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psnet.ahrq.gov/innovations-exchange
May 01, 2021 - Decisions that Improve Care Value and Quality of Care
December 2020
Nudges are a change in the way choices
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psnet.ahrq.gov/web-mm/i-just-want-go-home-understanding-deliriums-impact-treatment-preferences
December 18, 2019 - A patient (or surrogate) ideally should be able to understand the choices being considered, assess the
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psnet.ahrq.gov/issue/adverse-effects-medicare-psi-90-hospital-penalty-system-revenue-neutral-hospital-acquired
October 30, 2024 - Study
Adverse effects of the Medicare PSI-90 hospital penalty system on revenue-neutral hospital-acquired conditions.
Citation Text:
Padula WV, Black JM, Davidson PM, et al. Adverse Effects of the Medicare PSI-90 Hospital Penalty System on Revenue-Neutral Hospital-Acquired Conditions. J …
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psnet.ahrq.gov/node/33686/psn-pdf
August 01, 2009 - But even with measurement, if patients and payers can't
make informed choices based on those measures
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psnet.ahrq.gov/issue/impact-electronic-health-records-time-efficiency-physicians-and-nurses-systematic-review
March 11, 2011 - Review
Classic
The impact of electronic health records on time efficiency of physicians and nurses: a systematic review.
Citation Text:
Poissant L, Pereira J, Tamblyn R, et al. The impact of electronic health records on time efficiency of physicians and nurses…
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psnet.ahrq.gov/issue/variation-quality-urgent-health-care-provided-during-commercial-virtual-visits
November 02, 2016 - Study
Variation in quality of urgent health care provided during commercial virtual visits.
Citation Text:
Schoenfeld AJ, Davies JM, Marafino BJ, et al. Variation in Quality of Urgent Health Care Provided During Commercial Virtual Visits. JAMA Intern Med. 2016;176(5):635-42. doi:10.1001/…
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psnet.ahrq.gov/issue/how-guiding-coalitions-promote-positive-culture-change-hospitals-longitudinal-mixed-methods
February 21, 2018 - Study
How guiding coalitions promote positive culture change in hospitals: a longitudinal mixed methods interventional study.
Citation Text:
Bradley EH, Brewster AL, McNatt Z, et al. How guiding coalitions promote positive culture change in hospitals: a longitudinal mixed methods interve…
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psnet.ahrq.gov/issue/use-interactive-telephone-based-self-management-support-program-identify-adverse-events-among
June 11, 2010 - Study
Use of an interactive, telephone-based self-management support program to identify adverse events among ambulatory diabetes patients.
Citation Text:
Sarkar U, Handley MA, Gupta R, et al. Use of an interactive, telephone-based self-management support program to identify adverse ev…
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psnet.ahrq.gov/issue/narrative-review-do-state-laws-make-it-easier-say-im-sorry
June 16, 2010 - Review
Narrative review: do state laws make it easier to say "I'm sorry"?
Citation Text:
McDonnell WM, Guenther E. Narrative review: do state laws make it easier to say "I'm sorry?". Ann Intern Med. 2008;149(11):811-816.
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Format:
Google Scholar PubMed BibTeX En…
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psnet.ahrq.gov/issue/burnout-and-medical-errors-among-american-surgeons
December 21, 2014 - Study
Burnout and medical errors among American surgeons.
Citation Text:
Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995-1000. doi:10.1097/SLA.0b013e3181bfdab3.
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Format:
DOI Google Schol…
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psnet.ahrq.gov/issue/ethical-framework-allocating-scarce-life-saving-chemotherapy-and-supportive-care-drugs
September 07, 2016 - Commentary
An ethical framework for allocating scarce life-saving chemotherapy and supportive care drugs for childhood cancer.
Citation Text:
Unguru Y, Fernandez C, Bernhardt B, et al. An Ethical Framework for Allocating Scarce Life-Saving Chemotherapy and Supportive Care Drugs for Child…
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psnet.ahrq.gov/issue/board-bedside-how-application-financial-structures-safety-and-quality-can-drive
January 29, 2015 - Study
From board to bedside: how the application of financial structures to safety and quality can drive accountability in a large health care system.
Citation Text:
Austin M, Demski R, Callender T, et al. From Board to Bedside: How the Application of Financial Structures to Safety and Q…
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psnet.ahrq.gov/issue/what-attributes-patients-affect-their-involvement-safety-key-opinion-leaders-perspective
April 12, 2011 - Study
What attributes of patients affect their involvement in safety? A key opinion leaders' perspective.
Citation Text:
Buetow S, Davis R, Callaghan K, et al. What attributes of patients affect their involvement in safety? A key opinion leaders' perspective. BMJ Open. 2013;3(8):e003104.…
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psnet.ahrq.gov/node/49395/psn-pdf
April 01, 2003 - Medication Overdose
April 1, 2003
Kaushal R. Medication Overdose. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/medication-overdose
The Case
A 15-year-old boy with end-stage AIDS was admitted to the pediatric ICU with mental status changes. He
was diagnosed with status epilepticus and started on a loading…
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psnet.ahrq.gov/node/33579/psn-pdf
September 07, 2019 - Mistakes, by contrast, reflect incorrect choices, and more often reflect lack of experience,
insufficient
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psnet.ahrq.gov/issue/mortality-risks-associated-emergency-admissions-during-weekends-and-public-holidays-analysis
September 02, 2020 - Study
Classic
Mortality risks associated with emergency admissions during weekends and public holidays: an analysis of electronic health records.
Citation Text:
Walker S, Mason A, Quan P, et al. Mortality risks associated with emergency admissions during weekend…
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psnet.ahrq.gov/issue/patient-safety-and-telephone-medicine-some-lessons-closed-claim-case-review
May 18, 2022 - Study
Patient safety and telephone medicine: some lessons from closed claim case review.
Citation Text:
Katz HP, Kaltsounis D, Halloran L, et al. Patient safety and telephone medicine : some lessons from closed claim case review. J Gen Intern Med. 2008;23(5):517-22. doi:10.1007/s11606-…
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psnet.ahrq.gov/web-mm/lung-nodule-refused-grow
March 01, 2004 - SPOTLIGHT CASE
The Lung Nodule That Refused To Grow
Citation Text:
Balekian AA, Gould MK. The Lung Nodule That Refused To Grow. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/node/859646/psn-pdf
January 04, 2024 - In Conversation with...Jodi Sherman about Climate
Change and Patient Safety
January 4, 2024
Sherman J. In Conversation with..Jodi Sherman about Climate Change and Patient Safety. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/perspective/conversation-withjodi-sherman-about-climate-change-and-patient-safety
Editor…
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psnet.ahrq.gov/node/49851/psn-pdf
January 01, 2019 - One Bronchoscopy, Two Errors
January 1, 2019
Leiten E, Nielsen R. One Bronchoscopy, Two Errors. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors
The Case
A 67-year-old man with a history of hypertension was admitted to the intensive care unit (ICU) with hypoxic
respiratory failure…