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psnet.ahrq.gov/web-mm/hazards-distraction-ticking-all-ehr-boxes
April 09, 2014 - SPOTLIGHT CASE
The Hazards of Distraction: Ticking All the EHR Boxes
Citation Text:
Easty AC. The Hazards of Distraction: Ticking All the EHR Boxes. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers
August 30, 2023 - Annual Perspective
Impact of System Failures on Healthcare Workers
George Zangaro, PhD, RN, FAAN, Cindy Manaoat Van, MHSA, Sarah Mossburg, RN, PhD
| March 21, 2023
View more articles from the same authors.
Citation Text:
Zangaro G, Van CM, Mossburg S. Imp…
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psnet.ahrq.gov/web-mm/low-totem-pole
October 01, 2003 - SPOTLIGHT CASE
Low on the Totem Pole
Citation Text:
Wachter R. Low on the Totem Pole. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/web-mm/check-twice-transport-once
March 15, 2023 - Check Twice, Transport Once
Citation Text:
DePew A, Rice J, Chou J. Check Twice, Transport Once. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/node/49760/psn-pdf
May 01, 2016 - Mismanagement of Delirium
May 1, 2016
Merrilees J, Lee KP. Mismanagement of Delirium. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/mismanagement-delirium
The Case
An 85-year-old man with early stage vascular dementia fell on the sidewalk and fractured his leg. Although
fitted with a cast at a regional ho…
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psnet.ahrq.gov/web-mm/complaints-safety-surveillance
May 05, 2021 - Complaints as Safety Surveillance
Citation Text:
Morris JL, Bismark M. Complaints as Safety Surveillance. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/spinal-epidural-abscess
November 13, 2019 - Spinal Epidural Abscess
Citation Text:
Lu Y, Salvador D. Spinal Epidural Abscess. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/dangerous-dialysis
June 12, 2024 - SPOTLIGHT CASE
Dangerous Dialysis
Citation Text:
Holley JL. Dangerous Dialysis . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/issue/more-750-hospitals-face-medicare-crackdown-patient-injuries
June 27, 2018 - Newspaper/Magazine Article
More than 750 hospitals face Medicare crackdown on patient injuries.
Citation Text:
More than 750 hospitals face Medicare crackdown on patient injuries. Rau J. Kaiser Health News. June 22, 2014.
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psnet.ahrq.gov/node/39729/psn-pdf
September 20, 2011 - Contextual errors and failures in individualizing patient
care: a multicenter study.
September 20, 2011
Weiner SJ, Schwartz A, Weaver FM, et al. Contextual errors and failures in individualizing patient care: a
multicenter study. Ann Intern Med. 2010;153(2):69-75. doi:10.7326/0003-4819-153-2-201007200-00002.
https…
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psnet.ahrq.gov/node/39314/psn-pdf
December 21, 2014 - Patient characteristics and the occurrence of never
events.
December 21, 2014
Fry DE, Pine M, Jones BL, et al. Patient characteristics and the occurrence of never events. Arch Surg.
2010;145(2):148-51. doi:10.1001/archsurg.2009.277.
https://psnet.ahrq.gov/issue/patient-characteristics-and-occurrence-never-events
…
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psnet.ahrq.gov/node/46615/psn-pdf
January 23, 2019 - The surgical safety checklist and patient outcomes after
surgery: a prospective observational cohort study,
systematic review and meta-analysis.
January 23, 2019
Abbott TEF, Ahmad T, Phull MK, et al. The surgical safety checklist and patient outcomes after surgery: a
prospective observational cohort study, systema…
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psnet.ahrq.gov/node/41317/psn-pdf
January 31, 2013 - Variation in 17 obstetric care pathways: potential danger
for health professionals and patient safety?
January 31, 2013
Sarrechia M, Van Gerven E, Hermans L, et al. Variation in 17 obstetric care pathways: potential danger for
health professionals and patient safety? J Adv Nurs. 2013;69(2):278-85. doi:10.1111/j.136…
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psnet.ahrq.gov/web-mm/infection-after-carpal-tunnel-surgery
May 28, 2014 - Assess urgency if symptoms suggest a potential complication and require prompt attention such as wound
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psnet.ahrq.gov/node/37756/psn-pdf
December 15, 2008 - Do the AHRQ Patient Safety Indicators flag conditions
that are present at the time of hospital admission?
December 15, 2008
Bahl V, Thompson MA, Kau T-Y, et al. Do the AHRQ patient safety indicators flag conditions that are
present at the time of hospital admission? Med Care. 2008;46(5):516-22.
doi:10.1097/MLR.0b0…
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psnet.ahrq.gov/node/44056/psn-pdf
May 19, 2018 - Impact of inpatient harms on hospital finances and
patient clinical outcomes.
May 19, 2018
Adler L, Yi D, Li M, et al. Impact of Inpatient Harms on Hospital Finances and Patient Clinical Outcomes. J
Patient Saf. 2018;14(2):67-73. doi:10.1097/PTS.0000000000000171.
https://psnet.ahrq.gov/issue/impact-inpatient-harms…
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psnet.ahrq.gov/node/39231/psn-pdf
January 13, 2010 - The Checklist Manifesto: How to Get Things Right.
January 13, 2010
Gawande A. New York, NY: Metropolitan Books; 2009. ISBN: 9780805091748.
https://psnet.ahrq.gov/issue/checklist-manifesto-how-get-things-right
Harvard surgeon Atul Gawande has emerged as this generation's preeminent physician–author, through
his art…
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psnet.ahrq.gov/node/33665/psn-pdf
March 01, 2008 - During our first year, when use of the MPS was elective, we utilized these data to demonstrate that
complication
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psnet.ahrq.gov/node/42454/psn-pdf
September 09, 2013 - A perinatal care quality and safety initiative: are there
financial rewards for improved quality?
September 9, 2013
Kozhimannil KB, Sommerness SA, Rauk P, et al. A perinatal care quality and safety initiative: are there
financial rewards for improved quality? Jt Comm J Qual Patient Saf. 2013;39(8):339-48.
https://…
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psnet.ahrq.gov/node/46307/psn-pdf
August 20, 2018 - Post-operative mortality, missed care and nurse staffing
in nine countries: a cross-sectional study.
August 20, 2018
Ball JE, Bruyneel L, Aiken LH, et al. Post-operative mortality, missed care and nurse staffing in nine
countries: A cross-sectional study. Int J Nurs Stud. 2018;78:10-15. doi:10.1016/j.ijnurstu.2017.…