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psnet.ahrq.gov/perspective/health-equity-and-maternal-health
October 06, 2021 - However, when assessing maternal safety, it is also essential to also take a whole-person view. … from the patient’s entry point into the hospital and then through all of the steps of the process and assessing
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psnet.ahrq.gov/perspective/conversation-withalison-stuebe-md-msc-and-kristin-tully-phd
October 06, 2021 - from the patient’s entry point into the hospital and then through all of the steps of the process and assessing … However, when assessing maternal safety, it is also essential to also take a whole-person view.
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psnet.ahrq.gov/node/863650/psn-pdf
February 28, 2024 - ABCDEF Bundle + Data Literacy Training, Performance
Measurement Tracking, and Performance Feedback
February 28, 2024
https://psnet.ahrq.gov/innovation/abcdef-bundle-data-literacy-training-performance-measurement-tracking-
and-performance
Summary
To improve patient care and outcomes in the intensive care unit (ICU…
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psnet.ahrq.gov/primer/deprescribing-patient-safety-strategy
December 15, 2024 - Deprescribing as a Patient Safety Strategy
Citation Text:
Takhar S, Nelson N. Deprescribing as a Patient Safety Strategy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/node/33736/psn-pdf
September 01, 2012 - In Conversation With… Jack Needleman, PhD
September 1, 2012
In Conversation With… Jack Needleman, PhD. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-jack-needleman-phd
Editor's note: Jack Needleman, PhD, is a Professor in the Department of Health Policy and Management
at UCLA School of P…
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psnet.ahrq.gov/node/33806/psn-pdf
April 01, 2016 - In Conversation With… Amy J. Starmer, MD, MPH
April 1, 2016
In Conversation With… Amy J. Starmer, MD, MPH. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-amy-j-starmer-md-mph
Editor's note: Dr. Starmer is Director of Primary Care Quality Improvement and Assistant Professor of
Pediatrics a…
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psnet.ahrq.gov/web-mm/july-syndrome
July 01, 2011 - July Syndrome
Citation Text:
Young JQ. July Syndrome. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
D…
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psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_stable_airway_slides_final.pptx
January 01, 2024 - Spotlight
Spotlight
A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care
1
Source and Credits
This presentation is based on the May 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Elizabeth Gould, NP-C, COR…
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psnet.ahrq.gov/web-mm/hyperbilirubinemia-refractory-phototherapy
March 01, 2006 - Hyperbilirubinemia Refractory to Phototherapy
Citation Text:
Bhutani VK, Wong RJ. Hyperbilirubinemia Refractory to Phototherapy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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Format:
Google Scholar …
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psnet.ahrq.gov/node/39975/psn-pdf
March 03, 2011 - Communication failure in the operating room.
March 3, 2011
Halverson AL, Casey JT, Andersson J, et al. Communication failure in the operating room. Surgery.
2011;149(3):305-310. doi:10.1016/j.surg.2010.07.051.
https://psnet.ahrq.gov/issue/communication-failure-operating-room
Communication failures are a well-chara…
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psnet.ahrq.gov/node/44947/psn-pdf
November 18, 2016 - Impact of the 2011 ACGME resident duty hour reform on
hospital patient experience and processes-of-care.
November 18, 2016
Rajaram R, Saadat L, Chung JW, et al. Impact of the 2011 ACGME resident duty hour reform on hospital
patient experience and processes-of-care. BMJ Qual Saf. 2016;25(12):962-970. doi:10.1136/bmj…
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psnet.ahrq.gov/node/74102/psn-pdf
January 01, 2022 - Workforce planning and safe workload in sterile
compounding hospital pharmacy services.
November 24, 2021
Chaker A, Omair I, Mohamed WH, et al. Workforce planning and safe workload in sterile compounding
hospital pharmacy services. Am J Health Syst Pharm. 2022;79(3):187–192. doi:10.1093/ajhp/zxab379.
https://psnet…
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psnet.ahrq.gov/node/35805/psn-pdf
January 02, 2017 - Getting the board on board: engaging hospital boards in
quality and patient safety.
January 2, 2017
Joshi MS, Hines S. Getting the board on board: Engaging hospital boards in quality and patient safety. Jt
Comm J Qual Patient Saf. 2006;32(4):179-87.
https://psnet.ahrq.gov/issue/getting-board-board-engaging-hospita…
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psnet.ahrq.gov/node/45848/psn-pdf
November 19, 2018 - New Horizons in Patient Safety: Understanding
Communication: Case Studies for Physicians.
November 19, 2018
Hannawa AF, Wu AW, Juhasz RS, eds. Berlin, Germany: DeGruyter; 2017. ISBN: 9783110455014.
https://psnet.ahrq.gov/issue/new-horizons-patient-safety-understanding-communication-case-studies-
physicians
Poor c…
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psnet.ahrq.gov/node/46530/psn-pdf
February 03, 2018 - Identifying and characterizing preventable adverse drug
events for prioritizing pharmacist intervention in
hospitals.
February 3, 2018
Jeon N, Staley B, Johns T, et al. Identifying and characterizing preventable adverse drug events for
prioritizing pharmacist intervention in hospitals. Am J Health Syst Pharm. 2017…
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psnet.ahrq.gov/node/60359/psn-pdf
May 20, 2020 - Incorrect use of smart infusion pump in the operating
room (OR) leads to milrinone overdose.
May 20, 2020
ISMP Medication Safety Alert! Acute care edition. May 7, 2020;25(9).
https://psnet.ahrq.gov/issue/incorrect-use-smart-infusion-pump-operating-room-or-leads-milrinone-
overdose
Lack of familiarity with sm…
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psnet.ahrq.gov/node/46388/psn-pdf
September 24, 2017 - Recognizing and responding to the "toxic" work
environment: worker safety, patient safety, and
abuse/neglect in nursing homes.
September 24, 2017
Pickering CEZ, Nurenberg K, Schiamberg L. Recognizing and Responding to the "Toxic" Work
Environment: Worker Safety, Patient Safety, and Abuse/Neglect in Nursing Homes. …
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psnet.ahrq.gov/node/865583/psn-pdf
April 17, 2024 - Impact of repeated reimbursement penalties on hospital
total quality scores.
April 17, 2024
Brewer A, Hughes MC, Patel KN. Impact of repeated reimbursement penalties on hospital total quality
scores. J Patient Saf. 2024;20(3):198-201. doi:10.1097/pts.0000000000001199.
https://psnet.ahrq.gov/issue/impact-repeated-r…
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psnet.ahrq.gov/node/72600/psn-pdf
December 23, 2020 - Improving hospital safety culture for falls prevention
through interdisciplinary health education.
December 23, 2020
Lopez-Jeng C, Eberth SD. Improving hospital safety culture for falls prevention through interdisciplinary
health education. Health Promot Pract. 2020;21(6):918-925. doi:10.1177/1524839919840337.
htt…
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psnet.ahrq.gov/node/47400/psn-pdf
November 28, 2018 - Impact of the communication and patient hand-off tool
SBAR on patient safety: a systematic review.
November 28, 2018
Müller M, Jürgens J, Redaèlli M, et al. Impact of the communication and patient hand-off tool SBAR on
patient safety: a systematic review. BMJ Open. 2018;8(8):e022202. doi:10.1136/bmjopen-2018-022202…