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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47314/psn-pdf
    November 24, 2018 - Adverse effects of computers during bedside rounds in a critical care unit. November 24, 2018 Dhillon NK, Francis SE, Tatum JM, et al. Adverse Effects of Computers During Bedside Rounds in a Critical Care Unit. JAMA Surg. 2018;153(11):1052-1053. doi:10.1001/jamasurg.2018.1752. https://psnet.ahrq.gov/issue/adverse-…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45588/psn-pdf
    January 23, 2017 - Computer-assisted process modeling to enhance intraoperative safety in cardiac surgery. January 23, 2017 Tarola CL, Quin JA, Haime ME, et al. Computer-Assisted Process Modeling to Enhance Intraoperative Safety in Cardiac Surgery. JAMA Surg. 2016;151(12):1183-1186. doi:10.1001/jamasurg.2016.2839. https://psnet.ahrq…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72605/psn-pdf
    December 23, 2020 - Society for Maternal-Fetal Medicine Special Statement: a maternal transport briefing form and checklist. December 23, 2020 Gibson KS, McLean D. Society for Maternal-Fetal Medicine Special Statement: A maternal transport briefing form and checklist. Am J Obstet Gynecol. 2020;223(5):B12-B15. doi:10.1016/j.ajog.2020.0…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43139/psn-pdf
    April 23, 2014 - Patient safety in obstetrics and obstetric anesthesia. April 23, 2014 Kung A, Pratt SD. Patient safety in obstetrics and obstetric anesthesia. Int Anesthesiol Clin. 2014;52(2):86- 110. doi:10.1097/AIA.0000000000000017. https://psnet.ahrq.gov/issue/patient-safety-obstetrics-and-obstetric-anesthesia Labor and delive…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72800/psn-pdf
    March 03, 2021 - Reaching the summit of discharge summaries: a quality improvement project. March 3, 2021 Richmond RT, McFadzean IJ, Vallabhaneni P. Reaching the summit of discharge summaries: a quality improvement project. BMJ Open Qual. 2021;10(1):e001142. doi:10.1136/bmjoq-2020-001142. https://psnet.ahrq.gov/issue/reaching-summ…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44897/psn-pdf
    March 15, 2016 - The effect of a checklist on the quality of patient handover from the operating room to the intensive care unit: a randomized controlled trial. March 15, 2016 Salzwedel C, Mai V, Punke MA, et al. The effect of a checklist on the quality of patient handover from the operating room to the intensive care unit: A rand…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43172/psn-pdf
    May 14, 2014 - Clinical clerkship students' perceptions of (un)safe transitions for every patient. May 14, 2014 Koch PE, Simpson D, Toth H, et al. Clinical Clerkship Students’ Perceptions of (Un)Safe Transitions for Every Patient. Academic Medicine. 2014;89(3). doi:10.1097/acm.0000000000000153. https://psnet.ahrq.gov/issue/clini…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45331/psn-pdf
    August 03, 2016 - Health information technologies: from hazardous to the dark side. August 3, 2016 Saunders C, Rutkowski AF, Pluyter J, et al. Health information technologies: From hazardous to the dark side. J Assoc Inf Sci Technol. 2016;67(7). doi:10.1002/asi.23671. https://psnet.ahrq.gov/issue/health-information-technologies-haz…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60893/psn-pdf
    January 01, 2021 - When safety event reporting is seen as punitive: "I've been PSN-ed!" September 9, 2020 Feeser VR, Jackson AK, Savage NM, et al. When safety event reporting is seen as punitive: "I've been PSN-ed!". Ann Emerg Med. 2021;77(4):449-458. doi:10.1016/j.annemergmed.2020.06.048. https://psnet.ahrq.gov/issue/when-safety-ev…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46846/psn-pdf
    February 28, 2018 - Effects of interdisciplinary collaboration in hospitals on medication errors: an integrative review. February 28, 2018 Manias E. Effects of interdisciplinary collaboration in hospitals on medication errors: an integrative review. Expert Opin Drug Saf. 2018;17(3):259-275. doi:10.1080/14740338.2018.1424830. https://…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837866/psn-pdf
    August 17, 2022 - A System in Need of Repair: Addressing Organizational Failures of the U.S.’s Organ Procurement and Transplantation Network. August 17, 2022 US Senate Finance Committee. 117th Cong (2021-2022). August 3, 2022. https://psnet.ahrq.gov/issue/system-need-repair-addressing-organizational-failures-uss-organ- procurement…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72826/psn-pdf
    March 10, 2021 - Prescribers' perspectives on including reason for use information on prescriptions and medication labels: a qualitative thematic analysis. March 10, 2021 Whaley C, Bancsi A, Ho JM-W, et al. Prescribers’ perspectives on including reason for use information on prescriptions and medication labels: a qualitative thema…

  13. Exhibit 3.20. Major Factors that Inhibit Lean Success | Agency for Healthcare Research and Quality

    www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit3-20.html
    November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies Exhibit 3.20. Major Factors that Inhibit Lean Success Previous Page Next Page Table of Contents Improving Care Delivery Through Lean: Implementation Case Studies Introduction to the Case Studies Case 1. Lakeview Healthcare Case …

  14. Exhibit 5.18. Major Factors that Inhibited Lean Success | Agency for Healthcare Research and Quality

    www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit5-18.html
    November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies Exhibit 5.18. Major Factors that Inhibited Lean Success Previous Page Next Page Table of Contents Improving Care Delivery Through Lean: Implementation Case Studies Introduction to the Case Studies Case 1. Lakeview Healthcare Cas…

  15. AHRQ's Quality & Patient Safety Programs by Setting: Hospital Labor and Delivery Units | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/labor-delivery/index.html
    July 01, 2023 - AHRQ's Quality & Patient Safety Programs by Setting: Hospital Labor and Delivery Units AHRQ Safety Program for Perinatal Care – I aims to improve the patient safety culture of labor and delivery (L&D) units and decrease maternal and neonatal adverse events resulting from poor communication and system failures.…

  16. Holve, Erin | Digital Healthcare Research

    digital.ahrq.gov/principal-investigator/holve-erin
    January 01, 2023 - Holve, Erin Connect, Collaborate, Communicate: The Story of the EDM Forum Citation Adams L, Edmunds M, Johnson B. Connect, Collaborate, Communicate: The Story of the EDM Forum. AcademyHealth. http://www.academyhealth.org/EDMForumStory. March 2017. Principal Investigator …

  17. Making Healthcare Safer IV: Use of Structured Handoff Protocols for Intrahospital Transitions (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/related_files/structured-handoff-protocol.pdf
    December 31, 2024 - Making Healthcare Safer IV: Use of Structured Handoff Protocols for Intrahospital Transitions Evidence-based Practice Center Rapid Review Protocol Project Title: Making Healthcare Safer IV: Use of Structured Handoff Protocols for Intrahospital Transitions Review Questions Review Question Bas…

  18. Failure to Adhere to Dietary Restrictions Leading to Complications and Poor Follow-up | PSNet

    psnet.ahrq.gov/web-mm/failure-adhere-dietary-restrictions-leading-complications-and-poor-follow
    September 27, 2023 - Failure to Adhere to Dietary Restrictions Leading to Complications and Poor Follow-up Citation Text: Bohringer C, Bourgeois J, Xiong G, et al. Failure to adhere to dietary restrictions leading to complications and poor follow-up.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…

  19. A Model of Care Delivery to Reduce Falls in a Major Cancer Center (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Kline_32.pdf
    March 03, 2008 - A Model of Care Delivery to Reduce Falls in a Major Cancer Center A Model of Care Delivery to Reduce Falls in a Major Cancer Center Nancy E. Kline, PhD, RN, CPNP, FAAN; Bridgette Thom, MS; Wayne Quashie, MPH, RN; Patricia Brosnan, MPH, RN; Mary Dowling, MSN, RN Abstract Falls are a leading cause of injuries…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867035/psn-pdf
    October 30, 2024 - A Tale of Two Falls October 30, 2024 Jackson V, Satake A. A Tale of Two Falls. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/tale-two-falls The Cases Case #1: A 79-year-old woman with a history of impaired cognition at baseline was brought from a skilled nursing facility to the emergency department (ED) f…
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