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2381. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49591/psn-pdf
      October 01, 2009 - Difficult Encounters: A CMO and CNO Respond October 1, 2009 Ring EJ, Hirsch JE. Difficult Encounters: A CMO and CNO Respond. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/difficult-encounters-cmo-and-cno-respond Case Objectives Appreciate the risk of disruptive behavior and understand institutional respons…

2382. PSNet Curated Library (pdf file)
      psnet.ahrq.gov/print/pdf/node/854855
      January 01, 2024 - PSNet Curated Library AHRQ: Agency for Healthcare Research and Quality Patient as a Team Member in Clinical Care Curated Library Foundations Patient Engagement for Patient Safety: The Why, What, and How of Patient Engagement for Improving Patient Safety. Kendir C, Fujisawa R, Brito Fernandes O, et al. Paris, F…

2383. Despite Clues, Failed to Rescue | PSNet
      psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
      August 02, 2015 - SPOTLIGHT CASE Despite Clues, Failed to Rescue Citation Text: Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndN…

2384. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40375/psn-pdf
      August 08, 2014 - Coordination Between Emergency and Primary Care Physicians. August 8, 2014 Carrier E, Yee T, Holtzwart RA. Washington, DC: National Institute for Health Care Reform; 2011. NIHCR Research Brief No. 3. https://psnet.ahrq.gov/issue/coordination-between-emergency-and-primary-care-physicians This report analyzes commu…

2385. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37611/psn-pdf
      February 15, 2011 - SBAR for patients. February 15, 2011 Denham CR. SBAR for Patients. J Patient Saf. 2008;4(1). doi:10.1097/pts.0b013e2181660c06. https://psnet.ahrq.gov/issue/sbar-patients This commentary presents information and background on the standardized communication process known as SBAR (situation, background, assessment, a…

2386. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49664/psn-pdf
      January 01, 2013 - Empty Handoff September 1, 2012 Goldman A, Catchpole K. Empty Handoff. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/empty-handoff The Case A 29-year-old man with "brittle diabetes" was admitted to the surgery service for incision and drainage of a leg wound. The patient's medical history included chronic…

2387. FDA alerts patients and health care professionals of EpiPen auto-injector errors related to device malfunctions and user administration. | PSNet
      psnet.ahrq.gov/issue/fda-alerts-patients-and-health-care-professionals-epipen-auto-injector-errors-related-device
      April 07, 2019 - Press Release/Announcement FDA alerts patients and health care professionals of EpiPen auto-injector errors related to device malfunctions and user administration. Citation Text: FDA alerts patients and health care professionals of EpiPen auto-injector errors related to device malfunctio…

2388. Adverse drug events resulting from patient errors in older adults. | PSNet
      psnet.ahrq.gov/issue/adverse-drug-events-resulting-patient-errors-older-adults
      March 11, 2011 - Study Adverse drug events resulting from patient errors in older adults. Citation Text: Field TS, Mazor KM, Briesacher BA, et al. Adverse Drug Events Resulting from Patient Errors in Older Adults. J Am Geriatr Soc. 2007;55(2):271-276. doi:10.1111/j.1532-5415.2007.01047.x. Copy Citati…

2389. Relationships between pediatric safety indicators across a national sample of pediatric hospitals: dispelling the myth of the "safest" hospital. | PSNet
      psnet.ahrq.gov/issue/relationships-between-pediatric-safety-indicators-across-national-sample-pediatric-hospitals
      April 06, 2022 - Study Relationships between pediatric safety indicators across a national sample of pediatric hospitals: dispelling the myth of the "safest" hospital. Citation Text: Milliren CE, Bailey G, Graham DA, et al. Relationships between pediatric safety indicators across a national sample of ped…

2390. Developing a standard handoff process for operating room–to-ICU transitions: multidisciplinary clinician perspectives from the Handoffs and Transitions in Critical Care (HATRICC) study. | PSNet
      psnet.ahrq.gov/issue/developing-standard-handoff-process-operating-room-icu-transitions-multidisciplinary
      February 06, 2019 - Study Developing a standard handoff process for operating room–to-ICU transitions: multidisciplinary clinician perspectives from the Handoffs and Transitions in Critical Care (HATRICC) study. Citation Text: Lane-Fall MB, Pascual JL, Massa S, et al. Developing a Standard Handoff Process f…

2391. Effectiveness of different nursing handover styles for ensuring continuity of information in hospitalised patients. | PSNet
      psnet.ahrq.gov/issue/effectiveness-different-nursing-handover-styles-ensuring-continuity-information-hospitalised
      May 19, 2018 - Review Effectiveness of different nursing handover styles for ensuring continuity of information in hospitalised patients. Citation Text: Smeulers M, Lucas C, Vermeulen H. Effectiveness of different nursing handover styles for ensuring continuity of information in hospitalised patients. …

2392. Development and evaluation of I-PASS-to-PICU: a standard electronic template to improve referral communication for inter-facility transfers to the pediatric intensive care unit. | PSNet
      psnet.ahrq.gov/issue/development-and-evaluation-i-pass-picu-standard-electronic-template-improve-referral
      June 14, 2023 - Study Development and evaluation of I-PASS-to-PICU: a standard electronic template to improve referral communication for inter-facility transfers to the pediatric intensive care unit. Citation Text: Parikh NR, Francisco LS, Balikai SC, et al. Development and evaluation of I-PASS-to-PICU:…

2393. Implementing receiver-driven handoffs to the emergency department to reduce miscommunication. | PSNet
      psnet.ahrq.gov/issue/implementing-receiver-driven-handoffs-emergency-department-reduce-miscommunication
      December 05, 2018 - Study Implementing receiver-driven handoffs to the emergency department to reduce miscommunication. Citation Text: Huth K, Stack AM, Hatoun J, et al. Implementing receiver-driven handoffs to the emergency department to reduce miscommunication. BMJ Qual Saf. 2021;30(3):208-215. doi:10.113…

2394. Identifying factors leading to harm in English general practices: a mixed-methods study based on patient experiences integrating structural equation modeling and qualitative content analysis. | PSNet
      psnet.ahrq.gov/issue/identifying-factors-leading-harm-english-general-practices-mixed-methods-study-based-patient
      June 01, 2016 - Study Identifying factors leading to harm in English general practices: a mixed-methods study based on patient experiences integrating structural equation modeling and qualitative content analysis. Citation Text: Ricci-Cabello I, Gangannagaripalli J, Mounce LTA, et al. Identifying Factor…

2395. Discontinuation of outpatient medications: implications for electronic messaging to pharmacies using CancelRx. | PSNet
      psnet.ahrq.gov/issue/discontinuation-outpatient-medications-implications-electronic-messaging-pharmacies-using
      October 05, 2022 - Study Discontinuation of outpatient medications: implications for electronic messaging to pharmacies using CancelRx. Citation Text: Pitts S, Yang Y, Thomas BA, et al. Discontinuation of outpatient medications: implications for electronic messaging to pharmacies using CancelRx. J Am Med I…

2396. Hacking teamwork in health care: addressing adverse effects of ad hoc team composition in critical care medicine. | PSNet
      psnet.ahrq.gov/issue/hacking-teamwork-health-care-addressing-adverse-effects-ad-hoc-team-composition-critical-care
      October 11, 2023 - Study Hacking teamwork in health care: addressing adverse effects of ad hoc team composition in critical care medicine. Citation Text: McLeod PL, Cunningham QW, DiazGranados D, et al. Hacking teamwork in health care: Addressing adverse effects of ad hoc team composition in critical care …

2397. Analysis of errors in dictated clinical documents assisted by speech recognition software and professional transcriptionists. | PSNet
      psnet.ahrq.gov/issue/analysis-errors-dictated-clinical-documents-assisted-speech-recognition-software-and
      July 06, 2022 - Study Emerging Classic Analysis of errors in dictated clinical documents assisted by speech recognition software and professional transcriptionists. Citation Text: Zhou L, Blackley SV, Kowalski L, et al. Analysis of Errors in Dictated Clinical Documents Assisted…

2398. Design and implementation of an automated email notification system for results of tests pending at discharge. | PSNet
      psnet.ahrq.gov/issue/design-and-implementation-automated-email-notification-system-results-tests-pending-discharge
      March 04, 2015 - Study Design and implementation of an automated email notification system for results of tests pending at discharge. Citation Text: Dalal A, Schnipper JL, Poon EG, et al. Design and implementation of an automated email notification system for results of tests pending at discharge. J Am M…

2399. Talking about falls: a qualitative exploration of spoken communication of patients' fall risks in hospitals and implications for multifactorial approaches to fall prevention. | PSNet
      psnet.ahrq.gov/issue/talking-about-falls-qualitative-exploration-spoken-communication-patients-fall-risks
      July 20, 2022 - Study Talking about falls: a qualitative exploration of spoken communication of patients' fall risks in hospitals and implications for multifactorial approaches to fall prevention. Citation Text: McVey L, Alvarado N, Healey F, et al. Talking about falls: a qualitative exploration of spok…

2400. Adverse events in long-term care residents transitioning from hospital back to nursing home. | PSNet
      psnet.ahrq.gov/issue/adverse-events-long-term-care-residents-transitioning-hospital-back-nursing-home
      April 28, 2021 - Study Adverse events in long-term care residents transitioning from hospital back to nursing home. Citation Text: Kapoor A, Field T, Handler S, et al. Adverse Events in Long-term Care Residents Transitioning From Hospital Back to Nursing Home. JAMA Intern Med. 2019;179(9):1254-1261. doi:…