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psnet.ahrq.gov/issue/toward-safer-opioid-prescribing-hiv-care-tower-mixed-methods-cluster-randomized-trial
September 07, 2022 - Study
Toward safer opioid prescribing in HIV care (TOWER): a mixed-methods, cluster-randomized trial.
Citation Text:
Cedillo G, George MC, Deshpande R, et al. Toward safer opioid prescribing in HIV care (TOWER): a mixed-methods, cluster-randomized trial. Addict Sci Clin Pract. 2022;17(1)…
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psnet.ahrq.gov/issue/provider-patient-communication-and-hospital-ratings-perceived-gaps-and-forward-thinking-about
December 16, 2020 - Study
Provider-patient communication and hospital ratings: perceived gaps and forward thinking about the effects of COVID-19.
Citation Text:
Belasen AT, Hertelendy AJ, Belasen AR, et al. Provider–patient communication and hospital ratings: perceived gaps and forward thinking about the ef…
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psnet.ahrq.gov/issue/burnout-and-medical-errors-among-american-surgeons
December 21, 2014 - Study
Burnout and medical errors among American surgeons.
Citation Text:
Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995-1000. doi:10.1097/SLA.0b013e3181bfdab3.
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psnet.ahrq.gov/issue/effect-nonpayment-hospital-acquired-catheter-associated-urinary-tract-infection-statewide
October 17, 2017 - Study
Effect of nonpayment for hospital-acquired, catheter–associated urinary tract infection: a statewide analysis.
Citation Text:
Meddings JA, Reichert H, Rogers MAM, et al. Effect of nonpayment for hospital-acquired, catheter-associated urinary tract infection: a statewide analysis.…
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psnet.ahrq.gov/issue/effects-i-pass-nursing-handoff-bundle-communication-quality-and-workflow
November 12, 2014 - Study
Effects of the I-PASS nursing handoff bundle on communication quality and workflow.
Citation Text:
Starmer AJ, Schnock KO, Lyons A, et al. Effects of the I-PASS Nursing Handoff Bundle on communication quality and workflow. BMJ Qual Saf. 2017;26(12):949-957. doi:10.1136/bmjqs-2016-0…
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psnet.ahrq.gov/issue/support-hospital-home-elders-randomized-trial
November 30, 2016 - Study
Support from hospital to home for elders: a randomized trial.
Citation Text:
Goldman E, Sarkar U, Kessell E, et al. Support from hospital to home for elders: a randomized trial. Ann Intern Med. 2014;161(7):472-81. doi:10.7326/M14-0094.
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psnet.ahrq.gov/issue/nature-and-timing-incidents-intercepted-surpass-checklist-surgical-patients
September 20, 2011 - Study
Nature and timing of incidents intercepted by the SURPASS checklist in surgical patients.
Citation Text:
de Vries EN, Prins HA, Bennink C, et al. Nature and timing of incidents intercepted by the SURPASS checklist in surgical patients. BMJ Qual Saf. 2012;21(6):503-8. doi:10.1136/…
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psnet.ahrq.gov/node/38106/psn-pdf
November 17, 2009 - Effective use of medication-related decision support in
CPOE.
November 17, 2009
Metzger JB, Welebob E, Turisco F, Classen DC. Patient Saf Qual Healthc. Sept/Oct 2008;5:16-24.
https://psnet.ahrq.gov/issue/effective-use-medication-related-decision-support-cpoe
This article describes strategies for integrating…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.245_slideshow.ppt
July 01, 2011 - Spotlight Case July 2008
Spotlight Case
Watch the Warfarin!
1
2
Source and Credits
This presentation is based on the July 2011
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Raman Khanna, MD, and Margaret Fang, MD, MPH; University of California, Sa…
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psnet.ahrq.gov/innovation/adverse-drug-event-ade-surveillance-and-pharmacist-counseling
June 28, 2023 - Adverse Drug Event (ADE) Surveillance and Pharmacist Counseling
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January 31, 2024
Innovation
Contact
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psnet.ahrq.gov/node/39212/psn-pdf
March 04, 2011 - The impact of computerized provider order entry on
medication errors in a multispecialty group practice.
March 4, 2011
Devine EB, Hansen RN, Wilson-Norton JL, et al. The impact of computerized provider order entry on
medication errors in a multispecialty group practice. J Am Med Inform Assoc. 2010;17(1):78-84.
doi…
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psnet.ahrq.gov/node/48009/psn-pdf
May 15, 2019 - Associations between in-hospital mortality, health care
utilization, and inpatient costs with the 2011 resident duty
hour revision.
May 15, 2019
Eid SM, Ponor L, Reed DA, et al. Associations Between In-Hospital Mortality, Health Care Utilization, and
Inpatient Costs With the 2011 Resident Duty Hour Revision. J Gra…
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psnet.ahrq.gov/node/40073/psn-pdf
July 01, 2011 - Residents' perspectives on ACGME regulation of
supervision and duty hours—a national survey.
December 8, 2010
Drolet BC, Spalluto LB, Fischer SA. Residents' perspectives on ACGME regulation of supervision and duty
hours--a national survey. N Engl J Med. 2010;363(23):e34. doi:10.1056/NEJMp1011413.
https://psnet.ahr…
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psnet.ahrq.gov/node/40904/psn-pdf
January 04, 2012 - Effect of illness severity and comorbidity on patient
safety and adverse events.
January 4, 2012
Naessens JM, Campbell CR, Shah ND, et al. Effect of illness severity and comorbidity on patient safety
and adverse events. Am J Med Qual. 2012;27(1):48-57. doi:10.1177/1062860611413456.
https://psnet.ahrq.gov/issue/eff…
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psnet.ahrq.gov/node/49810/psn-pdf
November 01, 2017 - Palliative Care: Comfort vs. Harm
November 1, 2017
Jox RJ. Palliative Care: Comfort vs. Harm. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm
Case Objectives
Recognize errors may be difficult to identify in palliative care.
State that medication errors and errors in communica…
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psnet.ahrq.gov/node/41832/psn-pdf
November 26, 2012 - Healthcare management strategies: interdisciplinary team
factors.
November 26, 2012
Andreatta P, Marzano D. Healthcare management strategies: interdisciplinary team factors. Curr Opin
Obstet Gynecol. 2012;24(6):445-52. doi:10.1097/GCO.0b013e328359f007.
https://psnet.ahrq.gov/issue/healthcare-management-strategies-…
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psnet.ahrq.gov/issue/improving-process-while-changing-practice-fmea-and-medication-administration
January 18, 2011 - Commentary
Improving process while changing practice: FMEA and medication administration.
Citation Text:
Riehle MA, Bergeron D, Hyrkäs K. Improving process while changing practice. Nurs Manage. 2009;39(2). doi:10.1097/01.numa.0000310533.54708.38.
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psnet.ahrq.gov/issue/nurses-sleep-work-hours-and-patient-care-quality-and-safety
April 23, 2012 - Study
Nurses' sleep, work hours, and patient care quality, and safety
Citation Text:
Nurses' sleep, work hours, and patient care quality, and safety Stimpfel AW, Fatehi F, Kovner C. Sleep Health. 2020;6(3):314-320.
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psnet.ahrq.gov/issue/critical-laboratory-value-notification-failure-mode-effects-and-criticality-analysis
June 27, 2018 - Commentary
Critical laboratory value notification: a failure mode effects and criticality analysis.
Citation Text:
Saxena S, Kempf R, Wilcox S, et al. Critical laboratory value notification: a failure mode effects and criticality analysis. Jt Comm J Qual Patient Saf. 2005;31(9):495-506…
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psnet.ahrq.gov/issue/drug-related-hospital-admissions
September 07, 2016 - Study
Classic
Drug-related hospital admissions.
Citation Text:
Drug-related hospital admissions. Einarson TR
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