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psnet.ahrq.gov/node/36673/psn-pdf
January 18, 2011 - Patient safety: honoring advanced directives.
January 18, 2011
Tice MA. Patient safety: honoring advanced directives. Home Healthc Nurse. 2007;25(2):79-81.
https://psnet.ahrq.gov/issue/patient-safety-honoring-advanced-directives
The author discusses why failure to follow an advance directive should be considered a …
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psnet.ahrq.gov/node/837606/psn-pdf
June 29, 2022 - Nonopioid directives: unintended consequences in the
operating room.
June 29, 2022
Bicket MC, Waljee JF, Hilliard P. Nonopioid directives: unintended consequences in the operating room.
JAMA Health Forum. 2022;3(6):e221356. doi:10.1001/jamahealthforum.2022.1356.
https://psnet.ahrq.gov/issue/nonopioid-directives-un…
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psnet.ahrq.gov/node/45193/psn-pdf
October 03, 2017 - Choice, transparency, coordination, and quality among
direct-to-consumer telemedicine websites and apps
treating skin disease.
October 3, 2017
Resneck JS, Abrouk M, Steuer M, et al. Choice, Transparency, Coordination, and Quality Among Direct-to-
Consumer Telemedicine Websites and Apps Treating Skin Disease. JAMA …
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psnet.ahrq.gov/node/73284/psn-pdf
May 19, 2021 - Safety participation at the direct care level: results of a
patient questionnaire.
May 19, 2021
Duhn L, Gumapac N, Medves J. Safety participation at the direct care level: results of a patient
questionnaire. Patient Exp J. 2021;8(1):59-68. doi:10.35680/2372-0247.1506.
https://psnet.ahrq.gov/issue/safety-participat…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.365_slideshow.ppt
January 01, 2016 - PowerPoint Presentation
Spotlight
A Room Without Orders
1
This presentation is based on the January 2016
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Amy Vogelsmeier, PhD, RN, Sinclair School of Nursing; and Laurel Despins, PhD, RN, Sinclair Sc…
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psnet.ahrq.gov/node/37457/psn-pdf
February 15, 2011 - Benefits of direct observation in medication
administration to detect errors.
February 15, 2011
Diaz-Navarlaz T, Pronovost P, Beortegui E, et al. Benefits of Direct Observation in Medication
Administration to Detect Errors. J Patient Saf. 2009;3(4). doi:10.1097/pts.0b013e31815b4cc3.
https://psnet.ahrq.gov/issue/be…
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psnet.ahrq.gov/node/35674/psn-pdf
June 28, 2010 - Medication errors and adverse drug events in an intensive
care unit: direct observation approach for detection.
June 28, 2010
Kopp BJ, Erstad BL, Allen ME, et al. Medication errors and adverse drug events in an intensive care unit:
direct observation approach for detection. Crit Care Med. 2006;34(2):415-25.
https:…
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psnet.ahrq.gov/node/39065/psn-pdf
January 03, 2017 - Family alert: implementing direct family activation of a
pediatric rapid response team.
January 3, 2017
Ray EM, Smith R, Massie S, et al. Family alert: implementing direct family activation of a pediatric rapid
response team. Jt Comm J Qual Patient Saf. 2009;35(11):575-580.
https://psnet.ahrq.gov/issue/family-aler…
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psnet.ahrq.gov/node/38425/psn-pdf
January 29, 2010 - Hospitalists as Emerging Leaders in Patient Safety:
lessons learned and future directions.
January 29, 2010
Flanders S, Kaufman SR, Saint S, et al. Hospitalists as emerging leaders in patient safety: lessons learned
and future directions. J Patient Saf. 2009;5(1):3-8. doi:10.1097/PTS.0b013e31819751f2.
https://psne…
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psnet.ahrq.gov/node/44476/psn-pdf
September 26, 2016 - The impact of interruptions on the duration of nursing
interventions: a direct observation study in an academic
emergency department.
September 26, 2016
Cole G, Stefanus D, Gardner H, et al. The impact of interruptions on the duration of nursing interventions: a
direct observation study in an academic emergency de…
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psnet.ahrq.gov/node/49750/psn-pdf
January 01, 2016 - A Room Without Orders
January 1, 2016
Vogelsmeier A, Despins L. A Room Without Orders. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/room-without-orders
Case Objectives
Review a common process for planned direct hospital admissions.
Describe challenges of prioritizing day-to-day patient care activities wi…
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psnet.ahrq.gov/node/47006/psn-pdf
October 13, 2018 - Assessment of the safety of discharging select patients
directly home from the intensive care unit: a multicenter
population-based cohort study.
October 13, 2018
Stelfox HT, Soo A, Niven DJ, et al. Assessment of the Safety of Discharging Select Patients Directly Home
From the Intensive Care Unit: A Multicenter Pop…
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psnet.ahrq.gov/node/46829/psn-pdf
July 23, 2018 - Quality and variability of patient directions in electronic
prescriptions in the ambulatory care setting.
July 23, 2018
Yang Y, Ward-Charlerie S, Dhavle AA, et al. Quality and Variability of Patient Directions in Electronic
Prescriptions in the Ambulatory Care Setting. J Manag Care Spec Pharm. 2018;24(7):691-699.
…
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psnet.ahrq.gov/node/43918/psn-pdf
September 27, 2017 - Medication-administration errors in an urban mental
health hospital: a direct observation study.
September 27, 2017
Cottney A, Innes J. Medication-administration errors in an urban mental health hospital: a direct
observation study. Int J Ment Health Nurs. 2015;24(1):65-74. doi:10.1111/inm.12096.
https://psnet.ahr…
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psnet.ahrq.gov/node/36788/psn-pdf
August 26, 2011 - Direct observation approach for detecting medication
errors and adverse drug events in a pediatric intensive
care unit.
August 26, 2011
Buckley MS, Erstad BL, Kopp BJ, et al. Direct observation approach for detecting medication errors and
adverse drug events in a pediatric intensive care unit. Pediatr Crit Care Me…
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psnet.ahrq.gov/node/43625/psn-pdf
October 29, 2014 - Assessing distractors and teamwork during surgery:
developing an event-based method for direct observation.
October 29, 2014
Seelandt JC, Tschan F, Keller S, et al. Assessing distractors and teamwork during surgery: developing an
event-based method for direct observation. BMJ Qual Saf. 2014;23(11):918-29. doi:10.11…
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psnet.ahrq.gov/node/44368/psn-pdf
September 29, 2017 - A systematic review of the effect of distraction on
surgeon performance: directions for operating room
policy and surgical training.
September 29, 2017
Mentis HM, Chellali A, Manser K, et al. A systematic review of the effect of distraction on surgeon
performance: directions for operating room policy and surgical …
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psnet.ahrq.gov/node/49646/psn-pdf
February 01, 2012 - Poorly Advanced Directives
February 1, 2012
Anderson WG. Poorly Advanced Directives. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/poorly-advanced-directives
The Case
Cared for at home by his wife and family, an 82-year-old man with multiple chronic medical conditions
described his overall health as decli…
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psnet.ahrq.gov/node/44028/psn-pdf
April 01, 2015 - Alarm system management: evidence-based guidance
encouraging direct measurement of informativeness to
improve alarm response.
April 1, 2015
Rayo MF, Moffatt-Bruce SD. Alarm system management: evidence-based guidance encouraging direct
measurement of informativeness to improve alarm response. BMJ Qual Saf. 2015;24(…
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psnet.ahrq.gov/issue/building-bridges-future-directions-medical-error-disclosure-research
October 10, 2018 - Study
Building bridges: future directions for medical error disclosure research.
Citation Text:
Hannawa AF, Beckman H, Mazor KM, et al. Building bridges: future directions for medical error disclosure research. Patient Educ Couns. 2013;92(3):319-327. doi:10.1016/j.pec.2013.05.017.
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