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psnet.ahrq.gov/issue/comparing-errors-ed-computer-assisted-vs-conventional-pediatric-drug-dosing-and
November 22, 2017 - Study
Comparing errors in ED computer-assisted vs conventional pediatric drug dosing and administration.
Citation Text:
Yamamoto LG, Kanemori J. Comparing errors in ED computer-assisted vs conventional pediatric drug dosing and administration. Am J Emerg Med. 2010;28(5):588-92. doi:10.…
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psnet.ahrq.gov/issue/family-perceptions-medication-administration-school-errors-risk-factors-and-consequences
April 24, 2018 - Study
Family perceptions of medication administration at school: errors, risk factors, and consequences.
Citation Text:
Clay D, Farris K, McCarthy AM, et al. Family perceptions of medication administration at school: errors, risk factors, and consequences. J Sch Nurs. 2008;24(2):95-102…
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psnet.ahrq.gov/issue/consensus-bundle-prevention-surgical-site-infections-after-major-gynecologic-surgery
January 15, 2014 - Commentary
Consensus bundle on prevention of surgical site infections after major gynecologic surgery.
Citation Text:
Pellegrini JE, Toledo P, Soper DE, et al. Consensus Bundle on Prevention of Surgical Site Infections After Major Gynecologic Surgery. Obstet Gynecol. 2017;129(1):50-61. d…
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psnet.ahrq.gov/issue/errors-administration-intravenous-medications-hospital-and-role-correct-procedures-and-nurse
September 26, 2016 - Study
Errors in the administration of intravenous medications in hospital and the role of correct procedures and nurse experience.
Citation Text:
Westbrook JI, Rob MI, Woods A, et al. Errors in the administration of intravenous medications in hospital and the role of correct procedures a…
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psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-comparison-two-common-risk-prioritisation-methods
September 09, 2015 - Study
Failure mode and effects analysis: a comparison of two common risk prioritisation methods.
Citation Text:
McElroy LM, Khorzad R, Nannicelli AP, et al. Failure mode and effects analysis: a comparison of two common risk prioritisation methods. BMJ Qual Saf. 2016;25(5):329-336. doi:10…
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psnet.ahrq.gov/issue/root-cause-analysis-reported-patient-falls-ors-veterans-health-administration
January 17, 2019 - Commentary
Root cause analysis of reported patient falls in ORs in the Veterans Health Administration.
Citation Text:
Soncrant CM, Warner LJ, Neily J, et al. Root Cause Analysis of Reported Patient Falls in ORs in the Veterans Health Administration. AORN J. 2018;108(4):386-397. doi:10.10…
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psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd-0
October 01, 2010 - Adhere to basic usability guidelines. … Basic usability guidelines improve human perception and expectancy of the task steps. … checklist embraced human factors principles, which helped user perception, they later learned that basic
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psnet.ahrq.gov/issue/triad-vii-do-prehospital-providers-understand-physician-orders-life-sustaining-treatment
September 15, 2021 - Study
TRIAD VII: do prehospital providers understand Physician Orders for Life-Sustaining Treatment documents?
Citation Text:
Mirarchi FL, Cammarata C, Zerkle SW, et al. TRIAD VII: do prehospital providers understand Physician Orders for Life-Sustaining Treatment documents? J Patient Saf…
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psnet.ahrq.gov/issue/adherence-surgical-care-improvement-project-measures-and-association-postoperative-infections
November 25, 2020 - Study
Classic
Adherence to Surgical Care Improvement Project measures and the association with postoperative infections.
Citation Text:
Stulberg JJ, Delaney CP, Neuhauser D, et al. Adherence to surgical care improvement project measures and the association wit…
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psnet.ahrq.gov/issue/interprofessional-clinical-event-debriefing-does-it-make-difference-attitudes-emergency
April 06, 2022 - Study
Interprofessional clinical event debriefing-does it make a difference? Attitudes of emergency department care providers to INFO clinical event debriefings.
Citation Text:
Rose SC, Ashari NA, Davies JM, et al. Interprofessional clinical event debriefing-does it make a difference? At…
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psnet.ahrq.gov/node/33732/psn-pdf
July 01, 2012 - We already have a substantial number of hospitals, a third with basic electronic health
records. … I
am finding that some of the basic skills and requirements that pertain in public policy also pertain
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psnet.ahrq.gov/issue/impact-nursing-led-intervention-bundle-bedside-checklist-reduce-mortality-during-initial
May 05, 2010 - Study
The impact of a nursing-led intervention bundle with a bedside checklist to reduce mortality during the initial COVID-19 pandemic and implications for future emergencies.
Citation Text:
Pugh S, Chan F, Han S, et al. The impact of a nursing-led intervention bundle with a bedside che…
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psnet.ahrq.gov/issue/designing-distractions-human-factors-approach-decreasing-interruptions-centralised-medication
July 27, 2018 - Study
Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication station.
Citation Text:
Colligan L, Guerlain S, Steck SE, et al. Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication…
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psnet.ahrq.gov/issue/are-temporary-staff-associated-more-severe-emergency-department-medication-errors
June 29, 2011 - Study
Are temporary staff associated with more severe emergency department medication errors?
Citation Text:
Pham JC, Andrawis M, Shore AD, et al. Are temporary staff associated with more severe emergency department medication errors? J Healthc Qual. 2011;33(4):9-18. doi:10.1111/j.1945…
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psnet.ahrq.gov/issue/risk-factors-retained-instruments-and-sponges-after-surgery
February 17, 2011 - Study
Classic
Risk factors for retained instruments and sponges after surgery.
Citation Text:
Gawande AA, Studdert DM, Orav J, et al. Risk factors for retained instruments and sponges after surgery. N Engl J Med. 2003;348(3):229-35.
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Format:…
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psnet.ahrq.gov/issue/centers-disease-control-and-prevention-guideline-prevention-surgical-site-infection-2017
June 27, 2018 - Review
Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017.
Citation Text:
Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JA…
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psnet.ahrq.gov/node/49587/psn-pdf
May 01, 2009 - PHTLS: Basic and Advanced Prehospital Trauma Life Support. 5th ed. St Louis, MO: Mosby;
2003.
4.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.76_slideshow.ppt
October 01, 2004 - New York, NY: Basic Books; 1988.
Engineered Safety Devices (cont.)
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psnet.ahrq.gov/node/49770/psn-pdf
September 01, 2016 - Wrong-Time Error With High-Alert Medication
September 1, 2016
Yang A, Nelson LS. Wrong-Time Error With High-Alert Medication. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/wrong-time-error-high-alert-medication
The Case
A 60-year-old man was admitted to the hospital for a total knee arthroplasty. During th…
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psnet.ahrq.gov/web-mm/costly-colonoscopy-leads-delay-diagnosis
September 01, 2014 - future medical, dental, or psychiatric care, or if they reduce spending on food, clothing, and other basic … case cost more than $6000, resulting in a 30% copay of $2000, whereas in other developed countries, a basic