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psnet.ahrq.gov/node/35015/psn-pdf
June 16, 2011 - Keeping Patients Safe: Transforming the Work
Environment of Nurses.
June 16, 2011
Page A; Committee on the Work Environment for Nurses and Patient Safety, Board on Health Care
Services. Washington, DC: The National Academies Press; 2004. ISBN: 9780309090674.
https://psnet.ahrq.gov/issue/keeping-patients-safe-trans…
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psnet.ahrq.gov/node/39559/psn-pdf
December 17, 2010 - Understanding vs. competency: the case of accuracy
checking dispensed medicines in pharmacy.
December 17, 2010
James L, Davies G, Kinchin I, et al. Understanding vs. competency: the case of accuracy checking
dispensed medicines in pharmacy. Adv Health Sci Educ Theory Pract. 2010;15(5):735-47.
doi:10.1007/s10459-01…
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psnet.ahrq.gov/web-mm/electronic-err
April 01, 2014 - acquiring or using EHR systems:
Select electronic health record systems that incorporate the IOM's key capabilities … Key capabilities of an electronic health record system. July 31, 2003.
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psnet.ahrq.gov/node/60049/psn-pdf
March 18, 2020 - Who gets the benefit of the doubt? Performance
evaluations, medical errors, and the production of gender
inequality in emergency medical education.
March 18, 2020
Brewer A, Osborne M, Mueller AS, et al. Who Gets the Benefit of the Doubt? Performance Evaluations,
Medical Errors, and the Production of Gender Inequal…
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psnet.ahrq.gov/node/73517/psn-pdf
July 21, 2021 - Disparate perspectives: exploring healthcare
professionals' misaligned mental models of older adults'
transitions of care between the emergency department
and skilled nursing facility.
July 21, 2021
Werner NE, Rutkowski RA, Krause S, et al. Disparate perspectives: exploring healthcare professionals'
misaligned me…
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psnet.ahrq.gov/node/34755/psn-pdf
September 06, 2011 - Safe Practices for Better Healthcare: 2006 Update.
September 6, 2011
Washington DC: National Quality Forum; 2007.
https://psnet.ahrq.gov/issue/safe-practices-better-healthcare-2006-update
The National Quality Forum used expert consensus and evidence review to identify 30 health care “safe
practices” that should be…
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psnet.ahrq.gov/node/39605/psn-pdf
December 17, 2010 - The effect of facility complexity on perceptions of safety
climate in the operating room: size matters.
December 17, 2010
Carney BT, West P, Neily J, et al. The effect of facility complexity on perceptions of safety climate in the
operating room: size matters. Am J Med Qual. 2010;25(6):457-61. doi:10.1177/106286061…
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psnet.ahrq.gov/node/33809/psn-pdf
June 01, 2016 - As we try to build up our capabilities in patient safety, we need to have a qualified workforce. … in patient safety to see that a certain group has demonstrated that they have this broad range of
capabilities
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psnet.ahrq.gov/node/43925/psn-pdf
December 04, 2015 - More than just crushing: a prospective pre-post
intervention study to reduce drug preparation errors in
patients with feeding tubes.
December 4, 2015
Lohmann K, Gartner D, Kurze R, et al. More than just crushing: a prospective pre-post intervention study to
reduce drug preparation errors in patients with feeding t…
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psnet.ahrq.gov/node/74258/psn-pdf
January 19, 2022 - Care quality, patient safety, and nurse outcomes at
hospitals serving economically disadvantaged patients: a
case for investment in nursing.
January 19, 2022
Viscardi MK, French R, Brom H, et al. Care quality, patient safety, and nurse outcomes at hospitals serving
economically disadvantaged patients: a case for i…
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psnet.ahrq.gov/node/34916/psn-pdf
March 09, 2009 - Using a claims data-based sentinel system to improve
compliance with clinical guidelines: results of a
randomized prospective study.
March 9, 2009
Javitt JC, Steinberg G, Locke T, et al. Using a claims data-based sentinel system to improve compliance
with clinical guidelines: results of a randomized prospective st…
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psnet.ahrq.gov/node/47612/psn-pdf
February 27, 2019 - The impact of computerised physician order entry and
clinical decision support on pharmacist–physician
communication in the hospital setting: a qualitative study.
February 27, 2019
Pontefract SK, Coleman JJ, Vallance HK, et al. The impact of computerised physician order entry and
clinical decision support on pharm…
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psnet.ahrq.gov/print/pdf/node/865308
January 01, 2024 - As knowledge and skills
frequently become outdated, a need to develop new learning capabilities must … As knowledge and skills
frequently become outdated, a need to develop new learning capabilities must
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psnet.ahrq.gov/node/33816/psn-pdf
October 01, 2016 - We have recently begun a PCORI-sponsored effort to
develop and implement governance and technical capabilities
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psnet.ahrq.gov/node/837499/psn-pdf
June 22, 2022 - Relationships between pediatric safety indicators across
a national sample of pediatric hospitals: dispelling the
myth of the "safest" hospital.
June 22, 2022
Milliren CE, Bailey G, Graham DA, et al. Relationships between pediatric safety indicators across a national
sample of pediatric hospitals: dispelling the m…
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psnet.ahrq.gov/node/45350/psn-pdf
October 21, 2016 - A National Trauma Care System: Integrating Military and
Civilian Trauma Systems to Achieve Zero Preventable
Deaths After Injury.
October 21, 2016
National Academies of Sciences, Engineering, and Medicine. Washington, DC: National Academies Press;
2016.
https://psnet.ahrq.gov/issue/national-trauma-care-system-inte…
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psnet.ahrq.gov/node/33715/psn-pdf
July 01, 2011 - our members to understand the implications of these changes and how to best utilize
our skills and capabilities
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psnet.ahrq.gov/web-mm/transfer-or-not-transfer
November 23, 2016 - EMS may have considered Hospital Y the closest appropriate facility because it had better capabilities … For "unstable" patients, EMS policies are designed to match hospital capabilities with patient complaints
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psnet.ahrq.gov/node/41884/psn-pdf
December 21, 2014 - Supratherapeutic dosing of acetaminophen among
hospitalized patients.
December 21, 2014
Zhou L, Maviglia SM, Mahoney LM, et al. Supratherapeutic dosing of acetaminophen among hospitalized
patients. Arch Intern Med. 2012;172(22):1721-8.
https://psnet.ahrq.gov/issue/supratherapeutic-dosing-acetaminophen-among-hospit…
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psnet.ahrq.gov/node/49742/psn-pdf
September 01, 2015 - A Fumbled Handoff to Inpatient Rehab
September 1, 2015
Ashcraft LE, Kahn JM. A Fumbled Handoff to Inpatient Rehab. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/fumbled-handoff-inpatient-rehab
The Case
An 18-year-old man with no significant past medical history sustained a traumatic brain injury after a mo…