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psnet.ahrq.gov/issue/interhospital-transfer-patients-discharged-academic-hospitalists-and-general-internists
August 01, 2018 - Study
Interhospital transfer patients discharged by academic hospitalists and general internists: characteristics and outcomes.
Citation Text:
Sokol-Hessner L, White AA, Davis KF, et al. Interhospital transfer patients discharged by academic hospitalists and general internists: Character…
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psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors
March 30, 2022 - Adverse Events, Near Misses, and Errors
Citation Text:
Adverse Events, Near Misses, and Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/issue/creating-safer-operating-room-groups-team-dynamics-and-crew-resource-management-principles
June 11, 2008 - Review
Emerging Classic
Creating a safer operating room: groups, team dynamics and crew resource management principles.
Citation Text:
Wakeman D, Langham MR. Creating a safer operating room: Groups, team dynamics and crew resource management principles. Semin Pe…
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psnet.ahrq.gov/issue/medication-management-strategies-community-dwelling-older-adults-multisite-qualitative
November 20, 2024 - Study
Medication management strategies by community-dwelling older adults: a multisite qualitative analysis.
Citation Text:
Jallow F, Stehling E, Sajwani-Merchant Z, et al. Medication management strategies by community-dwelling older adults: a multisite qualitative analysis. J Patient Sa…
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psnet.ahrq.gov/node/850361/psn-pdf
June 14, 2023 - a role that
could have helped draw attention to the vegetation finding in this case earlier after patient … discharge and
transfer back to the SNF.
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psnet.ahrq.gov/node/836941/psn-pdf
April 27, 2022 - primer/post-acute-transitional-services-safety-home-based-care-programs
https://psnet.ahrq.gov/primer/discharge-planning-and-transitions-care
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psnet.ahrq.gov/web-mm/direct-oral-anticoagulants-are-high-risk-medications-potentially-complex-dosing
August 21, 2005 - Direct Oral Anticoagulants are High-Risk Medications with Potentially Complex Dosing
Citation Text:
Giannini J, Wong M, Dager W, et al. Direct Oral Anticoagulants are High-Risk Medications with Potentially Complex Dosing. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depar…
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psnet.ahrq.gov/issue/surgeon-agreement-time-handover-prospective-cohort-study
July 19, 2010 - Study
Surgeon agreement at the time of handover, a prospective cohort study.
Citation Text:
Hilsden R, Moffat B, Knowles S, et al. Surgeon agreement at the time of handover, a prospective cohort study. World J Emerg Surg. 2016;11:11. doi:10.1186/s13017-016-0065-6.
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psnet.ahrq.gov/issue/competition-and-health-plan-performance-evidence-health-maintenance-organization-insurance
July 14, 2009 - Study
Competition and health plan performance: evidence from health maintenance organization insurance markets.
Citation Text:
Scanlon D, Swaminathan S, Chernew M, et al. Competition and health plan performance: evidence from health maintenance organization insurance markets. Med Care.…
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psnet.ahrq.gov/issue/qualitative-exploration-patients-attitudes-towards-participate-inform-notice-know-pink
July 06, 2012 - Study
A qualitative exploration of patients' attitudes towards the 'Participate Inform Notice Know' (PINK) patient safety video.
Citation Text:
Pinto A, Vincent CA, Darzi A, et al. A qualitative exploration of patients' attitudes towards the 'Participate Inform Notice Know' (PINK) patien…
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psnet.ahrq.gov/issue/lack-patient-knowledge-regarding-hospital-medications
September 20, 2006 - Study
Lack of patient knowledge regarding hospital medications.
Citation Text:
Lack of patient knowledge regarding hospital medications.
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…
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psnet.ahrq.gov/issue/improving-handoff-deliberate-cognitive-processing-results-randomized-controlled-experimental
March 18, 2020 - Study
Improving handoff by deliberate cognitive processing: results from a randomized controlled experimental study.
Citation Text:
van Heesch G, Frenkel J, Kollen W, et al. Improving handoff by deliberate cognitive processing: results from a randomized controlled experimental study. Jt …
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psnet.ahrq.gov/node/50698/psn-pdf
November 27, 2019 - Missed Opportunities for Suicide Risk Assessment
November 27, 2019
Xiong G, Kahn D. Missed Opportunities for Suicide Risk Assessment. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment
Disclosure of Relevant Financial Relationships: As a provider accredited by the Acc…
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psnet.ahrq.gov/issue/what-patient-centered-should-mean-confessions-extremist
August 04, 2021 - Commentary
What 'patient-centered' should mean: confessions of an extremist.
Citation Text:
Berwick DM. What 'patient-centered' should mean: confessions of an extremist. Health Aff (Millwood). 2009;28(4):w555-65. doi:10.1377/hlthaff.28.4.w555.
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DOI Goog…
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psnet.ahrq.gov/issue/primer-pdsa-executing-plan-do-study-act-cycles-practice-not-just-name
December 04, 2016 - Review
A primer on PDSA: executing plan–do–study–act cycles in practice, not just in name.
Citation Text:
Leis JA, Shojania KG. A primer on PDSA: executing plan-do-study-act cycles in practice, not just in name. BMJ Qual Saf. 2017;26(7):572-577. doi:10.1136/bmjqs-2016-006245.
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psnet.ahrq.gov/issue/safety-lessons-nih-clinical-center
April 10, 2024 - Commentary
Safety lessons from the NIH Clinical Center.
Citation Text:
Gandhi TK. Safety Lessons from the NIH Clinical Center. N Engl J Med. 2016;375(18):1705-1707.
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…
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psnet.ahrq.gov/node/851568/psn-pdf
July 31, 2023 - Strong
discharge planning support is needed to refer the patient to appropriate resources, such as substance
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psnet.ahrq.gov/web-mm/complicated-course-severe-alcohol-withdrawal-dexmedetomidine-infusion
June 14, 2023 - Strong discharge planning support is needed to refer the patient to appropriate resources, such as substance
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psnet.ahrq.gov/node/49568/psn-pdf
September 01, 2008 - Failure to Latch
September 1, 2008
Rodriguez M, Mannel R, Frye DR. Failure to Latch. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/failure-latch
The Case
The patient is a full-term, 8.5-pound, healthy infant whose parents were strongly committed to
breastfeeding exclusively for 6 months. However, early br…
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psnet.ahrq.gov/node/49762/psn-pdf
June 01, 2016 - The Case of Mistaken Intubation
June 1, 2016
Silveira MJ. The Case of Mistaken Intubation. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/case-mistaken-intubation
Case Objectives
Appreciate that most older adults and many younger chronically ill patients have discussed or
documented their preferences for l…