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psnet.ahrq.gov/issue/leading-successful-rapid-response-teams-multisite-implementation-evaluation
August 04, 2010 - Image/Poster
Leading successful rapid response teams: a multisite implementation evaluation.
Citation Text:
Donaldson N, Shapiro S, Scott M, et al. Leading successful rapid response teams: A multisite implementation evaluation. J Nurs Adm. 2009;39(4):176-81. doi:10.1097/NNA.0b013e31819…
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psnet.ahrq.gov/issue/incivility-and-clinical-performance-teamwork-and-emotions-randomized-controlled-trial
May 22, 2013 - Study
Incivility and clinical performance, teamwork, and emotions: a randomized controlled trial.
Citation Text:
Johnson SL, Haerling KA, Yuwen W, et al. Incivility and Clinical Performance, Teamwork, and Emotions: A Randomized Controlled Trial. J Nurs Care Qual. 2020;35(1):70-76. doi:10…
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psnet.ahrq.gov/issue/immersive-high-fidelity-simulation-critically-ill-patients-study-cognitive-errors-pilot-study
August 15, 2018 - Study
Immersive high fidelity simulation of critically ill patients to study cognitive errors: a pilot study.
Citation Text:
Prakash S, Bihari S, Need P, et al. Immersive high fidelity simulation of critically ill patients to study cognitive errors: a pilot study. BMC Med Educ. 2017;17(1…
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psnet.ahrq.gov/issue/crew-resource-management-improved-perception-patient-safety-operating-room
April 27, 2010 - Study
Crew resource management improved perception of patient safety in the operating room.
Citation Text:
Gore DC, Powell JM, Baer JG, et al. Crew resource management improved perception of patient safety in the operating room. Am J Med Qual. 2010;25(1):60-3. doi:10.1177/1062860609351…
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psnet.ahrq.gov/issue/teamgains-tool-structured-debriefings-simulation-based-team-trainings
October 08, 2016 - Study
TeamGAINS: a tool for structured debriefings for simulation-based team trainings.
Citation Text:
Kolbe M, Weiss M, Grote G, et al. TeamGAINS: a tool for structured debriefings for simulation-based team trainings. BMJ Qual Saf. 2013;22(7):541-53. doi:10.1136/bmjqs-2012-000917.
Co…
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psnet.ahrq.gov/node/33621/psn-pdf
November 01, 2005 - Rapid Response Teams: Lessons from the Early
Experience
November 1, 2005
Krimsky WS. Rapid Response Teams: Lessons from the Early Experience. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/rapid-response-teams-lessons-early-experience
Perspective
Health care organizations throughout the world have ide…
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psnet.ahrq.gov/node/49805/psn-pdf
September 01, 2017 - The Forgotten Radiographic Read
September 1, 2017
Coil CJ, Witt MD. The Forgotten Radiographic Read. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/forgotten-radiographic-read
The Case
A 60-year-old woman with peripheral artery disease and chronic mesenteric ischemia was admitted for
management of inferior…
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psnet.ahrq.gov/node/866826/psn-pdf
September 25, 2024 - Hypoxic Gas Supply from Cross-Connected Pipelines
September 25, 2024
Bohringer C, Guemidjian A, Utter G. Hypoxic Gas Supply from Cross-Connected Pipelines. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/web-mm/hypoxic-gas-supply-cross-connected-pipelines
The Case
An 8-year-old boy with no significant past medical…
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psnet.ahrq.gov/issue/does-patient-centered-design-guarantee-patient-safety-using-human-factors-engineering-find
November 23, 2016 - Study
Does patient-centered design guarantee patient safety?: Using human factors engineering to find a balance between provider and patient needs.
Citation Text:
France DJ, Throop P, Walczyk B, et al. Does Patient-Centered Design Guarantee Patient Safety? J Patient Saf. 2008;1(3):145-15…
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psnet.ahrq.gov/issue/effect-illness-severity-and-comorbidity-patient-safety-and-adverse-events
December 01, 2011 - Study
Effect of illness severity and comorbidity on patient safety and adverse events.
Citation Text:
Naessens JM, Campbell CR, Shah ND, et al. Effect of illness severity and comorbidity on patient safety and adverse events. Am J Med Qual. 2012;27(1):48-57. doi:10.1177/1062860611413456…
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psnet.ahrq.gov/issue/failure-engage-hospitalized-elderly-patients-and-their-families-advance-care-planning
November 21, 2016 - Study
Classic
Failure to engage hospitalized elderly patients and their families in advance care planning.
Citation Text:
Heyland DK, Barwich D, Pichora D, et al. Failure to engage hospitalized elderly patients and their families in advance care planning. JAMA I…
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psnet.ahrq.gov/issue/clinical-triggers-alternative-rapid-response-team
December 21, 2014 - Study
Clinical triggers: an alternative to a rapid response team.
Citation Text:
Moldenhauer K, Sabel A, Chu ES, et al. Clinical triggers: an alternative to a rapid response team. Jt Comm J Qual Patient Saf. 2009;35(3):164-74.
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Format:
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psnet.ahrq.gov/issue/intensive-care-unit-nurses-information-needs-and-recommendations-integrated-displays-improve
March 01, 2011 - Study
Intensive care unit nurses' information needs and recommendations for integrated displays to improve nurses' situation awareness.
Citation Text:
Koch SH, Weir C, Haar M, et al. Intensive care unit nurses' information needs and recommendations for integrated displays to improve nurs…
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psnet.ahrq.gov/issue/wellbeing-burnout-and-safe-practice-among-healthcare-professionals-predictive-influences
December 01, 2011 - Study
Wellbeing, burnout, and safe practice among healthcare professionals: predictive influences of mindfulness, values, and self-compassion.
Citation Text:
Prudenzi A, D. Graham C, Flaxman PE, et al. Wellbeing, burnout, and safe practice among healthcare professionals: predictive influ…
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psnet.ahrq.gov/node/33562/psn-pdf
September 15, 2024 - Rapid Response Systems
September 15, 2024
Rapid Response Systems. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/rapid-response-systems
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field.…
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psnet.ahrq.gov/issue/simulation-based-assessment-management-critical-events-board-certified-anesthesiologists
February 19, 2010 - Study
Simulation-based assessment of the management of critical events by board-certified anesthesiologists.
Citation Text:
Weinger MB, Banerjee A, Burden AR, et al. Simulation-based assessment of the management of critical events by board-certified anesthesiologists. Anesthesiology. 201…
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psnet.ahrq.gov/innovation/awareness-human-factors-operating-theatres-during-covid-19-pandemic
January 13, 2021 - EMERGING INNOVATIONS
Awareness of human factors in the operating theatres during the COVID-19 pandemic
Citation Text:
Britton CR, Hayman G, Stroud N. Awareness of Human Factors in the operating theatres during the COVID-19 pandemic. Journal of Perioperative Practice. 2020;31(1-2). doi:10.1177/1750…
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psnet.ahrq.gov/web-mm/hypoxic-gas-supply-cross-connected-pipelines
February 05, 2020 - Hypoxic Gas Supply from Cross-Connected Pipelines
Citation Text:
Bohringer C, Guemidjian A, Utter G. Hypoxic Gas Supply from Cross-Connected Pipelines. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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Format:
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.155_slideshow.ppt
July 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case July 2007
Resuscitation Errors:
A Shocking Problem
Source and Credits
This presentation is based on the July 2007
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available online
Commentary by: Benjamin Abella, MD, MPhil, …
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psnet.ahrq.gov/innovation/michigan-hospital-medicine-safety-consortium-hms-finds-infectious-diseases-id-physician
July 23, 2024 - The Michigan Hospital Medicine Safety Consortium (HMS) Finds Infectious Diseases (ID) Physician Approval for Placement of Peripherally Inserted Central Catheters (PICCs) Prevents Unnecessary PICC Use and Reduces Complications
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