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psnet.ahrq.gov/node/49551/psn-pdf
December 01, 2007 - Too Hot For Comfort
December 1, 2007
Cleland H, Wasiak J. Too Hot For Comfort. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/too-hot-comfort
The Case
A 4-month-old infant admitted to rule out sepsis was receiving maintenance intravenous (IV) fluid and IV
antibiotics via a peripheral line in the left antec…
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psnet.ahrq.gov/issue/understanding-why-quality-initiatives-succeed-or-fail-sociotechnical-systems-perspective
March 10, 2021 - Commentary
Understanding why quality initiatives succeed or fail: a sociotechnical systems perspective.
Citation Text:
Wiegmann DA. Understanding Why Quality Initiatives Succeed or Fail: A Sociotechnical Systems Perspective. Ann Surg. 2016;263(1):9-11. doi:10.1097/SLA.0000000000001333.
…
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psnet.ahrq.gov/node/73699/psn-pdf
September 15, 2021 - Making safety training stickier: a richer model of safety
training engagement and transfer.
September 15, 2021
Casey T, Turner N, Hu X, et al. Making safety training stickier: a richer model of safety training engagement
and transfer. J Safety Res. 2021;78:303-313. doi:10.1016/j.jsr.2021.06.004.
https://psnet.ahrq…
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psnet.ahrq.gov/issue/measuring-handoff-quality-labor-and-delivery-development-validation-and-application
January 03, 2017 - Study
Measuring handoff quality in labor and delivery: development, validation, and application of the Coordination of Handoff Effectiveness Questionnaire (CHEQ).
Citation Text:
Block M, Ehrenworth JF, Cuce VM, et al. Measuring handoff quality in labor and delivery: development, valid…
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psnet.ahrq.gov/issue/duke-surgery-patient-safety-open-source-application-anonymous-reporting-adverse-and-near-miss
February 15, 2011 - Commentary
Duke Surgery Patient Safety: an open-source application for anonymous reporting of adverse and near-miss surgical events.
Citation Text:
Pietrobon R, Lima R, Shah A, et al. Duke Surgery Patient Safety: an open-source application for anonymous reporting of adverse and near-mi…
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psnet.ahrq.gov/node/47941/psn-pdf
January 01, 2020 - Usability and feasibility of consumer-facing technology to
reduce unsafe medication use by older adults.
May 22, 2019
Holden RJ, Campbell NL, Abebe E, et al. Usability and feasibility of consumer-facing technology to reduce
unsafe medication use by older adults. Res Social Adm Pharm. 2020;16(1):54-61.
doi:10.1016/…
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psnet.ahrq.gov/node/841305/psn-pdf
January 27, 2023 - Safety-I is more applicable when there is a steady state and when there is a known best way. … Debriefing skills learned in simulation are very applicable to real patient care circumstances.
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psnet.ahrq.gov/issue/false-dawns-and-new-horizons-patient-safety-research-and-practice
July 24, 2024 - Commentary
False dawns and new horizons in patient safety research and practice.
Citation Text:
Mannion R, Braithwaite J. False Dawns and New Horizons in Patient Safety Research and Practice. Int J Health Policy Manag. 2017;6(12). doi:10.15171/ijhpm.2017.115.
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Format: …
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psnet.ahrq.gov/issue/learning-incidents-health-care-critique-safety-ii-perspective
August 19, 2020 - Commentary
Learning from incidents in health care: critique from a Safety-II perspective.
Citation Text:
Learning from incidents in health care: critique from a Safety-II perspective. Sujan MA, Huang H, Braithwaite J. Safety Sci. 2017;99:115-121.
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…
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psnet.ahrq.gov/issue/development-and-applications-veterans-health-administrations-stratification-tool-opioid-risk
April 01, 2020 - Study
Development and applications of the Veterans Health Administration's Stratification Tool for Opioid Risk Mitigation (STORM) to improve opioid safety and prevent overdose and suicide.
Citation Text:
Oliva EM, Bowe T, Tavakoli S, et al. Development and applications of the Veterans He…
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psnet.ahrq.gov/issue/can-surveillance-systems-identify-and-avert-adverse-drug-events-prospective-evaluation
February 10, 2015 - Study
Can surveillance systems identify and avert adverse drug events? A prospective evaluation of a commercial application.
Citation Text:
Jha AK, Laguette J, Seger AC, et al. Can surveillance systems identify and avert adverse drug events? A prospective evaluation of a commercial app…
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psnet.ahrq.gov/issue/systematic-review-behavioural-marker-systems-healthcare-what-do-we-know-about-their
January 23, 2019 - Review
A systematic review of behavioural marker systems in healthcare: what do we know about their attributes, validity and application?
Citation Text:
Dietz AS, Pronovost P, Benson KN, et al. A systematic review of behavioural marker systems in healthcare: what do we know about their a…
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psnet.ahrq.gov/issue/application-iv-medication-harm-index-assess-nature-harm-averted-smart-infusion-safety-systems
January 23, 2017 - Study
Application of the IV Medication Harm Index to assess the nature of harm averted by "smart" infusion safety systems.
Citation Text:
Williams CK, Maddox RR, Heape E, et al. Application of the IV Medication Harm Index to Assess the Nature of Harm Averted by "Smart" Infusion Safety …
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psnet.ahrq.gov/issue/preventing-central-line-associated-bloodstream-infections-intensive-care-unit-application
March 10, 2010 - Commentary
Preventing central line–associated bloodstream infections in the intensive care unit: application of high-reliability principles.
Citation Text:
McCraw B, Crutcher T, Polancich S, et al. Preventing Central Line-Associated Bloodstream Infections in the Intensive Care Unit: Appl…
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psnet.ahrq.gov/issue/cognitive-performance-altering-effects-electronic-medical-records-application-human-factors
May 16, 2012 - Study
Cognitive performance-altering effects of electronic medical records: an application of the human factors paradigm for patient safety.
Citation Text:
Holden RJ. Cognitive performance-altering effects of electronic medical records: An application of the human factors paradigm for …
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psnet.ahrq.gov/node/43897/psn-pdf
August 21, 2015 - Guidelines for Adult IV Push Medications.
August 21, 2015
Horsham, PA: The Institute for Safe Medication Practices; July 2015.
https://psnet.ahrq.gov/issue/guidelines-adult-iv-push-medications
To address the lack of standards on intravenous (IV) push medication administration, this guidance reflects
applied expert…
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psnet.ahrq.gov/issue/fall-prevention-acute-care-hospitals-randomized-trial
February 01, 2023 - Study
Classic
Fall prevention in acute care hospitals: a randomized trial.
Citation Text:
Dykes PC, Carroll DL, Hurley A, et al. Fall prevention in acute care hospitals: a randomized trial. JAMA. 2010;304(17):1912-1918. doi:10.1001/jama.2010.1567.
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psnet.ahrq.gov/node/36832/psn-pdf
August 26, 2011 - The role of information technology in healthcare
communications, efficiency, and patient safety:
application and results.
August 26, 2011
Prince SB, Herrin DM. The role of information technology in healthcare communications, efficiency, and
patient safety: application and results. J Nurs Adm. 2007;37(4):184-7.
ht…
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psnet.ahrq.gov/node/35302/psn-pdf
July 14, 2009 - Technology induced error and usability: the relationship
between usability problems and prescription errors when
using a handheld application.
July 14, 2009
Kushniruk AW, Triola MM, Borycki EM, et al. Technology induced error and usability: The relationship
between usability problems and prescription errors when u…
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psnet.ahrq.gov/issue/orthopaedic-error-index-development-and-application-novel-national-indicator-assessing
July 18, 2016 - Study
The Orthopaedic Error Index: development and application of a novel national indicator for assessing the relative safety of hospital care using a cross-sectional approach.
Citation Text:
Panesar SS, Netuveli G, Carson-Stevens A, et al. The orthopaedic error index: development and…