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psnet.ahrq.gov/node/845357/psn-pdf
March 29, 2023 - Reducing hospital harm: establishing a command centre
to foster situational awareness.
March 29, 2023
Collins B. Reducing hospital harm: establishing a command centre to foster situational awareness. Healthc
Q. 2022;25(2):75-81. doi:10.12927/hcq.2022.26885.
https://psnet.ahrq.gov/innovation/reducing-hospital-harm-…
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psnet.ahrq.gov/node/48095/psn-pdf
June 26, 2019 - Exposure to incivility hinders clinical performance in a
simulated operative crisis.
June 26, 2019
Katz D, Blasius K, Isaak R, et al. Exposure to incivility hinders clinical performance in a simulated operative
crisis. BMJ Qual Saf. 2019;28(9):750-757. doi:10.1136/bmjqs-2019-009598.
https://psnet.ahrq.gov/issue/ex…
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psnet.ahrq.gov/node/38674/psn-pdf
February 17, 2011 - Cost implications of reduced work hours and workloads
for resident physicians.
February 17, 2011
Nuckols TK, Bhattacharya J, Wolman DM, et al. Cost implications of reduced work hours and workloads for
resident physicians. N Engl J Med. 2009;360(21):2202-15. doi:10.1056/NEJMsa0810251.
https://psnet.ahrq.gov/issue/c…
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psnet.ahrq.gov/node/41226/psn-pdf
April 22, 2012 - Defining impact of a rapid response team: qualitative
study with nurses, physicians and hospital
administrators.
April 22, 2012
Benin AL, Borgstrom CP, Jenq GY, et al. Defining impact of a rapid response team: qualitative study with
nurses, physicians and hospital administrators. BMJ Qual Saf. 2012;21(5):391-8. do…
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psnet.ahrq.gov/node/42150/psn-pdf
July 03, 2014 - Effects of the 2011 duty hour reforms on interns and their
patients: a prospective longitudinal cohort study.
July 3, 2014
Sen S, Kranzler HR, Didwania AK, et al. Effects of the 2011 duty hour reforms on interns and their patients:
a prospective longitudinal cohort study. JAMA Intern Med. 2013;173(8):657-62; discus…
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psnet.ahrq.gov/node/847717/psn-pdf
April 19, 2023 - Quality improvement initiative to decrease central line-
associated bloodstream infections during the COVID-19
pandemic: a "zero harm" approach.
April 19, 2023
Redstone CS, Zadeh M, Wilson M-A, et al. Quality improvement initiative to decrease central line-
associated bloodstream infections during the COVID-19 pan…
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psnet.ahrq.gov/node/42900/psn-pdf
September 19, 2016 - Suicide attempts and completions on medical-surgical
and intensive care units.
September 19, 2016
Mills PD, Watts V, Hemphill RR. Suicide attempts and completions on medical-surgical and intensive care
units. J Hosp Med. 2014;9(3):182-5. doi:10.1002/jhm.2141.
https://psnet.ahrq.gov/issue/suicide-attempts-and-compl…
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psnet.ahrq.gov/node/39143/psn-pdf
February 14, 2011 - Impact of a pharmacist-facilitated hospital discharge
program: a quasi-experimental study.
February 14, 2011
Walker PC, Bernstein SJ, Jones JNT, et al. Impact of a pharmacist-facilitated hospital discharge program: a
quasi-experimental study. Arch Intern Med. 2009;169(21):2003-10. doi:10.1001/archinternmed.2009.398…
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psnet.ahrq.gov/node/39551/psn-pdf
May 26, 2010 - Simulation-based training improves physicians'
performance in patient care in high-stakes clinical setting
of cardiac surgery.
May 26, 2010
Bruppacher HR, Alam SK, LeBlanc VR, et al. Simulation-based training improves physicians' performance
in patient care in high-stakes clinical setting of cardiac surgery. Anest…
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psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
October 31, 2023 - disclose relevant financial relationships with commercial interests related to the subject matter of this educational
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psnet.ahrq.gov/perspective/missed-nursing-care-key-measure-patient-safety
March 01, 2018 - Our research shows that variation in nurse staffing and the educational qualifications of nurses
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psnet.ahrq.gov/perspective/conversation-linda-aiken-phd-rn
March 01, 2018 - Our research shows that variation in nurse staffing and the educational qualifications of nurses
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psnet.ahrq.gov/node/33566/psn-pdf
September 15, 2024 - Teamwork Training
September 15, 2024
Teamwork Training. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/teamwork-training
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed …
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psnet.ahrq.gov/node/49445/psn-pdf
May 01, 2004 - No Blood, Please
May 1, 2004
Liang BA. No Blood, Please. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/no-blood-please
The Case
A young woman, about 30 years of age, was injured in an automobile collision. She was brought to the
emergency department (ED) via ambulance, where she was found to be suffering …
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psnet.ahrq.gov/node/33743/psn-pdf
December 01, 2012 - Quality and Safety Challenges in Critical Care: Preventing
and Treating Delirium in the Intensive Care Unit
December 1, 2012
Vasilevskis EE, Ely WE, Dittus RS. Quality and Safety Challenges in Critical Care: Preventing and Treating
Delirium in the Intensive Care Unit. PSNet [internet]. 2012.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/33883/psn-pdf
July 01, 2019 - In Conversation With… Suchi Saria, PhD
July 1, 2019
In Conversation With… Suchi Saria, PhD. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-suchi-saria-phd
Editor's note: Dr. Saria is the John C. Malone Assistant Professor of computer science, statistics, and
health policy at Johns Hopkins …
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psnet.ahrq.gov/web-mm/hyponatremia-secondary-home-parenteral-nutrition-error
May 27, 2020 - Hyponatremia Secondary to Home Parenteral Nutrition Error
Citation Text:
Haas K, Lee A. Hyponatremia Secondary to Home Parenteral Nutrition Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
Copy Citation
Format:
…
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psnet.ahrq.gov/node/49630/psn-pdf
July 01, 2011 - Watch the Warfarin!
July 1, 2011
Khanna R, Fang MC. Watch the Warfarin!. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/watch-warfarin
Case Objectives
Understand best practices for safe discharge of patients on warfarin.
Describe recent advances in anticoagulation monitoring for ambulatory patients.
Discu…
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psnet.ahrq.gov/sites/default/files/2020-05/final_may-spotlight-fatal_pca_slides_05.01.2020_cme_review-revised.pdf
January 01, 2020 - Editor: Meghan Weyrich, MPH
2
https://psnet.ahrq.gov/webmm
Objectives
At the conclusion of this educational
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psnet.ahrq.gov/node/45279/psn-pdf
September 27, 2016 - Does clinical supervision of health professionals improve
patient safety? A systematic review and meta-analysis.
September 27, 2016
Snowdon DA, Hau R, Leggat SG, et al. Does clinical supervision of health professionals improve patient
safety? A systematic review and meta-analysis. Int J Qual Health Care. 2016;28(4)…