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psnet.ahrq.gov/perspective/what-have-we-learned-about-safe-inpatient-handovers
March 01, 2011 - more savvy thinking about how to do this research, we can also think about how to use that to more effectively
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psnet.ahrq.gov/node/60858/psn-pdf
August 26, 2020 - When the Meds Don’t Reach the Bed
August 26, 2020
Molla M, Le K, Mendoza P. When the Meds Don’t Reach the Bed. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/when-meds-dont-reach-bed
The Case
A 69-year-old man with cognitive impairment and marginal housing was admitted for acute exacerbation of
chronic obs…
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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/perspective/conversation-paul-g-shekelle-md-mph-phd
February 26, 2025 - In Conversation With… Paul G. Shekelle, MD, MPH, PhD
October 1, 2011
Citation Text:
In Conversation With… Paul G. Shekelle, MD, MPH, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. …
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psnet.ahrq.gov/node/33614/psn-pdf
June 01, 2005 - Interpreting the Patient Safety Literature
June 1, 2005
Shojania KG. Interpreting the Patient Safety Literature. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/interpreting-patient-safety-literature
Perspective
Five years ago, a widely publicized randomized trial reported a 90% reduction in the inciden…
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psnet.ahrq.gov/web-mm/when-meds-dont-reach-bed
May 16, 2022 - When the Meds Don’t Reach the Bed
Citation Text:
Molla M, Le K, Mendoza P. When the Meds Don’t Reach the Bed. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 X…
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psnet.ahrq.gov/node/49559/psn-pdf
April 01, 2008 - The Forgotten Drip
April 1, 2008
Josephson AS. The Forgotten Drip. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/forgotten-drip
The Case
A 45-year-old man was brought to the emergency department by his friends because of a 1-day history of a
severe headache and "bizarre behavior." A computed tomography (C…
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psnet.ahrq.gov/node/33606/psn-pdf
December 15, 2024 - Opioid Safety
December 15, 2024
Opioid Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/opioid-safety
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 in 2024.
Bac…
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psnet.ahrq.gov/node/45171/psn-pdf
August 01, 2016 - Weekly variation in health-care quality by day and time of
admission: a nationwide, registry-based, prospective
cohort study of acute stroke care.
August 1, 2016
Bray BD, Cloud GC, James MA, et al. Weekly variation in health-care quality by day and time of admission:
a nationwide, registry-based, prospective cohor…
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psnet.ahrq.gov/node/35872/psn-pdf
September 07, 2011 - Improving ambulatory prescribing safety with a handheld
decision support system: a randomized controlled trial.
September 7, 2011
Berner ES, Houston TK, Ray MN, et al. Improving ambulatory prescribing safety with a handheld decision
support system: a randomized controlled trial. J Am Med Inform Assoc. 2006;13(2):17…
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psnet.ahrq.gov/node/36222/psn-pdf
March 10, 2011 - Impact of a computerized clinical decision support
system on reducing inappropriate antimicrobial use: a
randomized controlled trial.
March 10, 2011
McGregor JC, Weekes E, Forrest GN, et al. Impact of a computerized clinical decision support system on
reducing inappropriate antimicrobial use: a randomized controll…
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psnet.ahrq.gov/node/72508/psn-pdf
January 01, 2021 - Helping healthcare teams save lives during COVID-19:
insights and countermeasures from team science.
November 25, 2020
Traylor AM. Helping healthcare teams save lives during COVID-19: insights and countermeasures from
team science. Am Psychol. 2021;76(1):1-13. doi:10.1037/amp0000750.
https://psnet.ahrq.gov/issue/h…