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psnet.ahrq.gov/issue/implementation-cpoe-and-medication-errors
July 18, 2012 - Commentary
Implementation, CPOE, and medication errors.
Citation Text:
Bradley V. Implementation, CPOE, and medication errors. Comput Inform Nurs. 2005;23(3):113-114, 138.
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psnet.ahrq.gov/issue/graphical-display-diagnostic-test-results-electronic-health-records-comparison-8-systems
November 11, 2020 - Study
Graphical display of diagnostic test results in electronic health records: a comparison of 8 systems.
Citation Text:
Sittig DF, Murphy DR, Smith MW, et al. Graphical display of diagnostic test results in electronic health records: a comparison of 8 systems. J Am Med Inform Assoc. 2…
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psnet.ahrq.gov/issue/economic-burden-nurse-sensitive-adverse-events-22-medical-surgical-units-retrospective-and
December 15, 2021 - Study
The economic burden of nurse-sensitive adverse events in 22 medical-surgical units: retrospective and matching analysis.
Citation Text:
Tchouaket E, Dubois C-A, D'Amour D. The economic burden of nurse-sensitive adverse events in 22 medical-surgical units: retrospective and matching…
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psnet.ahrq.gov/issue/causes-adverse-events-home-mechanical-ventilation-nursing-perspective
November 10, 2021 - Study
Causes of adverse events in home mechanical ventilation: a nursing perspective.
Citation Text:
Lipprandt M, Liedtke W, Langanke M, et al. Causes of adverse events in home mechanical ventilation: a nursing perspective. BMC Nurs. 2022;21(1):264. doi:10.1186/s12912-022-01038-2.
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psnet.ahrq.gov/issue/whatever-you-cut-i-can-fix-it-clinical-supervisors-interview-accounts-allowing-trainee
November 24, 2021 - Study
'Whatever you cut, I can fix it': clinical supervisors' interview accounts of allowing trainee failure while guarding patient safety.
Citation Text:
Klasen JM, Driessen E, Teunissen PW, et al. ‘Whatever you cut, I can fix it’: clinical supervisors’ interview accounts of allowing t…
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psnet.ahrq.gov/issue/exploring-nurses-attitudes-skills-and-beliefs-medication-safety-practices
October 21, 2020 - Study
Exploring nurses' attitudes, skills, and beliefs of medication safety practices.
Citation Text:
Arkin L, Schuermann A, Penoyer D, et al. Exploring nurses' attitudes, skills, and beliefs of medication safety practices. J Nurs Care Qual. 2022;37(4):319-326. doi:10.1097/ncq.0000000000…
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psnet.ahrq.gov/issue/evaluating-horizontal-violence-and-bullying-nursing-workforce-oncology-academic-medical
February 24, 2021 - Study
Evaluating horizontal violence and bullying in the nursing workforce of an oncology academic medical center.
Citation Text:
Lewis-Pierre LT, Anglade D, Saber D, et al. Evaluating horizontal violence and bullying in the nursing workforce of an oncology academic medical center. J Nur…
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psnet.ahrq.gov/issue/predicting-avoidable-hospital-events-maryland
April 06, 2022 - Study
Predicting avoidable hospital events in Maryland.
Citation Text:
Henderson M, Han F, Perman C, et al. Predicting avoidable hospital events in Maryland. Health Serv Res. 2022;57(1):192-199. doi:10.1111/1475-6773.13891.
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psnet.ahrq.gov/issue/unveiling-hidden-struggle-healthcare-students-second-victims-through-systematic-review
September 06, 2023 - Review
Unveiling the hidden struggle of healthcare students as second victims through a systematic review.
Citation Text:
Mira JJ, Matarredona V, Tella S, et al. Unveiling the hidden struggle of healthcare students as second victims through a systematic review. BMC Med Educ. 2024;24(1):3…
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psnet.ahrq.gov/issue/barriers-and-enablers-nurses-use-harm-prevention-strategies-older-patients-hospital-cross
August 10, 2022 - Study
Barriers and enablers to nurses' use of harm prevention strategies for older patients in hospital: a cross-sectional survey.
Citation Text:
Redley B, Taylor N, Hutchinson A. Barriers and enablers to nurses' use of harm prevention strategies for older patients in hospital: a cross‐s…
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psnet.ahrq.gov/issue/effects-hospital-physician-financial-integration-adverse-incident-rate-agency-theory
August 10, 2022 - Study
The effects of hospital-physician financial integration on adverse incident rate: an agency theory perspective.
Citation Text:
Upadhyay S, Weech-Maldonado R, Opoku-Agyeman W. The effects of hospital-physician financial integration on adverse incident rate: an agency theory perspect…
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psnet.ahrq.gov/issue/principles-automation-patient-safety-intensive-care-learning-aviation
April 20, 2022 - Commentary
Principles of automation for patient safety in intensive care: learning from aviation.
Citation Text:
Dominiczak J, Khansa L. Principles of Automation for Patient Safety in Intensive Care: Learning From Aviation. Jt Comm J Qual Patient Saf. 2018;44(6):366-371. doi:10.1016/j.jc…
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psnet.ahrq.gov/issue/medication-reconciliation-improvement-utilizing-process-redesign-and-clinical-decision
November 16, 2022 - Study
Medication reconciliation improvement utilizing process redesign and clinical decision support.
Citation Text:
Rungvivatjarus T, Kuelbs CL, Miller L, et al. Medication Reconciliation Improvement Utilizing Process Redesign and Clinical Decision Support. Jt Comm J Qual Patient Saf. …
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psnet.ahrq.gov/issue/patient-safety-when-receiving-telephone-advice-primary-care-swedish-qualitative-interview
October 13, 2021 - Study
Patient safety when receiving telephone advice in primary care - a Swedish qualitative interview study.
Citation Text:
Berntsson K, Eliasson M, Beckman L. Patient safety when receiving telephone advice in primary care – a Swedish qualitative interview study. BMC Nurs. 2022;21(1):24…
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psnet.ahrq.gov/issue/enabling-sustained-communication-patients-safe-and-effective-management-oral-chemotherapy
October 14, 2020 - Study
Enabling sustained communication with patients for safe and effective management of oral chemotherapy: a longitudinal ethnography.
Citation Text:
Mitchell G, Porter S, Manias E. Enabling sustained communication with patients for safe and effective management of oral chemotherapy: a…
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psnet.ahrq.gov/issue/methodological-approaches-analyzing-medication-error-reports-patient-safety-reporting-systems
May 11, 2022 - Review
Methodological approaches for analyzing medication error reports in patient safety reporting systems: a scoping review.
Citation Text:
Tchijevitch O, Hansen SM-B, Hallas J, et al. Methodological approaches for analyzing medication error reports in patient safety reporting systems:…
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psnet.ahrq.gov/issue/analysis-critical-incident-reports-using-natural-language-processing
June 14, 2023 - Study
Analysis of critical incident reports using natural language processing.
Citation Text:
Denecke K, Paula H. Analysis of critical incident reports using natural language processing. Stud Health Technol Inform. 2024;313:1-6. doi:10.3233/shti240002.
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psnet.ahrq.gov/node/49730/psn-pdf
April 01, 2015 - Transition to Nowhere
April 1, 2015
Farrell TW. Transition to Nowhere. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/transition-nowhere
The Case
A 75-year-old man with a history of prostate cancer, poorly controlled myotonic dystrophy, hypertension,
and chronic kidney disease was admitted to the hospital …
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psnet.ahrq.gov/sites/default/files/2020-10/final_slides_oct_2020_spotlight_case_inpt_stroke_mngt_in_adolescent_with_type1_diabetes.pdf
January 01, 2020 - Spotlight
Spotlight
Inpatient Stroke Management in a Patient
with Type 1 Diabetes and Home Insulin
Pump
Source and Credits
• This presentation is based on the October 2020 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Berit B…
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psnet.ahrq.gov/web-mm/fatal-error-neonate-does-just-culture-provide-answer
June 24, 2020 - SPOTLIGHT CASE
Fatal Error in Neonate: Does "Just Culture" Provide an Answer?
Citation Text:
Dekker SWA. Fatal Error in Neonate: Does "Just Culture" Provide an Answer?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. …