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psnet.ahrq.gov/node/49858/psn-pdf
April 01, 2019 - What Happened on Telemetry?
April 1, 2019
Sandau KE, Funk M. What Happened on Telemetry? PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/what-happened-telemetry
Case Objectives
Describe current hospital practices for continuous telemetry monitoring.
Appreciate key recommendations from the Update to Practice…
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psnet.ahrq.gov/node/853962/psn-pdf
September 27, 2023 - Diagnosing fast and slow: cognitive bias in obstetrics.
September 27, 2023
Atallah F, Gomes C, Minkoff H. Diagnosing fast and slow: cognitive bias in obstetrics. Obstet Gynecol.
2023;142(3):727-732. doi:10.1097/aog.0000000000005303.
https://psnet.ahrq.gov/issue/diagnosing-fast-and-slow-cognitive-bias-obstetrics
Re…
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psnet.ahrq.gov/node/44386/psn-pdf
August 12, 2015 - Using simulation to improve systems.
August 12, 2015
Lundberg PW, Korndorffer JR. Using Simulation to Improve Systems. Surg Clin North Am. 2015;95(4):885-
92. doi:10.1016/j.suc.2015.04.007.
https://psnet.ahrq.gov/issue/using-simulation-improve-systems
Safety approaches from aviation that can be applied to health c…
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psnet.ahrq.gov/node/42308/psn-pdf
June 10, 2013 - Little shop of errors: an innovative simulation patient
safety workshop for community health care
professionals.
June 10, 2013
Tupper JB, Pearson KB, Meinersmann KM, et al. Little shop of errors: an innovative simulation patient
safety workshop for community health care professionals. J Contin Educ Nurs. 2013;44(6…
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psnet.ahrq.gov/node/837140/psn-pdf
May 18, 2022 - Nursing surveillance: a concept analysis
May 18, 2022
Halverson CC, Scott Tilley D. Nursing surveillance: a concept analysis. Nurs Forum. 2022;57(3):454-460.
doi:10.1111/nuf.12702.
https://psnet.ahrq.gov/issue/nursing-surveillance-concept-analysis
Nursing surveillance is an intervention for maintaining patient saf…
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psnet.ahrq.gov/node/50652/psn-pdf
January 01, 2020 - Preventable adverse drug events: descriptive
epidemiology.
November 13, 2019
Woo SA, Cragg A, Wickham ME, et al. Preventable adverse drug events: Descriptive epidemiology. Br J
Clin Pharmacol. 2020;86(2):291-302. doi:10.1111/bcp.14139.
https://psnet.ahrq.gov/issue/preventable-adverse-drug-events-descriptive-epidem…
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psnet.ahrq.gov/node/43967/psn-pdf
November 16, 2015 - Equipped: overcoming barriers to change to improve
quality of care (theories of change).
November 16, 2015
Lachman P, Runnacles J, Dudley J, et al. Equipped: overcoming barriers to change to improve quality of
care (theories of change). Arch Dis Child Educ Pract Ed. 2015;100(1):13-8. doi:10.1136/archdischild-2013-
…
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psnet.ahrq.gov/node/850929/psn-pdf
June 21, 2023 - Requirements for implementing a 'just culture' within
healthcare organisations: an integrative review.
June 21, 2023
Murray JS, Lee J, Larson S, et al. Requirements for implementing a ‘just culture’ within healthcare
organisations: an integrative review. BMJ Open Qual. 2023;12(2):e002237. doi:10.1136/bmjoq-2022-
0…
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psnet.ahrq.gov/node/44591/psn-pdf
March 15, 2016 - Lacerations and embedded needles caused by
epinephrine autoinjector use in children.
March 15, 2016
Brown JC, Tuuri RE, Akhter S, et al. Lacerations and Embedded Needles Caused by Epinephrine
Autoinjector Use in Children. Ann Emerg Med. 2016;67(3):307-315.e8.
doi:10.1016/j.annemergmed.2015.07.011.
https://psnet.a…
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psnet.ahrq.gov/node/47032/psn-pdf
May 23, 2018 - Clinical dental faculty members' perceptions of diagnostic
errors and how to avoid them.
May 23, 2018
Nikdel C, Nikdel K, Ibarra-Noriega A, et al. Clinical Dental Faculty Members' Perceptions of Diagnostic
Errors and How to Avoid Them. J Dent Educ. 2018;82(4):340-348. doi:10.21815/JDE.018.037.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/43478/psn-pdf
August 27, 2014 - Is it time to move beyond errors in clinical reasoning and
discuss accuracy?
August 27, 2014
Wood TJ. Is it time to move beyond errors in clinical reasoning and discuss accuracy? Adv Health Sci Educ
Theory Pract. 2014;19(3):403-407. doi:10.1007/s10459-014-9498-4.
https://psnet.ahrq.gov/issue/it-time-move-beyond-er…
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psnet.ahrq.gov/node/39517/psn-pdf
May 25, 2010 - A prospective controlled trial of the effect of a multi-
faceted intervention on early recognition and intervention
in deteriorating hospital patients.
May 25, 2010
Mitchell IA, McKay H, Van Leuvan C, et al. A prospective controlled trial of the effect of a multi-faceted
intervention on early recognition and inter…
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psnet.ahrq.gov/node/44516/psn-pdf
June 10, 2018 - Managing hospitalized patients with ambulatory pumps:
findings from an ISMP survey—Part 1.
June 10, 2018
ISMP Medication Safety Alert! Acute care edition. November 19, 2015;20(23):1-5.
https://psnet.ahrq.gov/issue/managing-hospitalized-patients-ambulatory-pumps-findings-ismp-survey-part-1
Infusion therapies are in…
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psnet.ahrq.gov/node/36769/psn-pdf
June 15, 2011 - Using incident reporting to improve patient safety: a
conceptual model.
June 15, 2011
Pronovost PJ, Holzmueller CG, Young J, et al. Using Incident Reporting to Improve Patient Safety. J
Patient Saf. 2008;3(1). doi:10.1097/pts.0b013e318030ca05.
https://psnet.ahrq.gov/issue/using-incident-reporting-improve-patient-s…
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psnet.ahrq.gov/node/43404/psn-pdf
August 06, 2014 - 'Even now it makes me angry': health care students'
professionalism dilemma narratives.
August 6, 2014
Monrouxe L, Rees CE, Endacott R, et al. 'Even now it makes me angry': health care students'
professionalism dilemma narratives. Med Educ. 2014;48(5):502-17. doi:10.1111/medu.12377.
https://psnet.ahrq.gov/issue/ev…
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psnet.ahrq.gov/node/44265/psn-pdf
January 22, 2016 - How surgical trainees handle catastrophic errors: a
qualitative study.
January 22, 2016
Balogun JA, Bramall AN, Bernstein M. How Surgical Trainees Handle Catastrophic Errors: A Qualitative
Study. J Surg Educ. 2015;72(6):1179-84. doi:10.1016/j.jsurg.2015.05.003.
https://psnet.ahrq.gov/issue/how-surgical-trainees-ha…
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psnet.ahrq.gov/node/40454/psn-pdf
June 01, 2012 - Influence of unit-level staffing on medication errors and
falls in military hospitals.
June 1, 2012
Breckenridge-Sproat S, Johantgen M, Patrician PA. Influence of unit-level staffing on medication errors and
falls in military hospitals. West J Nurs Res. 2012;34(4):455-74. doi:10.1177/0193945911407090.
https://psne…
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psnet.ahrq.gov/node/73592/psn-pdf
August 11, 2021 - Using performance improvement to enhance time-out
compliance and prevent wrong-site surgery.
August 11, 2021
Vance ME, Proctor T, Schmidt KA. Using performance improvement to enhance time-out compliance and
prevent wrong-site surgery. AORN J. 2021;113(6):635-642. doi:10.1002/aorn.13413.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/45398/psn-pdf
August 15, 2016 - Incorporating indications into medication ordering—time
to enter the age of reason.
August 15, 2016
Schiff G, Seoane-Vazquez E, Wright A. Incorporating Indications into Medication Ordering--Time to Enter
the Age of Reason. N Engl J Med. 2016;375(4):306-9. doi:10.1056/NEJMp1603964.
https://psnet.ahrq.gov/issue/inco…
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psnet.ahrq.gov/node/73911/psn-pdf
October 06, 2021 - Misdiagnosis of acute myocardial infarction: a systematic
review of the literature.
October 6, 2021
Kwok CS, Bennett S, Azam Z, et al. Misdiagnosis of acute myocardial infarction: a systematic review of the
literature. Crit Pathw Cardiol. 2021;20(3):155-162. doi:10.1097/hpc.0000000000000256.
https://psnet.ahrq.gov…