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psnet.ahrq.gov/node/44714/psn-pdf
November 25, 2015 - Continuous Improvement of Patient Safety: The Case for
Change in the NHS.
November 25, 2015
Illingworth J. London, UK: The Health Foundation; 2015. ISBN: 9781906461706.
https://psnet.ahrq.gov/issue/continuous-improvement-patient-safety-case-change-nhs
The Francis inquiry uncovered problems in the National Health S…
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psnet.ahrq.gov/issue/infection-control-deficiencies-were-widespread-and-persistent-nursing-homes-prior-covid-19
April 29, 2020 - Book/Report
Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes Prior to COVID-19 Pandemic.
Citation Text:
Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes Prior to COVID-19 Pandemic. Washington, DC: United States Government Accoun…
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psnet.ahrq.gov/node/46816/psn-pdf
March 21, 2018 - Results of an enhanced clinic handoff and resident
education on resident patient ownership and patient
safety.
March 21, 2018
Pincavage A, Dahlstrom M, Prochaska M, et al. Results of an enhanced clinic handoff and resident
education on resident patient ownership and patient safety. Acad Med. 2013;88(6):795-801.
d…
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psnet.ahrq.gov/node/49576/psn-pdf
January 01, 2009 - To Transfer or Not to Transfer
January 1, 2009
Pines JM. To Transfer or Not to Transfer. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/transfer-or-not-transfer
Case Objectives
Explore the benefits of the continuity of hospital care.
Understand the rules and regulations behind triage and hospital choice de…
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psnet.ahrq.gov/node/39512/psn-pdf
June 11, 2010 - An intervention to decrease patient identification band
errors in a children's hospital.
June 11, 2010
Hain PD, Joers B, Rush M, et al. An intervention to decrease patient identification band errors in a
children's hospital. Qual Saf Health Care. 2010;19(3):244-7. doi:10.1136/qshc.2008.030288.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/34949/psn-pdf
June 23, 2009 - A randomized, controlled trial evaluating the impact of a
computerized rounding and sign-out system on continuity
of care and resident work hours.
June 23, 2009
Van Eaton EG, Horvath KD, Lober WB, et al. A randomized, controlled trial evaluating the impact of a
computerized rounding and sign-out system on continui…
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psnet.ahrq.gov/node/38759/psn-pdf
April 05, 2010 - Perceptions of the impact of a large-scale collaborative
improvement programme: experience in the UK Safer
Patients Initiative.
April 5, 2010
Benn J, Burnett S, Parand A, et al. Perceptions of the impact of a large-scale collaborative improvement
programme: experience in the UK Safer Patients Initiative. J Eval Cl…
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psnet.ahrq.gov/issue/smart-pumps-practice-survey-results-reveal-widespread-use-optimization-challenging
December 27, 2018 - Newspaper/Magazine Article
Smart pumps in practice: survey results reveal widespread use, but optimization is challenging.
Citation Text:
Smart pumps in practice: survey results reveal widespread use, but optimization is challenging. ISMP Medication Safety Alert! Acute Care Edition. Apri…
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psnet.ahrq.gov/node/49406/psn-pdf
June 01, 2003 - The Dangerous Detour
June 1, 2003
Gibson J, HTaylor D. The Dangerous Detour. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/dangerous-detour
The Case
Following an overdose of alcohol and Ativan, a 26-year-old woman was admitted to the Medicine service
for observation after being placed on a 72-hour hold by…
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psnet.ahrq.gov/perspective/role-graduate-medical-education-gme-improving-patient-safety
February 01, 2010 - Requirements and Policies
The Outcomes Project
The mainstay of resident education has been and continues … associated with discontinuity of care.( 1 ) At the present time, the ACGME Resident Duty Hour Task Force continues
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psnet.ahrq.gov/perspective/conversation-withthomas-j-nasca-md
February 01, 2010 - Requirements and Policies
The Outcomes Project
The mainstay of resident education has been and continues … associated with discontinuity of care.( 1 ) At the present time, the ACGME Resident Duty Hour Task Force continues
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psnet.ahrq.gov/web-mm/transfer-or-not-transfer
November 23, 2016 - SPOTLIGHT CASE
To Transfer or Not to Transfer
Citation Text:
Pines JM. To Transfer or Not to Transfer. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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Format:
Google Scholar BibTeX EndNote …
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psnet.ahrq.gov/issue/organizational-culture-critical-success-factors-and-reduction-hospital-errors
December 12, 2014 - Study
Organizational culture, critical success factors, and the reduction of hospital errors.
Citation Text:
Stock GN, McFadden KL, Gowen CR. Organizational culture, critical success factors, and the reduction of hospital errors. Int J Prod Econ. 2006;106(2). doi:10.1016/j.ijpe.2006.0…
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psnet.ahrq.gov/issue/health-care-associated-infections-hospitals-leadership-needed-hhs-prioritize-prevention
October 15, 2008 - Book/Report
Health-Care-Associated Infections in Hospitals: Leadership Needed from HHS to Prioritize Prevention Practices and Improve Data on these Infections.
Citation Text:
Health-Care-Associated Infections in Hospitals: Leadership Needed from HHS to Prioritize Prevention Practices a…
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psnet.ahrq.gov/node/40232/psn-pdf
February 23, 2011 - Large scale organisational intervention to improve patient
safety in four UK hospitals: mixed method evaluation.
February 23, 2011
Benning A, Ghaleb M, Suokas A, et al. Large scale organisational intervention to improve patient safety in
four UK hospitals: mixed method evaluation. BMJ. 2011;342(feb03 1):d195. doi:1…
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psnet.ahrq.gov/web-mm/departure-central-line-ritual
October 13, 2018 - "( 1,2 ) Nevertheless, this error continues to occur in numerous hospitals annually with a relatively
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psnet.ahrq.gov/node/49676/psn-pdf
February 01, 2013 - prescriber for order processing
Dispensing
Begins with a pharmacist's assessment of a medication order and continues
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psnet.ahrq.gov/web-mm/wandering-floors-safety-and-security-risks-patient-wandering
August 21, 2007 - Patients not willing to comply with these policies should be counseled and, if their behavior continues
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psnet.ahrq.gov/web-mm/premature-extubation
May 25, 2011 - reliably identifying when a patient is ready to be extubated following invasive mechanical ventilation continues
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psnet.ahrq.gov/web-mm/late-anemia-following-rh-disease-newborn
June 17, 2010 - Generally, once the bilirubin peaks and begins to decline on its own, it continues to decline unless