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psnet.ahrq.gov/issue/use-maternal-early-warning-trigger-tool-reduces-maternal-morbidity
September 27, 2017 - Study
Use of maternal early warning trigger tool reduces maternal morbidity.
Citation Text:
Shields LE, Wiesner S, Klein C, et al. Use of Maternal Early Warning Trigger tool reduces maternal morbidity. Am J Obstet Gynecol. 2016;214(4):527.e1-527.e6. doi:10.1016/j.ajog.2016.01.154.
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psnet.ahrq.gov/issue/designing-intervention-improve-medication-safety-nursing-home-residents-based-experiential
February 14, 2024 - Commentary
Designing an intervention to improve medication safety for nursing home residents based on experiential knowledge related to patient safety culture at the nursing home front line: cocreative process study.
Citation Text:
Juhl MH, Soerensen AL, Vardinghus-Nielsen H, et al. Desi…
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psnet.ahrq.gov/issue/characterising-nature-primary-care-patient-safety-incident-reports-england-and-wales-national
December 16, 2015 - Book/Report
Characterising the nature of primary care patient safety incident reports in the England and Wales National Reporting and Learning System: a mixed-methods agenda-setting study for general practice.
Citation Text:
Carson-Stevens A, Hibbert P, Williams H, et al. Characterising …
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psnet.ahrq.gov/issue/intervention-decrease-catheter-related-bloodstream-infections-icu
June 16, 2011 - Study
Classic
An intervention to decrease catheter-related bloodstream infections in the ICU.
Citation Text:
Pronovost P, Needham DM, Berenholtz SM, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355(2…
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psnet.ahrq.gov/issue/complications-daytime-elective-laparoscopic-cholecystectomies-performed-surgeons-who-operated
April 12, 2019 - Study
Complications of daytime elective laparoscopic cholecystectomies performed by surgeons who operated the night before.
Citation Text:
Vinden C, Nash DM, Rangrej J, et al. Complications of daytime elective laparoscopic cholecystectomies performed by surgeons who operated the night be…
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psnet.ahrq.gov/issue/use-structured-approach-and-virtual-simulation-practice-improve-diagnostic-reasoning
December 15, 2021 - Study
Use of a structured approach and virtual simulation practice to improve diagnostic reasoning.
Citation Text:
Dekhtyar M, Park YS, Kalinyak J, et al. Use of a structured approach and virtual simulation practice to improve diagnostic reasoning. Diagnosis (Berl). 2022;9(1):69-76. doi:…
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psnet.ahrq.gov/issue/patient-harm-resulting-medication-reconciliation-process-failures-study-serious-events
October 07, 2020 - Study
Patient harm resulting from medication reconciliation process failures: a study of serious events reported by Pennsylvania hospitals.
Citation Text:
Harper A, Kukielka E, Jones RM. Patient harm resulting from medication reconciliation process failures: a study of serious events rep…
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psnet.ahrq.gov/issue/association-nurse-workload-missed-nursing-care-neonatal-intensive-care-unit
September 27, 2017 - Study
Emerging Classic
Association of nurse workload with missed nursing care in the neonatal intensive care unit.
Citation Text:
Tubbs-Cooley HL, Mara CA, Carle AC, et al. Association of Nurse Workload With Missed Nursing Care in the Neonatal Intensive Care Uni…
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psnet.ahrq.gov/issue/its-two-worlds-apart-analysis-vulnerable-patient-handover-practices-discharge-hospital
January 15, 2025 - Study
"It's like two worlds apart": an analysis of vulnerable patient handover practices at discharge from hospital.
Citation Text:
Groene RO, Orrego C, Suñol R, et al. "It's like two worlds apart": an analysis of vulnerable patient handover practices at discharge from hospital. BMJ Qu…
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psnet.ahrq.gov/issue/characteristics-disease-specific-and-generic-diagnostic-pitfalls-qualitative-study
December 02, 2020 - Study
Characteristics of disease-specific and generic diagnostic pitfalls: a qualitative study.
Citation Text:
Schiff GD, Volodarskaya M, Ruan E, et al. Characteristics of disease-specific and generic diagnostic pitfalls: a qualitative study. JAMA Netw Open. 2022;5(1):e2144531. doi:10.10…
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psnet.ahrq.gov/issue/does-patient-centered-design-guarantee-patient-safety-using-human-factors-engineering-find
November 23, 2016 - Study
Does patient-centered design guarantee patient safety?: Using human factors engineering to find a balance between provider and patient needs.
Citation Text:
France DJ, Throop P, Walczyk B, et al. Does Patient-Centered Design Guarantee Patient Safety? J Patient Saf. 2008;1(3):145-15…
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psnet.ahrq.gov/perspective/conversation-withalison-stuebe-md-msc-and-kristin-tully-phd
October 06, 2021 - In many ways, this viewpoint may be just as important to patients when it comes to defining safe maternal
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psnet.ahrq.gov/perspective/health-equity-and-maternal-health
October 06, 2021 - In many ways, this viewpoint may be just as important to patients when it comes to defining safe maternal
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.344_slideshow.ppt
April 01, 2015 - PowerPoint Presentation
Spotlight
Dissecting the Presentation
*
This presentation is based on the April 2015
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Shirley Beng Suat Ooi, MBBS (S'pore), Emergency Medicine Department, National Univers…
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psnet.ahrq.gov/web-mm/falling-between-cracks-software
March 09, 2011 - Falling Between the Cracks in the Software
Citation Text:
Adler-Milstein J. Falling Between the Cracks in the Software. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
Google Scholar BibTeX En…
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psnet.ahrq.gov/web-mm/picture-speaks-1000-words
July 16, 2015 - A Picture Speaks 1000 Words
Citation Text:
Hemphill RR. A Picture Speaks 1000 Words. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …
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psnet.ahrq.gov/node/49836/psn-pdf
July 01, 2018 - Primary Workaround, Secondary Complication
July 1, 2018
Debono D, Levett-Jones T. Primary Workaround, Secondary Complication. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/primary-workaround-secondary-complication
The Case
A young adult with a progressive neurological disorder presented to a hospital emerg…
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psnet.ahrq.gov/node/49844/psn-pdf
October 01, 2018 - Diffusion of Responsibility Leads to Danger
October 1, 2018
Balcezak TJ, Deshpande O. Diffusion of Responsibility Leads to Danger. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/diffusion-responsibility-leads-danger
The Case
A 70-year-old man was sent to the emergency department (ED) from a nursing facility…
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psnet.ahrq.gov/node/33634/psn-pdf
May 04, 2006 - The Wild West: Patient Safety in Office-Based Anesthesia
May 1, 2006
Kaushal R, Upadhyayula S, Gaba DM, et al. The Wild West: Patient Safety in Office-Based Anesthesia.
PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/wild-west-patient-safety-office-based-anesthesia
Perspective
Over the last decade, sur…
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psnet.ahrq.gov/node/49761/psn-pdf
May 01, 2016 - The Fluidity of Diagnostic "Wet Reads"
May 1, 2016
Lee CS, Hess CP. The Fluidity of Diagnostic "Wet Reads". PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/fluidity-diagnostic-wet-reads
The Case
A 64-year-old man with heavy tobacco use presented to the emergency department (ED) with chest pain.
His electroc…