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psnet.ahrq.gov/issue/what-do-emergency-department-physicians-and-nurses-feel-qualitative-study-emotions-triggers
January 25, 2023 - Study
What do emergency department physicians and nurses feel? A qualitative study of emotions, triggers, regulation strategies, and effects on patient care.
Citation Text:
Isbell LM, Boudreaux ED, Chimowitz H, et al. What do emergency department physicians and nurses feel? A qualitative…
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psnet.ahrq.gov/issue/developing-process-measure-actual-harm-medication-errors-paediatric-inpatients-design
January 18, 2023 - Study
Developing a process to measure actual harm from medication errors in paediatric inpatients: from design to implementation.
Citation Text:
Mumford V, Raban MZ, Li L, et al. Developing a process to measure actual harm from medication errors in paediatric inpatients: from design to i…
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psnet.ahrq.gov/issue/exploring-theory-barriers-and-enablers-patient-and-public-involvement-across-health-social
February 17, 2021 - Review
Classic
Exploring the theory, barriers and enablers for patient and public involvement across health, social care and patient safety: a systematic review of reviews.
Citation Text:
Ocloo J, Garfield S, Franklin BD, et al. Exploring the theory, barriers an…
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psnet.ahrq.gov/issue/longitudinal-study-clinical-peer-reviews-impact-quality-and-safety-us-hospitals
March 29, 2023 - Study
A longitudinal study of clinical peer review's impact on quality and safety in US hospitals.
Citation Text:
Edwards MT. A longitudinal study of clinical peer review's impact on quality and safety in U.S. hospitals. J Healthc Manag. 2013;58(5):369-85.
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Format:
…
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psnet.ahrq.gov/issue/covid-19-patient-safety-and-quality-improvement-skills-deploy-during-surge
March 23, 2022 - Commentary
COVID-19: patient safety and quality improvement skills to deploy during the surge.
Citation Text:
Staines A, Amalberti R, Berwick DM, et al. COVID-19: patient safety and quality improvement skills to deploy during the surge. Int J Qual Health Care. 2021;33(1):mzaa050. doi:10.…
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psnet.ahrq.gov/issue/vital-signs-are-still-vital-instability-discharge-and-risk-post-discharge-adverse-outcomes
September 23, 2020 - Study
Vital signs are still vital: instability on discharge and the risk of post-discharge adverse outcomes.
Citation Text:
Nguyen OK, Makam AN, Clark C, et al. Vital Signs Are Still Vital: Instability on Discharge and the Risk of Post-Discharge Adverse Outcomes. J Gen Intern Med. 2017;3…
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psnet.ahrq.gov/issue/intravenous-infusion-administration-comparative-study-practices-and-errors-between-united
October 18, 2018 - Study
Intravenous infusion administration: a comparative study of practices and errors between the United States and England and their implications for patient safety.
Citation Text:
Blandford A, Dykes PC, Franklin BD, et al. Intravenous Infusion Administration: A Comparative Study of Pr…
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psnet.ahrq.gov/issue/artificial-intelligence-identifying-prevention-medication-incidents-causing-serious-or
March 11, 2020 - Study
Artificial intelligence for identifying the prevention of medication incidents causing serious or moderate harm: an analysis using incident reporters' views.
Citation Text:
Härkänen M, Haatainen K, Vehviläinen-Julkunen K, et al. Artificial intelligence for identifying the preventio…
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psnet.ahrq.gov/web-mm/agitated-delirium-contributes-missed-testing-and-delayed-diagnosis-gastric-perforation
June 28, 2023 - patients, providing natural light and minimizing nocturnal awakenings, and encouraging mobility. 16-19
Approaches
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psnet.ahrq.gov/perspective/conversation-linda-aiken-phd-rn
March 01, 2018 - If these conditions—including staffing levels—are not met, services are suspended.( 13 ) Such approaches
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psnet.ahrq.gov/node/836850/psn-pdf
March 31, 2022 - indicate that machine learning classifiers can better predict adverse
outcomes compared with individual approaches
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psnet.ahrq.gov/innovation/rehearsing-team-care-relatively-rare-obstetric-emergencies-leads-improved-outcomes
July 23, 2024 - Focus
This innovation uses core patient safety communication and teamwork competencies and simulation approaches
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psnet.ahrq.gov/perspective/missed-nursing-care-key-measure-patient-safety
March 01, 2018 - If these conditions—including staffing levels—are not met, services are suspended.( 13 ) Such approaches
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psnet.ahrq.gov/perspective/risk-management-and-patient-safety
December 01, 2010 - data and supporting literature, RMF convened the Harvard surgical chiefs to develop evidence-based approaches
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psnet.ahrq.gov/perspective/what-do-we-know-about-emergency-department-safety
June 01, 2010 - What's your sense of the utility of those kinds of approaches?
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.344_slideshow.ppt
April 01, 2015 - PowerPoint Presentation
Spotlight
Dissecting the Presentation
*
This presentation is based on the April 2015
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Shirley Beng Suat Ooi, MBBS (S'pore), Emergency Medicine Department, National Univers…
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psnet.ahrq.gov/node/49580/psn-pdf
March 21, 2009 - Medication Reconciliation Victory After an Avoidable
Error
March 21, 2009
Cutler TW. Medication Reconciliation Victory After an Avoidable Error. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/medication-reconciliation-victory-after-avoidable-error
The Case
A 91-year-old woman, previously active and indepen…
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psnet.ahrq.gov/node/49844/psn-pdf
October 01, 2018 - Diffusion of Responsibility Leads to Danger
October 1, 2018
Balcezak TJ, Deshpande O. Diffusion of Responsibility Leads to Danger. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/diffusion-responsibility-leads-danger
The Case
A 70-year-old man was sent to the emergency department (ED) from a nursing facility…
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psnet.ahrq.gov/node/49756/psn-pdf
April 01, 2016 - Lost in Sign Out and Documentation
April 1, 2016
Detsky ME. Lost in Sign Out and Documentation. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/lost-sign-out-and-documentation
The Case
A 71-year-old man presented to the emergency department with chest pain. While being evaluated by the
emergency physician, …
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psnet.ahrq.gov/node/49616/psn-pdf
December 01, 2010 - Milliliters vs. Milligrams
December 1, 2010
Poole RL, Dixon T. Milliliters vs. Milligrams. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/milliliters-vs-milligrams
The Case
A 32-year-old man was admitted to the hospital after a vehicle collision and multiple traumatic injuries. His
evaluation showed acu…