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psnet.ahrq.gov/node/850909/psn-pdf
June 21, 2023 - Context matters: toward a multilevel perspective on
context in clinical reasoning and error.
June 21, 2023
Choi JJ, Durning SJ. Context matters: toward a multilevel perspective on context in clinical reasoning and
error. Diagnosis (Berl). 2023;10(2):89-95. doi:10.1515/dx-2022-0117.
https://psnet.ahrq.gov/issue/con…
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psnet.ahrq.gov/node/34957/psn-pdf
February 28, 2011 - Coordinating care across diseases, settings, and
clinicians: a key role for the generalist in practice.
February 28, 2011
Stille CJ, Jerant A, Bell D, et al. Coordinating care across diseases, settings, and clinicians: a key role for
the generalist in practice. Ann Intern Med. 2005;142(8):700-708.
https://psnet.ah…
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psnet.ahrq.gov/web-mm/bleeding-risk
November 01, 2003 - Bleeding Risk
Citation Text:
Crowther MA. Bleeding Risk. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/node/34767/psn-pdf
November 28, 2018 - Why Things Bite Back: Technology and the Revenge of
Unintended Consequences.
November 28, 2018
Tenner E. New York, NY: Knopf; 1996. ISBN: 0679425632.
https://psnet.ahrq.gov/issue/why-things-bite-back-technology-and-revenge-unintended-consequences
Tenner’s discussions of medical and nonmedical examples provide an e…
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psnet.ahrq.gov/node/47001/psn-pdf
August 17, 2018 - Realist synthesis of intentional rounding in hospital
wards: exploring the evidence of what works, for whom,
in what circumstances and why.
August 17, 2018
Sims S, Leamy M, Davies N, et al. Realist synthesis of intentional rounding in hospital wards: exploring the
evidence of what works, for whom, in what circumst…
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psnet.ahrq.gov/node/42909/psn-pdf
December 12, 2014 - Does applying technology throughout the medication use
process improve patient safety with antineoplastics?
December 12, 2014
Bubalo J, Warden BA, Wiegel JJ, et al. Does applying technology throughout the medication use process
improve patient safety with antineoplastics? J Oncol Pharm Pract. 2014;20(6):445-60.
do…
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psnet.ahrq.gov/node/50431/psn-pdf
October 02, 2019 - Time-series analysis of health care–associated infections
in a new hospital with all private rooms.
October 2, 2019
McDonald EG, Dendukuri N, Frenette C, et al. Time-Series Analysis of Health Care-Associated Infections
in a New Hospital With All Private Rooms. JAMA Intern Med. 2019. doi:10.1001/jamainternmed.2019.2…
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psnet.ahrq.gov/node/47768/psn-pdf
February 27, 2019 - Challenging authority and speaking up in the operating
room environment: a narrative synthesis.
February 27, 2019
Pattni N, Arzola C, Malavade A, et al. Challenging authority and speaking up in the operating room
environment: a narrative synthesis. Br J Anaesth. 2019;122(2):233-244. doi:10.1016/j.bja.2018.10.056.
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psnet.ahrq.gov/node/73637/psn-pdf
August 25, 2021 - Failures in Care Coordination and Reviewing a Patient's
Death at the VA Salt Lake City Healthcare System in Utah.
August 25, 2021
Washington, DC: Department of Veterans Affairs, Office of Inspector General. July 29, 2021. Report
No. 21-00657-197.
https://psnet.ahrq.gov/issue/failures-care-coordination-and-re…
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psnet.ahrq.gov/node/47554/psn-pdf
November 07, 2018 - Diagnostic Excellence Initiative.
November 7, 2018
Gordon and Betty Moore Foundation.
https://psnet.ahrq.gov/issue/diagnostic-excellence-improving-experience-and-outcomes-patient-care
Missed or delayed diagnoses lead to delays in care and significant preventable harm for patients. Despite
an increasing focus on di…
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psnet.ahrq.gov/node/45432/psn-pdf
September 14, 2016 - Clinical decision support: a 25 year retrospective and a 25
year vision.
September 14, 2016
Middleton B, Sittig DF, Wright A. Clinical Decision Support: a 25 Year Retrospective and a 25 Year Vision.
Yearb Med Inform. 2016;Suppl 1:S103-16. doi:10.15265/IYS-2016-s034.
https://psnet.ahrq.gov/issue/clinical-decision-s…
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psnet.ahrq.gov/node/840140/psn-pdf
January 01, 2023 - Implementation of the I-PASS handoff program in diverse
clinical environments: a multicenter prospective
effectiveness implementation study.
November 16, 2022
Starmer AJ, Spector ND, O'Toole JK, et al. Implementation of the I?PASS handoff program in diverse
clinical environments: a multicenter prospective effectiv…
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psnet.ahrq.gov/issue/advancing-effective-communication-cultural-competence-and-patient-and-family-centered-care
September 21, 2011 - Book/Report
Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals.
Citation Text:
Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals. Oakbrook Terrace, IL:…
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psnet.ahrq.gov/issue/risk-management-pearls-disclosure-adverse-events
July 05, 2017 - Book/Report
Risk Management Pearls on Disclosure of Adverse Events.
Citation Text:
Risk Management Pearls on Disclosure of Adverse Events. Amori GH. Chicago, IL: American Society for Healthcare Risk Management; 2006.
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psnet.ahrq.gov/issue/efficacy-tolerability-and-dose-dependent-effects-opioid-analgesics-low-back-pain-systematic
March 02, 2011 - Review
Efficacy, tolerability, and dose-dependent effects of opioid analgesics for low back pain: a systematic review and meta-analysis.
Citation Text:
Shaheed CA, Maher CG, Williams KA, et al. Efficacy, Tolerability, and Dose-Dependent Effects of Opioid Analgesics for Low Back Pain: A S…
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psnet.ahrq.gov/issue/computerized-clinical-decision-support-during-medication-ordering-long-term-care-residents
February 11, 2009 - Study
Computerized clinical decision support during medication ordering for long-term care residents with renal insufficiency.
Citation Text:
Field T, Rochon P, Lee M, et al. Computerized clinical decision support during medication ordering for long-term care residents with renal insuf…
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psnet.ahrq.gov/issue/impact-closed-loop-electronic-prescribing-and-administration-system-prescribing-errors
November 13, 2009 - Study
The impact of a closed-loop electronic prescribing and administration system on prescribing errors, administration errors and staff time: a before-and-after study.
Citation Text:
Franklin BD, O'Grady K, Donyai P, et al. The impact of a closed-loop electronic prescribing and admin…
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psnet.ahrq.gov/issue/effect-transitions-intervention-ensure-patient-safety-and-satisfaction-when-transferred
October 20, 2021 - Review
The effect of transitions intervention to ensure patient safety and satisfaction when transferred from hospital to home health care-a systematic review.
Citation Text:
Oksholm T, Gissum KR, Hunskår I, et al. The effect of transitions intervention to ensure patient safety and satis…
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psnet.ahrq.gov/issue/evaluation-quality-do-not-use-medication-abbreviation-audits-key-enabler-successful
September 15, 2021 - Study
Evaluation of the quality of 'do not use' medication abbreviation audits: a key enabler to successful implementation of audit and feedback.
Citation Text:
Li E, Marrandino J, Marshall S, et al. Evaluation of the quality of ‘do not use’ medication abbreviation audits: a key enabler…
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psnet.ahrq.gov/issue/medication-dosage-calculation-among-nursing-students-does-digital-technology-make-difference
October 12, 2022 - Review
Medication dosage calculation among nursing students: does digital technology make a difference? A literature review.
Citation Text:
Stake-Nilsson K, Almstedt M, Fransson G, et al. Medication dosage calculation among nursing students: does digital technology make a difference? A …