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221. Patterns of nurse–physician communication and agreement on the plan of care. | PSNet
     psnet.ahrq.gov/issue/patterns-nurse-physician-communication-and-agreement-plan-care
     December 21, 2014 - Study Patterns of nurse–physician communication and agreement on the plan of care. Citation Text: O'Leary KJ, Thompson JA, Landler MP, et al. Patterns of nurse-physician communication and agreement on the plan of care. Qual Saf Health Care. 2010;19(3):195-9. doi:10.1136/qshc.2008.03022…

222. What cannot be said on television about health care. | PSNet
     psnet.ahrq.gov/issue/what-cannot-be-said-television-about-health-care
     January 10, 2018 - Commentary What cannot be said on television about health care. Citation Text: Emanuel EJ. What Cannot Be Said on Television About Health Care. JAMA. 2007;297(19). doi:10.1001/jama.297.19.2131. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML E…

223. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867986/psn-pdf
     March 24, 2025 - In Conversation with Edwin Boudreaux about Suicide Prevention March 24, 2025 Boudreaux E, Gale B, Mossburg SE. In Conversation with Edwin Boudreaux about Suicide Prevention. PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/conversation-edwin-boudreaux-about-suicide-prevention Editor’s note: Edwin Boudre…

224. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60363/psn-pdf
     March 01, 2021 - Transition Coaches® Reduce Readmissions for Medicare Patients With Complex Postdischarge Needs Originally published on June 12, 2020 Last updated on January 11, 2021 https://psnet.ahrq.gov/innovation/transition-coachesr-reduce-readmissions-medicare-patients-complex- postdischarge-needs Summary Under a program kn…

225. A Virtual Hospitalist Program to Address a Hospital’s Challenges at the Start of the COVID-19 Pandemic | PSNet
     psnet.ahrq.gov/innovation/virtual-hospitalist-program-address-hospitals-challenges-start-covid-19-pandemic
     October 30, 2024 - Virtual hospitalists also conducted discharge planning and provided bereavement support and staffing

226. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73092/psn-pdf
     March 31, 2021 - SAFER Care: improving caregiver comprehension of discharge instructions. March 31, 2021 Uong A, Philips K, Hametz P, et al. SAFER care: improving caregiver comprehension of discharge instructions. Pediatrics. 2021;147(4):e20200031. doi:10.1542/peds.2020-0031. https://psnet.ahrq.gov/issue/safer-care-improving-careg…

227. Talking with Patients and Families about Medical Error: A Guide for Education and Practice. | PSNet
     psnet.ahrq.gov/issue/talking-patients-and-families-about-medical-error-guide-education-and-practice
     July 24, 2019 - Book/Report Talking with Patients and Families about Medical Error: A Guide for Education and Practice. Citation Text: Talking with Patients and Families about Medical Error: A Guide for Education and Practice. Truog RD, Browning DM, Johnson JA, Gallagher TH. Baltimore, MD: Johns Hopkins…

228. Eliminating perioperative adverse events at Ascension Health. | PSNet
     psnet.ahrq.gov/issue/eliminating-perioperative-adverse-events-ascension-health
     November 16, 2022 - Commentary Eliminating perioperative adverse events at Ascension Health. Citation Text: Ewing H, Bruder G, Baroco P, et al. Eliminating perioperative adverse events at Ascension Health. Jt Comm J Qual Patient Saf. 2007;33(5):256-66. Copy Citation Format: Google Scholar PubM…

229. Spike in fatal medication errors at the beginning of each month. | PSNet
     psnet.ahrq.gov/issue/spike-fatal-medication-errors-beginning-each-month
     January 26, 2022 - Study Spike in fatal medication errors at the beginning of each month. Citation Text: Phillips DP, Jarvinen JR, Phillips RR. A spike in fatal medication errors at the beginning of each month. Pharmacotherapy. 2005;25(1):1-9. Copy Citation Format: Google Scholar PubMed BibT…

230. Surgical data recording technology: a solution to address medical errors? | PSNet
     psnet.ahrq.gov/issue/surgical-data-recording-technology-solution-address-medical-errors
     June 22, 2022 - Commentary Surgical data recording technology: a solution to address medical errors? Citation Text: Shah NA, Jue J, Mackey T. Surgical Data Recording Technology. Ann Surg. 2020;271(3):431-433. doi:10.1097/sla.0000000000003510. Copy Citation Format: DOI Google Scholar BibTeX…

231. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33604/psn-pdf
     December 15, 2024 - Pharmacist's Role in Medication Safety December 15, 2024 The Pharmacist's Role in Medication Safety. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/pharmacists-role-medication-safety PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current res…

232. Recurrent Hypoglycemia: A Care Transition Failure? | PSNet
     psnet.ahrq.gov/web-mm/recurrent-hypoglycemia-care-transition-failure
     December 23, 2020 - SPOTLIGHT CASE Recurrent Hypoglycemia: A Care Transition Failure? Citation Text: Eytan T. Recurrent Hypoglycemia: A Care Transition Failure?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format:…

233. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33592/psn-pdf
     December 15, 2024 - Adverse Events, Near Misses, and Errors December 15, 2024 Adverse Events, Near Misses, and Errors. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current re…

234. VHA's movement for change: implementing high-reliability principles and practices. | PSNet
     psnet.ahrq.gov/issue/vhas-movement-change-implementing-high-reliability-principles-and-practices
     August 21, 2024 - Commentary VHA's movement for change: implementing high-reliability principles and practices. Citation Text: Cox GR, Starr LM. VHA's movement for change: implementing high-reliability principles and practices. J Healthc Manag. 2023;68(3):151-157. doi:10.1097/jhm-d-23-00056. Copy Citati…

235. Neurologic patient safety: an in-depth study of malpractice claims. | PSNet
     psnet.ahrq.gov/issue/neurologic-patient-safety-depth-study-malpractice-claims
     November 11, 2015 - Study Neurologic patient safety: an in-depth study of malpractice claims. Citation Text: Glick TH, Cranberg LD, Hanscom RB, et al. Neurologic patient safety: an in-depth study of malpractice claims. Neurology. 2005;65(8):1284-6. Copy Citation Format: Google Scholar PubMed…

236. The Toolkit for Using the AHRQ Quality Indicators: How To Improve Hospital Quality and Safety. | PSNet
     psnet.ahrq.gov/issue/toolkit-using-ahrq-quality-indicators-how-improve-hospital-quality-and-safety
     August 01, 2012 - Audiovisual Presentation The Toolkit for Using the AHRQ Quality Indicators: How To Improve Hospital Quality and Safety. Citation Text: The Toolkit for Using the AHRQ Quality Indicators: How To Improve Hospital Quality and Safety. Rockville, MD: Agency for Healthcare Research and Quality;…

237. Residual Anesthesia: Tepid Burn | PSNet
     psnet.ahrq.gov/web-mm/residual-anesthesia-tepid-burn
     February 10, 2010 - Residual Anesthesia: Tepid Burn Citation Text: Kurrek MM, Twersky RS. Residual Anesthesia: Tepid Burn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndN…

238. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45484/psn-pdf
     December 04, 2016 - High prevalence of medication discrepancies between home health referrals and Centers for Medicare and Medicaid Services home health certification and plan of care and their potential to affect safety of vulnerable elderly adults. December 4, 2016 Brody AA, Gibson B, Tresner-Kirsch D, et al. High Prevalence of Me…

239. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50535/psn-pdf
     October 16, 2019 - Improving the quality of insulin prescribing for people with diabetes being discharged from hospital October 16, 2019 Bain A, Silcock J, Kavanagh S, et al. Improving the quality of insulin prescribing for people with diabetes being discharged from hospital. BMJ Open Qual. 2019;8(3):e000655. doi:10.1136/bmjoq-2019-0…

240. Reduced postdischarge incidents after implementation of a hospital-to-home transition intervention for children with medical complexity. | PSNet
     psnet.ahrq.gov/issue/reduced-postdischarge-incidents-after-implementation-hospital-home-transition-intervention
     September 06, 2023 - Study Reduced postdischarge incidents after implementation of a hospital-to-home transition intervention for children with medical complexity. Citation Text: Huth K, Hotz A, Emara N, et al. Reduced postdischarge incidents after implementation of a hospital-to-home transition intervention…