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psnet.ahrq.gov/web-mm/new-oral-anticoagulants
July 01, 2011 - SPOTLIGHT CASE
New Oral Anticoagulants
Citation Text:
Fang MC. New Oral Anticoagulants. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/node/49760/psn-pdf
May 01, 2016 - Mismanagement of Delirium
May 1, 2016
Merrilees J, Lee KP. Mismanagement of Delirium. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/mismanagement-delirium
The Case
An 85-year-old man with early stage vascular dementia fell on the sidewalk and fractured his leg. Although
fitted with a cast at a regional ho…
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psnet.ahrq.gov/web-mm/hyperbilirubinemia-refractory-phototherapy
March 01, 2006 - Hyperbilirubinemia Refractory to Phototherapy
Citation Text:
Bhutani VK, Wong RJ. Hyperbilirubinemia Refractory to Phototherapy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/sites/default/files/2023-07/spotlight_a_complicated_course.pdf
January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_A Complicated Course-Severe Alcohol Withdrawal - SLIDES.pptx
Spotlight
A Complicated Course: Severe Alcohol Withdrawal with
Dexmedetomidine Infusion
Source and Credits
• This presentation is based on the July 2023 AHRQ WebM&M
Spotlight Case
o See the full article at ht…
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psnet.ahrq.gov/node/46644/psn-pdf
June 20, 2018 - The Science of Teamwork.
June 20, 2018
McDaniel SH, Salas E, eds. Am Psychol. 2018;73:305-600.
https://psnet.ahrq.gov/issue/science-teamwork
Effective teams are core to safe practice in a wide range of work environments. This special issue explores
team psychology with an emphasis on high-risk industries such as s…
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psnet.ahrq.gov/node/40008/psn-pdf
January 04, 2011 - How is medication prescribing ceased? A systematic
review.
January 4, 2011
Ostini R, Jackson C, Hegney D, et al. How is medication prescribing ceased? A systematic review. Med
Care. 2011;49(1):24-36. doi:10.1097/MLR.0b013e3181ef9a7e.
https://psnet.ahrq.gov/issue/how-medication-prescribing-ceased-systematic-review
…
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psnet.ahrq.gov/node/41711/psn-pdf
September 26, 2012 - Beyond FMEA: the structured what-if technique (SWIFT).
September 26, 2012
Card AJ, Ward JR, Clarkson PJ. Beyond FMEA: The structured what-if technique (SWIFT). J Healthc Risk
Manag. 2012;31(4):23-29. doi:10.1002/jhrm.20101.
https://psnet.ahrq.gov/issue/swift-new-tool-identifying-prospective-hazards
This commentary…
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psnet.ahrq.gov/node/851568/psn-pdf
July 31, 2023 - A Complicated Course: Severe Alcohol Withdrawal with
Dexmedetomidine Infusion
July 31, 2023
Duong T, Boctor N, Bourgeois JA. A Complicated Course: Severe Alcohol Withdrawal with
Dexmedetomidine Infusion. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/complicated-course-severe-alcohol-withdrawal-dexmedetomid…
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psnet.ahrq.gov/node/34105/psn-pdf
December 24, 2008 - Barcode technology: its role in increasing the safety of
blood transfusion.
December 24, 2008
Turner CL, Casbard AC, Murphy MF. Barcode technology: its role in increasing the safety of blood
transfusion. Transfusion (Paris). 2004;43(9). doi:10.1046/j.1537-2995.2003.00428.x.
https://psnet.ahrq.gov/issue/barcode-tec…
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psnet.ahrq.gov/node/42875/psn-pdf
January 22, 2014 - Communication in the operating theatre.
January 22, 2014
Weldon S-M, Korkiakangas T, Bezemer J, et al. Communication in the operating theatre. Br J Surg.
2013;100(13):1677-88. doi:10.1002/bjs.9332.
https://psnet.ahrq.gov/issue/communication-operating-theatre
This systematic review of communication in the operating…
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psnet.ahrq.gov/node/844753/psn-pdf
September 18, 2019 - Detecting medication administration errors.
September 18, 2019
Durham ML, Jankiewicz A. Detecting Medication Administration Errors. J Patient Saf. 2019;15(3):181-183.
doi:10.1097/PTS.0000000000000384.
https://psnet.ahrq.gov/issue/detecting-medication-administration-errors
Considerable effort has been devoted to op…
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psnet.ahrq.gov/node/39824/psn-pdf
December 06, 2010 - Team working in intensive care: current evidence and
future endeavors.
December 6, 2010
Richardson J, West MA, Cuthbertson BH. Team working in intensive care: current evidence and future
endeavors. Curr Opin Crit Care. 2010;16(6):643-8. doi:10.1097/MCC.0b013e32833e9731.
https://psnet.ahrq.gov/issue/team-working-in…
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psnet.ahrq.gov/node/49803/psn-pdf
January 01, 2018 - Point-of-care Mixup: 1 Shot Turns Into 3
August 1, 2017
Berberich RF. Point-of-care Mixup: 1 Shot Turns Into 3. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/point-care-mixup-1-shot-turns-3
The Case
A 2-month-old boy was brought in for a routine 2-month well-child visit. The exam was completed and the
app…
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psnet.ahrq.gov/primer/computerized-provider-order-entry
March 15, 2025 - Computerized Provider Order Entry
Citation Text:
Computerized Provider Order Entry. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/communication-consultants
October 01, 2018 - Communication With Consultants
Citation Text:
Cohn SL. Communication With Consultants. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/primer/handoffs
October 18, 2023 - Handoffs
Citation Text:
Handoffs and Signouts. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Download…
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psnet.ahrq.gov/issue/obtaining-best-possible-medication-history-hospital-admission-description-pharmacy-technician
October 31, 2023 - Study
Obtaining the best possible medication history at hospital admission: description of a pharmacy technician-driven program to identify medication discrepancies.
Citation Text:
Kabir R, Liaw S, Cerise J, et al. Obtaining the best possible medication history at hospital admission: des…
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psnet.ahrq.gov/issue/does-suggested-diagnosis-general-practitioners-referral-question-impact-diagnostic-reasoning
September 14, 2022 - Study
Does a suggested diagnosis in a general practitioners' referral question impact diagnostic reasoning: an experimental study.
Citation Text:
Staal J, Speelman M, Brand R, et al. Does a suggested diagnosis in a general practitioners’ referral question impact diagnostic reasoning: an …
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psnet.ahrq.gov/issue/impact-pharmacists-led-medicines-reconciliation-healthcare-outcomes-secondary-care-systematic
August 07, 2024 - Review
Emerging Classic
The impact of pharmacists-led medicines reconciliation on healthcare outcomes in secondary care: a systematic review and meta-analysis of randomized controlled trials.
Citation Text:
Cheema E, Alhomoud FK, Kinsara ASA-D, et al. The impact…
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psnet.ahrq.gov/issue/nursing-implications-early-warning-system-implemented-reduce-adverse-events-qualitative-study
October 27, 2021 - Study
Nursing implications of an early warning system implemented to reduce adverse events: a qualitative study.
Citation Text:
Braun EJ, Singh S, Penlesky AC, et al. Nursing implications of an early warning system implemented to reduce adverse events: a qualitative study. BMJ Qual Saf. …