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psnet.ahrq.gov/node/50600/psn-pdf
October 30, 2019 - HHS Guide for Clinicians on the Appropriate Dosage
Reduction or Discontinuation of Long-Term Opioid
Analgesics.
October 30, 2019
HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid
Analgesics. Washington DC: US Department of Health and Human Services. October 2019.
…
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psnet.ahrq.gov/node/60997/psn-pdf
October 07, 2020 - ‘You’re going to release him when he was hurting
himself?’
October 7, 2020
Dahlberg B. Kaiser Health News. September 29, 2020.
https://psnet.ahrq.gov/issue/youre-going-release-him-when-he-was-hurting-himself
This story discusses failures related emergency psychiatric assessment, including premature discharge,
imp…
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psnet.ahrq.gov/node/60531/psn-pdf
May 27, 2020 - Telenursing in incidents and disasters: a systematic
review of the literature.
May 27, 2020
Nejadshafiee M, Bahaadinbeigy K, Kazemi M, et al. Telenursing in incidents and disasters: a systematic
review of the literature. J Emerg Nurs. 2020. doi:10.1016/j.jen.2020.03.005.
https://psnet.ahrq.gov/issue/telenursing-in…
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psnet.ahrq.gov/node/45492/psn-pdf
September 28, 2016 - Understanding human over-reliance on technology.
September 28, 2016
ISMP Medication Safety Alert! Acute Care Edition. September 8, 2016;21:1-4.
https://psnet.ahrq.gov/issue/understanding-human-over-reliance-technology
Over-reliance on technology can contribute to error due to user complacency. Reviewing how the ten…
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psnet.ahrq.gov/node/44126/psn-pdf
May 13, 2015 - SAFER Electronic Health Records: Safety Assurance
Factors for EHR Resilience.
May 13, 2015
Sittig DF, Singh H, eds. Waretown, NJ: Apple Academic Press; 2015. ISBN: 9781771881173.
https://psnet.ahrq.gov/issue/safer-electronic-health-records-safety-assurance-factors-ehr-resilience
Implementation of electronic health…
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psnet.ahrq.gov/node/35235/psn-pdf
September 27, 2017 - What is the measure of a safe hospital? Medication errors
missed by risk management, clinical staff, and surveyors.
September 27, 2017
Grasso BC, Rothschild JM, Jordan CW, et al. What is the measure of a safe hospital? Medication errors
missed by risk management, clinical staff, and surveyors. J Psychiatr Pract. 20…
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psnet.ahrq.gov/node/47320/psn-pdf
September 05, 2018 - Patient safety climate: a study of Southern California
healthcare organizations.
September 5, 2018
Avramchuk AS, McGuire SJJ. Patient Safety Climate: A Study of Southern California Healthcare
Organizations. J Healthc Manag. 2018;63(3):175-192. doi:10.1097/JHM-D-16-00004.
https://psnet.ahrq.gov/issue/patient-safety…
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psnet.ahrq.gov/node/44983/psn-pdf
April 20, 2016 - Back to basics: counting soft surgical goods.
April 20, 2016
Spruce L. Back to Basics: Counting Soft Surgical Goods. AORN J. 2016;103(3):298-301; quiz 302-3.
doi:10.1016/j.aorn.2015.12.021.
https://psnet.ahrq.gov/issue/back-basics-counting-soft-surgical-goods
Despite heightened awareness of hazards associated with…
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psnet.ahrq.gov/node/41738/psn-pdf
June 10, 2018 - Inappropriate use of pharmacy bulk packages of IV
contrast media increases risk of infections.
June 10, 2018
ISMP Medication Safety Alert! Acute Care Edition. September 20, 2012;17:1,3-4.
https://psnet.ahrq.gov/issue/inappropriate-use-pharmacy-bulk-packages-iv-contrast-media-increases-risk-
infections
This articl…
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psnet.ahrq.gov/node/36671/psn-pdf
January 18, 2011 - Increasing vigilance on the medical/surgical floor to
improve patient safety.
January 18, 2011
Jacobs JL, Apatov N, Glei M. Increasing vigilance on the medical/surgical floor to improve patient safety. J
Adv Nurs. 2007;57(5). doi:10.1111/j.1365-2648.2006.04161.x.
https://psnet.ahrq.gov/issue/increasing-vigilance-m…
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psnet.ahrq.gov/node/35043/psn-pdf
June 22, 2009 - Human factors engineering: a tool for medical device
evaluation in hospital procurement decision-making.
June 22, 2009
Ginsburg G. Human factors engineering: a tool for medical device evaluation in hospital procurement
decision-making. J Biomed Inform. 2005;38(3):213-9.
https://psnet.ahrq.gov/issue/human-factors-e…
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psnet.ahrq.gov/web-mm/falling-through-crack-bedrails
February 19, 2020 - SPOTLIGHT CASE
Falling Through the Crack (in the Bedrails)
Citation Text:
Dykes PC, Vacca V, Leung WY. Falling Through the Crack (in the Bedrails). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
Copy Citation
F…
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psnet.ahrq.gov/perspective/health-care-data-science-quality-improvement-and-patient-safety
October 01, 2016 - Health Care Data Science for Quality Improvement and Patient Safety
Alvin Rajkomar, MD | October 1, 2016
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Rajkomar A. Health Care Data Science for Quality Improvement and Patient S…
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psnet.ahrq.gov/node/49403/psn-pdf
June 01, 2003 - Missed Appendicitis
June 1, 2003
Adams JG. Missed Appendicitis. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/missed-appendicitis
Case Objectives
Appreciate the variable presentations of appendicitis
List complications of missed appendicitis
Understand the advantages and disadvantages of CT in diagnosing…
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psnet.ahrq.gov/node/49833/psn-pdf
June 01, 2018 - Perils in Diagnosing a Stroke
June 1, 2018
Schindler JL. Perils in Diagnosing a Stroke. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/perils-diagnosing-stroke
The Case
A 75-year-old man with a history of hypertension, diabetes, chronic back pain, and opioid use disorder was
brought to the emergency depart…
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psnet.ahrq.gov/node/49809/psn-pdf
October 01, 2017 - Hyperbilirubinemia Refractory to Phototherapy
October 1, 2017
Bhutani VK, Wong RJ. Hyperbilirubinemia Refractory to Phototherapy. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/hyperbilirubinemia-refractory-phototherapy
The Case
A 1-day-old full-term infant was noted to have elevated total serum bilirubin (…
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psnet.ahrq.gov/node/49763/psn-pdf
June 01, 2016 - July Syndrome
June 1, 2016
Young JQ. July Syndrome. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/july-syndrome
The Case
A 64-year-old man was seen in the thoracic surgery clinic in June after being diagnosed with a right lower
lobe lung cancer. The attending surgeon saw the patient along with his fellow,…
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psnet.ahrq.gov/issue/post-operative-mortality-missed-care-and-nurse-staffing-nine-countries-cross-sectional-study
December 12, 2014 - June 22, 2022
Factors associated with missed nursing care and nurse-assessed quality
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psnet.ahrq.gov/issue/safety-attitudes-questionnaire-psychometric-properties-benchmarking-data-and-emerging
June 16, 2011 - nursing homes: variance of six patient safety climate factor scores across nursing homes and wards—assessed
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psnet.ahrq.gov/issue/why-patient-summaries-electronic-health-records-do-not-provide-cognitive-support-necessary
January 18, 2013 - January 18, 2013
The effect of hospital electronic health record adoption on nurse-assessed