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psnet.ahrq.gov/node/35085/psn-pdf
July 24, 2018 - Working Knowledge: How Organizations Manage What
They Know.
July 24, 2018
Davenport TH, Prusak L. Boston MA: Harvard Business School Press; 1998. ISBN: 0875846556.
https://psnet.ahrq.gov/issue/working-knowledge-how-organizations-manage-what-they-know
Two innovators in management consulting introduce core concepts …
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psnet.ahrq.gov/node/846162/psn-pdf
July 01, 2020 - The effect of virtual nursing and missed nursing care.
July 1, 2020
Schuelke S, Aurit S, Connot N, et al. The effect of virtual nursing and missed nursing care. Nurs Adm Q.
2020;44(3):280-287. doi:10.1097/naq.0000000000000419.
https://psnet.ahrq.gov/issue/effect-virtual-nursing-and-missed-nursing-care
The COVID-19…
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psnet.ahrq.gov/web-mm/inpatient-stroke-management-adolescent-type-1-diabetes-and-home-insulin-pump
February 01, 2023 - SPOTLIGHT CASE
Inpatient Stroke Management in an Adolescent with Type 1 Diabetes and Home Insulin Pump
Citation Text:
Bagley B, Zuidema D, Crossen S, et al. Inpatient Stroke Management in an Adolescent with Type 1 Diabetes and Home Insulin Pump . PSNet [internet]. Rockville (MD): Agency for Heal…
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psnet.ahrq.gov/issue/missed-diagnosis-cancer-primary-care-insights-malpractice-claims-data
March 15, 2017 - Study
Missed diagnosis of cancer in primary care: insights from malpractice claims data.
Citation Text:
Aaronson E, Quinn GR, Wong CI, et al. Missed diagnosis of cancer in primary care: Insights from malpractice claims data. J Healthc Risk Manag. 2019;39(2):19-29. doi:10.1002/jhrm.21385.…
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psnet.ahrq.gov/node/72739/psn-pdf
February 10, 2021 - Clear communication between emergency physicians
and admitting consultants minimizes diagnostic momentum … Clinicians should independently verify information provided by
consultants to ensure that all available
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psnet.ahrq.gov/node/40973/psn-pdf
November 30, 2011 - A clinical nurse specialist intervention to facilitate safe
transfer from ICU.
November 30, 2011
St-Louis L, Brault D. A clinical nurse specialist intervention to facilitate safe transfer from ICU. Clin Nurse
Spec. 2011;25(6):321-6. doi:10.1097/NUR.0b013e318233eaab.
https://psnet.ahrq.gov/issue/clinical-nurse-spec…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.158_slideshow.ppt
September 01, 2007 - Pre-operative consultant obtained wrong pre-admission medication list (PAML) from patient
Consultant
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psnet.ahrq.gov/node/866955/psn-pdf
October 16, 2024 - Adverse diagnostic events in hospitalised patients: a
single-centre, retrospective cohort study.
October 16, 2024
Dalal AK, Plombon S, Konieczny K, et al. Adverse diagnostic events in hospitalised patients: a single-
centre, retrospective cohort study. BMJ Qual Saf. 2024;Epub Oct 1. doi:10.1136/bmjqs-2024-017183.
…
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psnet.ahrq.gov/node/49717/psn-pdf
September 01, 2014 - A Lot of Pain (Medications)
September 1, 2014
Herzig SJ. A Lot of Pain (Medications). PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/lot-pain-medications
Case Objectives
Appreciate the challenges of managing acute pain in hospitalized patients on chronic opioids.
Describe the importance of understanding th…
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psnet.ahrq.gov/issue/medication-errors-among-acutely-ill-and-injured-children-treated-rural-emergency-departments
December 13, 2013 - Study
Medication errors among acutely ill and injured children treated in rural emergency departments.
Citation Text:
Marcin JP, Dharmar M, Cho M, et al. Medication errors among acutely ill and injured children treated in rural emergency departments. Ann Emerg Med. 2007;50(4):361-7, 36…
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psnet.ahrq.gov/issue/evaluation-problem-specific-sbar-tool-improve-after-hours-nurse-physician-phone-communication
December 30, 2014 - Study
Evaluation of a problem-specific SBAR tool to improve after-hours nurse-physician phone communication: a randomized trial.
Citation Text:
Joffe E, Turley JP, Hwang KO, et al. Evaluation of a problem-specific SBAR tool to improve after-hours nurse-physician phone communication: a ra…
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psnet.ahrq.gov/node/73911/psn-pdf
October 06, 2021 - Misdiagnosis of acute myocardial infarction: a systematic
review of the literature.
October 6, 2021
Kwok CS, Bennett S, Azam Z, et al. Misdiagnosis of acute myocardial infarction: a systematic review of the
literature. Crit Pathw Cardiol. 2021;20(3):155-162. doi:10.1097/hpc.0000000000000256.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/60963/psn-pdf
September 30, 2020 - Organisation and characteristics of out-of-hours primary
care during a COVID-19 outbreak: a real-time
observational study.
September 30, 2020
Morreel S, Philips H, Verhoeven V. Organisation and characteristics of out-of-hours primary care during a
COVID-19 outbreak: a real-time observational study. PLoS One. 2020;…
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psnet.ahrq.gov/node/47860/psn-pdf
June 30, 2019 - New mother number 14.
June 30, 2019
Sangarlangkarn A. Healthc (Amst). 2019;7:31-32.
https://psnet.ahrq.gov/issue/new-mother-number-14
Rigid adherence to protocols may detract from safety when unexpected critical events occur that require
deviation from the standard process. This commentary explores insights from a…
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psnet.ahrq.gov/node/73148/psn-pdf
April 14, 2021 - 10 Leadership mindsets for high reliability organizations.
How to empower caregivers and engage patients in
patient safety.
April 14, 2021
Jurecko L. Consult QD. March 16, 2021.
https://psnet.ahrq.gov/issue/10-leadership-mindsets-high-reliability-organizations-how-empower-caregivers-
and-engage
Leadership a…
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psnet.ahrq.gov/node/73100/psn-pdf
March 31, 2021 - Public comment period extended for strategies to
improve patient safety: Draft Report to Congress for
Public Comment and Review by the National Academy of
Medicine.
March 31, 2021
Fed Register. 2021;86(51):14752-14753.
https://psnet.ahrq.gov/issue/public-comment-period-extended-strategies-improve-patient-safety-d…
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psnet.ahrq.gov/node/43732/psn-pdf
January 07, 2015 - Rethinking diagnostic delay in cancer: how difficult is the
diagnosis?
January 7, 2015
Lyratzopoulos G, Wardle J, Rubin G. Rethinking diagnostic delay in cancer: how difficult is the diagnosis?
BMJ. 2014;349:g7400. doi:10.1136/bmj.g7400.
https://psnet.ahrq.gov/issue/rethinking-diagnostic-delay-cancer-how-difficult…
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psnet.ahrq.gov/node/46553/psn-pdf
October 25, 2017 - Telehealth.
October 25, 2017
Tuckson R, Edmunds M, Hodgkins ML. Telehealth. N Engl J Med. 2017;377(16):1585-1592.
doi:10.1056/NEJMsr1503323.
https://psnet.ahrq.gov/issue/telehealth
Telemedicine can improve patient experience and access to health care. This commentary reviews the
current state of telehealth practi…
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psnet.ahrq.gov/perspective/what-do-we-know-about-emergency-department-safety
June 01, 2010 - Inadequate staffing with nurses, physicians, and consultants; problems with teamwork; and inadequate
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psnet.ahrq.gov/node/49543/psn-pdf
September 01, 2007 - First, the preoperative consultant sowed the seeds of this
adverse event by obtaining the wrong preadmission … The consultant
also failed to verify the medication history; he did not contact the patient's PCP, neurologist