
Pediatric adverse drug events in the outpatient setting: an 11-year national … April 8, 2011
Adverse drug events in the outpatient setting: an 11-year national analysis