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  1. 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…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49481/psn-pdf
    May 01, 2005 - Discharge Against Medical Advice May 1, 2005 Hwang SW. Discharge Against Medical Advice. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/discharge-against-medical-advice The Case A 50-year-old man with a history of alcohol abuse and alcohol-induced dementia was admitted to the medical service with mild alco…

  3. 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…

  4. 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…

  5. SAFER Care: improving caregiver comprehension of discharge instructions. | PSNet

    psnet.ahrq.gov/issue/safer-care-improving-caregiver-comprehension-discharge-instructions
    October 26, 2022 - Study SAFER Care: improving caregiver comprehension of discharge instructions. Citation Text: 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. Copy Citation Fo…

  6. 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…

  7. 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…

  8. 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…

  9. 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…

  10. 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…

  11. 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…

  12. 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:…

  13. 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…

  14. 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…

  15. 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;…

  16. 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…

  17. 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…

  18. 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…

  19. 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…

  20. Adverse drug events and medication problems in "Hospital at Home" patients. | PSNet

    psnet.ahrq.gov/issue/adverse-drug-events-and-medication-problems-hospital-home-patients
    December 16, 2020 - Study Adverse drug events and medication problems in "Hospital at Home" patients. Citation Text: Mann E, Zepeda O, Soones T, et al. Adverse drug events and medication problems in "Hospital at Home" patients. Home Health Care Serv Q. 2018;37(3):177-186. doi:10.1080/01621424.2018.1454372. …
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