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psnet.ahrq.gov/node/72762/psn-pdf
February 17, 2021 - Optimizing Health IT for Safe Integration of Behavioral
Health and Primary Care.
February 17, 2021
Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI Institute; 2021.
https://psnet.ahrq.gov/issue/optimizing-health-it-safe-integration-behavioral-health-and-primary-care
Effective integration of hea…
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psnet.ahrq.gov/node/846451/psn-pdf
March 22, 2023 - Reducing risks in complex care transitions in rural areas:
a grounded theory.
March 22, 2023
Winqvist I, Näppä U, Rönning H, et al. Reducing risks in complex care transitions in rural areas: a
grounded theory. Int J Qual Stud Health Well-being. 2023;18(1):2185964.
doi:10.1080/17482631.2023.2185964.
https://psnet.…
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psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
August 01, 2012 - SPOTLIGHT CASE
The Risks of a Malpositioned Gastrostomy Tube and Poor Communication
Citation Text:
Hight RA. The Risks of a Malpositioned Gastrostomy Tube and Poor Communication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servic…
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psnet.ahrq.gov/node/49831/psn-pdf
June 01, 2018 - Chest Pain in a Rural Hospital
June 1, 2018
MacKinney CA, Mohr NM. Chest Pain in a Rural Hospital. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/chest-pain-rural-hospital
Case Objectives
Recognize that a significant proportion of the Unites States population receives care in rural safety
net emergency dep…
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psnet.ahrq.gov/node/34623/psn-pdf
January 28, 2015 - Australian Commission on Safety and Quality in Health
Care.
January 28, 2015
Australian Commission for Safety and Quality in Health Care.
https://psnet.ahrq.gov/issue/australian-commission-safety-and-quality-health-care
Established in January 2006, the Commission leads and coordinates improvements in safety and qu…
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psnet.ahrq.gov/node/850913/psn-pdf
June 21, 2023 - Understanding ultrarare adverse events - lessons learned
from a twelve-year review of intraoperative deaths at an
academic medical center.
June 21, 2023
Cohen TN, Kanji FF, Wang AS, et al. Understanding ultrarare adverse events - lessons learned from a
twelve-year review of intraoperative deaths at an academic med…
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psnet.ahrq.gov/node/863756/psn-pdf
March 06, 2024 - Preoperative communication between anesthesia,
surgery, and primary care providers for older surgical
patients.
March 6, 2024
Ron D, Gunn CM, Havidich JE, et al. Preoperative communication between anesthesia, surgery, and
primary care providers for older surgical patients. Jt Comm J Qual Patient Saf. 2024;50(5):32…
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psnet.ahrq.gov/node/43318/psn-pdf
July 02, 2014 - Sign up to Safety.
July 2, 2014
National Health Service.
https://psnet.ahrq.gov/issue/sign-safety
Through a coordinated effort to set goals and devise plans to improve safety in hospitals, the Sign up to
Safety campaign aims to prevent 6000 patient deaths in the next 3 years in National Health Service
facilities.…
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psnet.ahrq.gov/node/50756/psn-pdf
December 18, 2019 - Erika Cutler, PharmD
Pharmacy and Therapeutics Coordinator
University of California, Davis
Assistant
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psnet.ahrq.gov/node/60609/psn-pdf
June 24, 2020 - Julia Munsch, PharmD
Pharmacist, Pharmacy & Therapeutics Committee Coordinator
UC Davis Health
Amy
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psnet.ahrq.gov/node/73515/psn-pdf
August 01, 2022 - home leaders were supported by a nurse project supervisor, an
INTERACT/QI coach, a health information coordinator
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psnet.ahrq.gov/node/72499/psn-pdf
November 25, 2020 - Transformational improvement in quality care and health
systems: the next decade.
November 25, 2020
Braithwaite J, Vincent CA, Garcia-Elorrio E, et al. Transformational improvement in quality care and health
systems: the next decade. BMC Med. 2020;18(1):340. doi:10.1186/s12916-020-01739-y.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/47872/psn-pdf
March 27, 2019 - Overview of the Environmental Scan of Primary Care-
Based Effort To Reduce Readmissions.
March 27, 2019
Hochman M, Bourgoin A, Saluja S, et al. Rockville, MD: Agency for Healthcare Research and Quality;
March 2019. AHRQ Publication No. 18(19)-0055-EF.
https://psnet.ahrq.gov/issue/overview-environmental-scan-primar…
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psnet.ahrq.gov/node/837140/psn-pdf
May 18, 2022 - Nursing surveillance: a concept analysis
May 18, 2022
Halverson CC, Scott Tilley D. Nursing surveillance: a concept analysis. Nurs Forum. 2022;57(3):454-460.
doi:10.1111/nuf.12702.
https://psnet.ahrq.gov/issue/nursing-surveillance-concept-analysis
Nursing surveillance is an intervention for maintaining patient saf…
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psnet.ahrq.gov/issue/inadequate-health-literacy-among-paid-caregivers-seniors
May 04, 2010 - Study
Inadequate health literacy among paid caregivers of seniors.
Citation Text:
Lindquist LA, Jain N, Tam K, et al. Inadequate health literacy among paid caregivers of seniors. J Gen Intern Med. 2011;26(5):474-9. doi:10.1007/s11606-010-1596-2.
Copy Citation
Format:
DOI …
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psnet.ahrq.gov/issue/adapting-new-technologies-operating-room
January 16, 2017 - Study
Classic
Adapting to new technologies in the operating room.
Citation Text:
Cook RI, Woods DD. Adapting to New Technology in the Operating Room. Hum Factors. 2006;38(4):593-613. doi:10.1518/001872096778827224.
Copy Citation
Format:
DOI Google …
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psnet.ahrq.gov/issue/application-human-factors-analysis-and-classification-system-methodology-cardiovascular
January 06, 2012 - Study
Application of the human factors analysis and classification system methodology to the cardiovascular surgery operating room.
Citation Text:
Elbardissi AW, Wiegmann DA, Dearani JA, et al. Application of the human factors analysis and classification system methodology to the cardi…
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psnet.ahrq.gov/issue/association-communication-between-hospital-based-physicians-and-primary-care-providers
September 09, 2013 - Study
Association of communication between hospital-based physicians and primary care providers with patient outcomes.
Citation Text:
Bell CM, Schnipper JL, Auerbach AD, et al. Association of communication between hospital-based physicians and primary care providers with patient out…
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psnet.ahrq.gov/node/47262/psn-pdf
August 22, 2018 - The Case for Medication Safety Officers (MSO).
August 22, 2018
Horsham, PA: Institute for Safe Medication Practices; 2018.
https://psnet.ahrq.gov/issue/case-medication-safety-officers-mso
Medication safety is a concern in various settings across an organization. This white paper discusses the
role of a medication …
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psnet.ahrq.gov/node/42875/psn-pdf
January 22, 2014 - Communication in the operating theatre.
January 22, 2014
Weldon S-M, Korkiakangas T, Bezemer J, et al. Communication in the operating theatre. Br J Surg.
2013;100(13):1677-88. doi:10.1002/bjs.9332.
https://psnet.ahrq.gov/issue/communication-operating-theatre
This systematic review of communication in the operating…