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psnet.ahrq.gov/issue/multiple-points-system-failure-underpin-continuous-subcutaneous-infusion-safety-incidents
December 16, 2020 - Study
Multiple points of system failure underpin continuous subcutaneous infusion safety incidents in palliative care: a mixed methods analysis.
Citation Text:
Brown AJ, Yardley S, Bowers B, et al. Multiple points of system failure underpin continuous subcutaneous infusion safety inciden…
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psnet.ahrq.gov/issue/identifying-barriers-and-opportunities-telehealth-implementation-amidst-covid-19-pandemic
July 07, 2021 - Commentary
Identifying barriers to and opportunities for telehealth implementation amidst the COVID-19 pandemic by using a human factors approach: a leap into the future of health care delivery?
Citation Text:
Zhang T, Mosier J, Subbian V. Identifying barriers to and opportunities for te…
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psnet.ahrq.gov/issue/impact-smart-pump-electronic-health-record-interoperability-patient-safety-and-finances
September 23, 2020 - Study
Impact of smart pump-electronic health record interoperability on patient safety and finances at a community hospital
Citation Text:
Wei W, Coffey W, Adeola M, et al. Impact of smart pump-electronic health record interoperability on patient safety and finances at a community hospit…
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psnet.ahrq.gov/issue/ashp-guidelines-safe-use-automated-compounding-devices-preparation-parenteral-nutrition
October 19, 2022 - Organizational Policy/Guidelines
ASHP Guidelines on the Safe Use of Automated Compounding Devices for the Preparation of Parenteral Nutrition Admixtures.
Citation Text:
Iredell B, Mourad H, Nickman NA, et al. ASHP Guidelines on the Safe Use of Automated Compounding Devices for the Prepar…
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psnet.ahrq.gov/issue/patient-safety-and-satisfaction-fully-remote-management-radiation-oncology-care
October 19, 2022 - Study
Patient safety and satisfaction with fully remote management of radiation oncology care.
Citation Text:
Cuaron JJ, McBride S, Chino F, et al. Patient safety and satisfaction with fully remote management of radiation oncology care. JAMA Netw Open. 2024;7(6):e2416570. doi:10.1001/jam…
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psnet.ahrq.gov/issue/triad-xii-are-patients-aware-and-agree-dnr-or-polst-orders-their-medical-records
September 15, 2021 - Study
TRIAD XII: are patients aware of and agree with DNR or POLST orders in their medical records.
Citation Text:
Mirarchi FL, Juhasz K, Cooney TE, et al. TRIAD XII: Are Patients Aware of and Agree With DNR or POLST Orders in Their Medical Records. J Patient Saf. 2019;15(3):230-237. doi…
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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/857059/psn-pdf
November 29, 2023 - information
into the EHR (or a team list) about patients with long inpatient courses and complex post-discharge … planning needs.
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psnet.ahrq.gov/node/33779/psn-pdf
March 01, 2015 - Handoffs and Transitions
January 22, 2014
Sehgal NL. Handoffs and Transitions. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/handoffs-and-transitions
Annual Perspective 2014
Despite recent efforts to promote clinical integration, the United States health care system remains highly
fragmented. From it…
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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/web-mm/correct-treatment-plan-incorrect-diagnosis-pharmacist-intervention
May 01, 2011 - Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention
Citation Text:
Nelson SD. Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Cop…
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psnet.ahrq.gov/issue/does-checklist-reduce-number-errors-made-nurse-assembled-discharge-prescriptions
March 24, 2019 - Study
Does a checklist reduce the number of errors made in nurse-assembled discharge prescriptions?
Citation Text:
Byrne C, Sierra H, Tolhurst R. Does a checklist reduce the number of errors made in nurse-assembled discharge prescriptions? Br J Nurs. 2017;26(8):464-467. doi:10.12968/bjon…
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psnet.ahrq.gov/node/49636/psn-pdf
October 01, 2011 - Acute care physical therapy examination and discharge planning. In: Malone DJ,
Lindsay KLB, eds.
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psnet.ahrq.gov/issue/improving-quality-insulin-prescribing-people-diabetes-being-discharged-hospital
November 16, 2022 - Journal Article
Improving the quality of insulin prescribing for people with diabetes being discharged from hospital
Citation Text:
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. 2…
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psnet.ahrq.gov/perspective/approach-improving-patient-safety-communication
August 31, 2020 - particular noting information about the patient’s family members and communicating with them prior to patient … discharge back to the community.
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psnet.ahrq.gov/issue/barriers-and-facilitators-implementing-interventions-reducing-avoidable-hospital-readmission
April 25, 2018 - Review
Barriers and facilitators to implementing interventions for reducing avoidable hospital readmission: systematic review of qualitative studies.
Citation Text:
Fu BQ, Zhong CCW, Wong CHL, et al. Barriers and facilitators to implementing interventions for reducing avoidable hospital …
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psnet.ahrq.gov/node/838197/psn-pdf
September 28, 2022 - Be Picky about your PICCs—Fragmented Care and Poor
Communication at Discharge Leads to a PICC without a
Plan.
September 28, 2022
Marti CS, Reese SK, Brown-McManus M. Be Picky about your PICCs—Fragmented Care and Poor
Communication at Discharge Leads to a PICC without a Plan. PSNet [internet]. 2022.
https://psnet.…
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psnet.ahrq.gov/node/73128/psn-pdf
July 01, 2022 - Hospital at Home? Care Reduces Costs, Readmissions,
and Complications and Enhances Satisfaction for Elderly
Patients.
April 7, 2021
https://psnet.ahrq.gov/innovation/hospital-homesm-care-reduces-costs-readmissions-and-complications-
and-enhances
Summary
The Hospital at Homesm program provides hospital-level care…
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psnet.ahrq.gov/perspective/patient-safety-frail-older-patients
November 26, 2019 - You can also have a very proactive multi-disciplinary team and discharge planning model for those patients
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psnet.ahrq.gov/perspective/conversation-heidi-wald-md
November 26, 2019 - You can also have a very proactive multi-disciplinary team and discharge planning model for those patients