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psnet.ahrq.gov/node/42748/psn-pdf
November 20, 2013 - Effectiveness of written hospitalist sign-outs in answering
overnight inquiries.
November 20, 2013
Fogerty RL, Schoenfeld A, Al-Damluji MS, et al. Effectiveness of written hospitalist sign-outs in answering
overnight inquiries. J Hosp Med. 2013;8(11):609-14. doi:10.1002/jhm.2090.
https://psnet.ahrq.gov/issue/effec…
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psnet.ahrq.gov/node/43969/psn-pdf
November 17, 2017 - Transparency when things go wrong: physician attitudes
about reporting medical errors to patients, peers, and
institutions.
November 17, 2017
Bell SK, White AA, Yi JC, et al. Transparency When Things Go Wrong. J Patient Saf. 2015;13(4):243-248.
doi:10.1097/pts.0000000000000153.
https://psnet.ahrq.gov/issue/transp…
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psnet.ahrq.gov/perspective/conversation-mark-l-graber-md
January 01, 2016 - Those are all higher levels of cognition that need to be and I think could easily be assessed.
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psnet.ahrq.gov/primer/fatigue-sleep-deprivation-and-patient-safety
September 15, 2024 - Fatigue, Sleep Deprivation, and Patient Safety
Citation Text:
Fatigue, Sleep Deprivation, and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/primer/missed-nursing-care
September 15, 2024 - Missed Nursing Care
Citation Text:
Missed Nursing Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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…
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psnet.ahrq.gov/sites/default/files/2020-05/webmm.ahrq_.gov_.392_slideshow.pptx
January 01, 2020 - Spotlight
Spotlight
Suicidal Ideation in the Family Medicine Clinic
1
Source and Credits
This presentation is based on the December 2016
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Christine Moutier, MD, Chief Medical Officer, American …
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psnet.ahrq.gov/web-mm/charcoal-lavage-lungs
January 01, 2016 - Charcoal Lavage of the Lungs
Citation Text:
Wigton RS. Charcoal Lavage of the Lungs. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/glossary/handoffs-and-handovers
September 13, 2021 - Handoffs and Handovers
September 13, 2021
Anonymous (not verified)
See Primer . The process when one health care professional updates another on the status of one or more patients for the purpose of taking over their care. Typical examples involve a physician who has been on call overnight telling an incoming …
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psnet.ahrq.gov/node/42855/psn-pdf
February 06, 2014 - Responding to clinicians who fail to follow patient safety
practices: perceptions of physicians, nurses, trainees,
and patients.
February 6, 2014
Driver TH, Katz PP, Trupin L, et al. Responding to clinicians who fail to follow patient safety practices:
perceptions of physicians, nurses, trainees, and patients. J H…
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psnet.ahrq.gov/node/46956/psn-pdf
January 23, 2019 - Impact of a national QI programme on reducing electronic
health record notifications to clinicians.
January 23, 2019
Shah T, Patel-Teague S, Kroupa L, et al. Impact of a national QI programme on reducing electronic health
record notifications to clinicians. BMJ Qual Saf. 2018;28(1):10-14. doi:10.1136/bmjqs-2017-007…
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psnet.ahrq.gov/node/42091/psn-pdf
December 31, 2014 - Reduction in medication errors in hospitals due to
adoption of computerized provider order entry systems.
December 31, 2014
Radley DC, Wasserman MR, Olsho LE, et al. Reduction in medication errors in hospitals due to adoption of
computerized provider order entry systems. J Am Med Info Asso. 2013;20(3):470-476. doi:…
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psnet.ahrq.gov/node/40618/psn-pdf
August 27, 2012 - Predictors of likelihood of speaking up about safety
concerns in labour and delivery.
August 27, 2012
Lyndon A, Sexton B, Simpson KR, et al. Correction. BMJ Qual Saf. 2011;22(2):791-799.
doi:10.1136/bmjqs.2010.050211.
https://psnet.ahrq.gov/issue/predictors-likelihood-speaking-about-safety-concerns-labour-and-deli…
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psnet.ahrq.gov/node/46902/psn-pdf
August 20, 2018 - Making soft intelligence hard: a multi-site qualitative
study of challenges relating to voice about safety
concerns.
August 20, 2018
Martin G, Aveling E-L, Campbell A, et al. Making soft intelligence hard: a multi-site qualitative study of
challenges relating to voice about safety concerns. BMJ Qual Saf. 2018;27(9…
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psnet.ahrq.gov/node/45167/psn-pdf
May 25, 2016 - AHRQ Communication and Optimal Resolution (CANDOR)
Toolkit.
May 25, 2016
Rockville, MD: Agency for Healthcare Research and Quality; May 2016.
https://psnet.ahrq.gov/issue/ahrq-communication-and-optimal-resolution-candor-toolkit
Traditionally, health systems have disclosed adverse events to patients only through a …
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psnet.ahrq.gov/node/41446/psn-pdf
June 13, 2012 - Concept and development of a discharge alert filter for
abnormal laboratory values coupled with computerized
provider order entry: a tool for quality improvement and
hospital risk management.
June 13, 2012
Mathew G, Kho A, Dexter P, et al. Concept and development of a discharge alert filter for abnormal
laborator…
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psnet.ahrq.gov/node/41212/psn-pdf
March 14, 2012 - A comprehensive overview of medical error in hospitals
using incident-reporting systems, patient complaints and
chart review of inpatient deaths.
March 14, 2012
de Feijter JM, de Grave WS, Muijtjens AM, et al. A comprehensive overview of medical error in hospitals
using incident-reporting systems, patient complain…
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psnet.ahrq.gov/node/46493/psn-pdf
January 24, 2019 - Four states with robust prescription drug monitoring
programs reduced opioid dosages.
January 24, 2019
Haffajee RL, Mello MM, Zhang F, et al. Four States With Robust Prescription Drug Monitoring Programs
Reduced Opioid Dosages. Health Aff (Millwood). 2018;37(6):964-974. doi:10.1377/hlthaff.2017.1321.
https://psnet…
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psnet.ahrq.gov/node/47471/psn-pdf
January 27, 2019 - Association of cataract surgical outcomes with late
surgeon career stages: a population-based cohort study.
January 27, 2019
Campbell RJ, El-Defrawy SR, Gill SS, et al. Association of Cataract Surgical Outcomes With Late Surgeon
Career Stages: A Population-Based Cohort Study. JAMA Ophthalmol. 2019;137(1):58-64.
do…
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psnet.ahrq.gov/issue/core-elements-hospital-diagnostic-excellence-dxex
April 26, 2023 - Multi-use Website
Core Elements of Hospital Diagnostic Excellence (DxEx).
Citation Text:
Core Elements of Hospital Diagnostic Excellence (DxEx). Centers for Disease Control and Prevention.
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psnet.ahrq.gov/node/46975/psn-pdf
November 16, 2018 - Electronic health record usability issues and potential
contribution to patient harm.
November 16, 2018
Howe JL, Adams KT, Hettinger Z, et al. Electronic Health Record Usability Issues and Potential
Contribution to Patient Harm. JAMA. 2018;319(12):1276-1278. doi:10.1001/jama.2018.1171.
https://psnet.ahrq.gov/issue…