-
psnet.ahrq.gov/node/47973/psn-pdf
July 18, 2019 - Transition planning for the senior surgeon: guidance and
recommendations from the Society of Surgical Chairs.
July 18, 2019
Rosengart TK, Doherty G, Higgins R, et al. Transition Planning for the Senior Surgeon: Guidance and
Recommendations From the Society of Surgical Chairs. JAMA Surg. 2019;154(7):647-653.
doi:10…
-
psnet.ahrq.gov/node/42947/psn-pdf
February 19, 2014 - Is the skillset obtained in surgical simulation transferable
to the operating theatre?
February 19, 2014
Buckley CE, Kavanagh DO, Traynor O, et al. Is the skillset obtained in surgical simulation transferable to
the operating theatre? Am J Surg. 2014;207(1):146-57. doi:10.1016/j.amjsurg.2013.06.017.
https://psnet.…
-
psnet.ahrq.gov/node/37874/psn-pdf
April 18, 2011 - Interprofessional handover and patient safety in
anaesthesia: observational study of handovers in the
recovery room.
April 18, 2011
Smith AF, Pope C, Goodwin D, et al. Interprofessional handover and patient safety in anaesthesia:
observational study of handovers in the recovery room. Br J Anaesth. 2008;101(3):332-…
-
psnet.ahrq.gov/node/852746/psn-pdf
August 23, 2023 - Common contributing factors of diagnostic error: a
retrospective analysis of 109 serious adverse event
reports from Dutch hospitals.
August 23, 2023
Hooftman J, Dijkstra AC, Suurmeijer I, et al. Common contributing factors of diagnostic error: a
retrospective analysis of 109 serious adverse event reports from Dutc…
-
psnet.ahrq.gov/node/46624/psn-pdf
November 29, 2017 - Empowerment failure: how shortcomings in physician
communication unwittingly undermine patient autonomy.
November 29, 2017
Ubel PA, Scherr KA, Fagerlin A. Empowerment Failure: How Shortcomings in Physician Communication
Unwittingly Undermine Patient Autonomy. Am J Bioeth. 2017;17(11):31-39.
doi:10.1080/15265161.20…
-
psnet.ahrq.gov/perspective/conversation-susan-mcgrath-phd-and-george-blike-md-about-surveillance-monitoring
April 26, 2023 - On a typical general care unit, patient vital signs are assessed intermittently every 4–8 hours. … Vital signs are assessed in both settings, but continuous monitoring used in critical and intermediate
-
psnet.ahrq.gov/perspective/surveillance-monitoring-improve-patient-safety-acute-hospital-care-units
April 26, 2023 - On a typical general care unit, patient vital signs are assessed intermittently every 4–8 hours. … Vital signs are assessed in both settings, but continuous monitoring used in critical and intermediate
-
psnet.ahrq.gov/perspective/conversation-chalapathy-venkatesan-and-kathy-helak-about-application-safety-ii
August 28, 2024 - In Conversation with Chalapathy Venkatesan and Kathy Helak about Application of Safety-II Principles
Chalapathy Venkatesan, MD, MS, CPPS, Kathy Helak, MSN, BSN, RN, FACHE, CPPS, Zoe Sousane, BS, Cindy Manaoat Van, MHSA, CPPS | August 28, 2024
Also Read the Essay
View more arti…
-
psnet.ahrq.gov/node/867428/psn-pdf
December 18, 2024 - In Conversation with Patricia Dykes about The Ongoing
Journey to Prevent Patient Falls
December 18, 2024
Dykes PC, Sousane Z, Mossburg SE. In Conversation with Patricia Dykes about The Ongoing Journey to
Prevent Patient Falls. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/conversation-patricia-dykes-a…
-
psnet.ahrq.gov/node/841467/psn-pdf
December 14, 2022 - A framework for assessing reasoning about controversial
end-of-life clinical decisions.
December 14, 2022
Fedyk M, Fairman N, Romano PS, et al. A framework for assessing reasoning about controversial end-of-
life clinical decisions. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/framework-assessing-reasonin…
-
psnet.ahrq.gov/perspective/diagnostic-errors-new-chapter-patient-safety-science-policy-and-practice
January 01, 2016 - Those are all higher levels of cognition that need to be and I think could easily be assessed.
-
psnet.ahrq.gov/print/pdf/node/867659
July 10, 2024 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Rapid Response Systems
Curated Library
Primers
Rapid Response Systems
UC Davis PSNet Editorial Team | September, 15 2024
Rapid response teams represent an intuitively simple concept: when a patient demonstrates signs of
imminent clinical de…
-
psnet.ahrq.gov/node/33604/psn-pdf
December 15, 2024 - Pharmacist's Role in Medication Safety
December 15, 2024
The Pharmacist's Role in Medication Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/pharmacists-role-medication-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current res…
-
psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event
July 01, 2017 - SPOTLIGHT CASE
“This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event
Citation Text:
Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Dep…
-
psnet.ahrq.gov/node/72911/psn-pdf
March 15, 2021 - The Impact of Communication on Medication Errors
March 15, 2021
Branch J, Hiner D, Jackson V. The Impact of Communication on Medication Errors. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/impact-communication-medication-errors
The Case
A 93-year-old man with a history of chronic systolic heart failure…
-
psnet.ahrq.gov/web-mm/room-without-orders
September 01, 2011 - SPOTLIGHT CASE
A Room Without Orders
Citation Text:
Vogelsmeier A, Despins L. A Room Without Orders. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3…
-
psnet.ahrq.gov/web-mm/failure-ensure-patient-safety-leads-patient-falls-nursing-homes
August 14, 2024 - SPOTLIGHT CASE
Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes.
Citation Text:
Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servic…
-
psnet.ahrq.gov/sites/default/files/2023-04/failure_to_ensure_patient_safety_leads_to_patient_falls_in_nursing_homes.pdf
January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight_Falls in Skilled Nursing Units_04.12.2023.pptx
Spotlight
Failure to Ensure Patient Safety Leads to Patient Falls in
Nursing Homes
Source and Credits
• This presentation is based on the April 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/we…
-
psnet.ahrq.gov/node/60268/psn-pdf
April 29, 2020 - Complications of ECMO During Transport
April 29, 2020
Broman M. Complications of ECMO During Transport. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/complications-ecmo-during-transport
The Case
A 54-year-old woman with end-stage chronic obstructive pulmonary disease (COPD) was admitted with
acute on chro…
-
psnet.ahrq.gov/node/33859/psn-pdf
June 01, 2018 - In Conversation With… Richard Hoppmann, MD
June 1, 2018
In Conversation With… Richard Hoppmann, MD. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/conversation-richard-hoppmann-md
Editor's note: Dr. Hoppmann is the Dorothea H. Krebs Endowed Chair of Ultrasound Education, Professor
of Medicine, and Dire…