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  1. psnet.ahrq.gov/web-mm/triaging-interhospital-transfers
    April 12, 2023 - SPOTLIGHT CASE Triaging Interhospital Transfers Citation Text: Mueller SK. Triaging Interhospital Transfers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX En…
  2. psnet.ahrq.gov/issue/apsf-endorsed-statement-revising-recommendations-patient-monitoring-during-anesthesia
    July 25, 2018 - Organizational Policy/Guidelines APSF endorsed statement on revising recommendations for patient monitoring during anesthesia. Citation Text: APSF endorsed statement on revising recommendations for patient monitoring during anesthesia. The APSF Committee on Technology. APSF Newsletter.&n…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49773/psn-pdf
    July 01, 2016 - Near Miss With Neonate October 1, 2016 Malana J, Lyndon A. Near Miss With Neonate. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/near-miss-neonate The Case A 37-year-old pregnant woman was admitted to the hospital for scheduled induction of labor for postterm dates. Early the next morning, intravenous oxy…
  4. psnet.ahrq.gov/web-mm/beeline-spine
    March 01, 2014 - SPOTLIGHT CASE Beeline to Spine Citation Text: Smetana GW. Beeline to Spine. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endno…
  5. psnet.ahrq.gov/issue/blood-sampling-guidelines-focus-patient-safety-and-identification-review
    August 10, 2016 - Review Blood sampling guidelines with focus on patient safety and identification—a review. Citation Text: Cornes M, Ibarz M, Ivanov H, et al. Blood sampling guidelines with focus on patient safety and identification - a review. Diagnosis (Berl). 2019;6(1):33-37. doi:10.1515/dx-2018-0042.…
  6. psnet.ahrq.gov/web-mm/contaminated-or-not-guidelines-interpretation-positive-blood-cultures
    November 16, 2022 - Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures Citation Text: Weinstein MP. Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …
  7. psnet.ahrq.gov/issue/managing-competing-organizational-priorities-clinical-handover-across-organizational
    February 07, 2024 - Study Managing competing organizational priorities in clinical handover across organizational boundaries. Citation Text: Sujan MA, Chessum P, Rudd M, et al. Managing competing organizational priorities in clinical handover across organizational boundaries. J Health Serv Res Policy. 2015;…
  8. psnet.ahrq.gov/issue/squire-guidelines-evaluation-field-5-years-post-release
    November 18, 2016 - Study The SQUIRE Guidelines: an evaluation from the field, 5 years post release. Citation Text: Davies L, Batalden P, Davidoff F, et al. The SQUIRE Guidelines: an evaluation from the field, 5 years post release. BMJ Qual Saf. 2015;24(12):769-75. doi:10.1136/bmjqs-2015-004116. Copy Cita…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849661/psn-pdf
    June 28, 2023 - Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery June 28, 2023 Curtin A, Schloemerkemper N. Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery. PSNet [internet]. 2023. https://psnet.ahrq.gov/web…
  10. psnet.ahrq.gov/issue/incidence-patterns-and-prevention-wrong-site-surgery
    September 30, 2010 - Study Classic Incidence, patterns, and prevention of wrong-site surgery. Citation Text: Kwaan MR, Studdert DM, Zinner MJ, et al. Incidence, patterns, and prevention of wrong-site surgery. Arch Surg. 2006;141(4):353-358. Copy Citation Format: Goog…
  11. psnet.ahrq.gov/issue/leveraging-science-teamwork-sustain-handoff-improvements-cardiovascular-surgery
    November 28, 2018 - Study Leveraging the science of teamwork to sustain handoff improvements in cardiovascular surgery. Citation Text: Keebler JR, Lynch I, Ngo F, et al. Leveraging the science of teamwork to sustain handoff improvements in cardiovascular surgery. Jt Comm J Qual Patient Saf. 2023;49(8):373-3…
  12. psnet.ahrq.gov/issue/risk-adverse-drug-events-neonates-treated-opioids-and-effect-bar-code-assisted-medication
    May 21, 2009 - Study Risk of adverse drug events in neonates treated with opioids and the effect of a bar-code–assisted medication administration system. Citation Text: Morriss FH, Abramowitz PW, Nelson S, et al. Risk of adverse drug events in neonates treated with opioids and the effect of a bar-cod…
  13. psnet.ahrq.gov/issue/medication-regimen-complexity-and-hospital-readmission-adverse-drug-event
    December 03, 2014 - Study Medication regimen complexity and hospital readmission for an adverse drug event. Citation Text: Willson MN, Greer CL, Weeks DL. Medication regimen complexity and hospital readmission for an adverse drug event. Ann Pharmacother. 2014;48(1):26-32. doi:10.1177/1060028013510898. C…
  14. psnet.ahrq.gov/issue/eight-years-decreased-methicillin-resistant-staphylococcus-aureus-health-care-associated
    March 23, 2012 - Study Eight years of decreased methicillin-resistant Staphylococcus aureus health care–associated infections associated with a Veterans Affairs prevention initiative. Citation Text: Evans ME, Kralovic SM, Simbartl LA, et al. Eight years of decreased methicillin-resistant Staphylococcus a…
  15. psnet.ahrq.gov/issue/medication-errors-and-adverse-drug-events-intensive-care-unit-direct-observation-approach
    August 26, 2011 - Study Medication errors and adverse drug events in an intensive care unit: direct observation approach for detection. Citation Text: Kopp BJ, Erstad BL, Allen ME, et al. Medication errors and adverse drug events in an intensive care unit: direct observation approach for detection. Crit…
  16. psnet.ahrq.gov/issue/review-healthcare-failure-mode-and-effects-analysis-hfmea-radiotherapy
    June 13, 2011 - Review A review of healthcare failure mode and effects analysis (HFMEA) in radiotherapy. Citation Text: Giardina M, Cantone MC, Tomarchio E, et al. A Review of Healthcare Failure Mode and Effects Analysis (HFMEA) in Radiotherapy. Health Phys. 2016;111(4):317-26. doi:10.1097/HP.0000000000…
  17. psnet.ahrq.gov/issue/medication-errors-acute-cardiovascular-and-stroke-patients-scientific-statement-american
    February 03, 2011 - Organizational Policy/Guidelines Medication errors in acute cardiovascular and stroke patients. A scientific statement from the American Heart Association. Citation Text: Michaels AD, Spinler SA, Leeper B, et al. Medication Errors in Acute Cardiovascular and Stroke Patients. Circulatio…
  18. psnet.ahrq.gov/issue/health-professionals-experiences-whistleblowing-maternal-and-newborn-healthcare-settings
    November 02, 2010 - Review Health professionals' experiences of whistleblowing in maternal and newborn healthcare settings: a scoping review and thematic analysis. Citation Text: Capper T, Ferguson B, Muurlink O. Health professionals' experiences of whistleblowing in maternal and newborn healthcare settings…
  19. psnet.ahrq.gov/issue/building-safer-systems-ecological-design-using-restoration-science-develop-medication-safety
    February 14, 2024 - Study Building safer systems by ecological design: using restoration science to develop a medication safety intervention. Citation Text: Marck PB, Kwan JA, Preville B, et al. Building safer systems by ecological design: using restoration science to develop a medication safety intervent…
  20. Psn-Pdf (pdf file)

    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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