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psnet.ahrq.gov/node/73102/psn-pdf
July 01, 2022 - organizations,
current program costs, additional results, considerations for planning and development, and ensuring
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psnet.ahrq.gov/web-mm/do-you-want-everything-done-clarifying-code-status
March 27, 2024 - Clear and concise communication about the meaning of each decision and ensuring the patient understands
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psnet.ahrq.gov/node/60977/psn-pdf
January 08, 2020 - https://psnet.ahrq.gov//#3
https://psnet.ahrq.gov//#7
https://psnet.ahrq.gov//#8
for consultation, ensuring
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psnet.ahrq.gov/web-mm/difficult-encounters-cmo-and-cno-respond
March 01, 2018 - nurse "jumped" several levels in the chain of command and communication, she is to be commended for ensuring
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psnet.ahrq.gov/web-mm/code-status-vs-care-status
September 30, 2020 - SPOTLIGHT CASE
Code Status vs. Care Status
Citation Text:
Krisman RK, Spero H. Code Status vs. Care Status. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/web-mm/errors-managing-open-wound-elbow-leading-multiple-complications-and-operations
September 27, 2023 - SPOTLIGHT CASE
Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations
Citation Text:
Barnes DK, Utter GH. Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations. PSNet [internet]. Agency for Healthcare Research and Qu…
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psnet.ahrq.gov/issue/optimizing-smart-pump-technology-increasing-critical-safety-alerts-and-reducing-clinically
February 12, 2014 - Study
Optimizing smart pump technology by increasing critical safety alerts and reducing clinically insignificant alerts.
Citation Text:
Mansfield J, Jarrett S. Optimizing smart pump technology by increasing critical safety alerts and reducing clinically insignificant alerts. Hosp Pharm.…
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psnet.ahrq.gov/issue/conducting-safety-research-safely-policy-based-approach-conducting-research-peer-review
June 15, 2022 - Commentary
Conducting safety research safely: a policy-based approach for conducting research with peer review protected material.
Citation Text:
Myers LC, Blumenthal K, Phadke NA, et al. Conducting Safety Research Safely: A Policy-Based Approach for Conducting Research with Peer Review …
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psnet.ahrq.gov/issue/how-do-we-learn-errors-prospective-study-link-between-wards-learning-practices-and-medication
August 30, 2017 - Study
(How) do we learn from errors? A prospective study of the link between the ward's learning practices and medication administration errors.
Citation Text:
Drach-Zahavy A, Somech A, Admi H, et al. (How) do we learn from errors? A prospective study of the link between the ward's lea…
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psnet.ahrq.gov/issue/simulation-and-diagnostic-process-pilot-study-trauma-and-rapid-response-teams
July 16, 2015 - Study
Simulation and the diagnostic process: a pilot study of trauma and rapid response teams.
Citation Text:
Juriga LL, Murray DJ, Boulet JR, et al. Simulation and the diagnostic process: a pilot study of trauma and rapid response teams. Diagnosis (Berl). 2017;4(4):241-249. doi:10.1515/…
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psnet.ahrq.gov/issue/research-practice-factors-affecting-implementation-prospective-targeted-injury-detection
August 04, 2021 - Study
From research to practice: factors affecting implementation of prospective targeted injury-detection systems.
Citation Text:
Sorensen A, Harrison MI, Kane HL, et al. From research to practice: factors affecting implementation of prospective targeted injury-detection systems. BMJ …
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psnet.ahrq.gov/issue/evidence-based-medicine-cornerstone-clinical-care-not-quality-improvement
September 01, 2021 - Commentary
Evidence-based medicine: a cornerstone for clinical care but not for quality improvement.
Citation Text:
Mondoux S, Shojania KG. Evidence-based medicine: A cornerstone for clinical care but not for quality improvement. J Eval Clin Pract. 2019;25(3):363-368. doi:10.1111/jep.131…
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psnet.ahrq.gov/issue/trends-opioid-use-commercially-insured-and-medicare-advantage-populations-2007-16
March 13, 2018 - Study
Trends in opioid use in commercially insured and Medicare Advantage populations in 2007–16: retrospective cohort study.
Citation Text:
Jeffery MM, Hooten M, Henk HJ, et al. Trends in opioid use in commercially insured and Medicare Advantage populations in 2007-16: retrospective coh…
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psnet.ahrq.gov/issue/sources-and-magnitude-error-preparing-morphine-infusions-nurse-patient-controlled-analgesia
January 07, 2015 - Study
Sources and magnitude of error in preparing morphine infusions for nurse–patient controlled analgesia in a UK paediatric hospital.
Citation Text:
Rashed AN, Tomlin S, Aguado V, et al. Sources and magnitude of error in preparing morphine infusions for nurse-patient controlled analge…
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psnet.ahrq.gov/issue/telehealth-safety-framework-addressing-new-frontier-patient-safety
December 21, 2022 - Commentary
Telehealth safety framework: addressing a new frontier in patient safety.
Citation Text:
Gomes KM, Apathy N, Krevat SA, et al. Telehealth safety framework: addressing a new frontier in patient safety. J Patient Saf. 2024;20(5):358-359. doi:10.1097/pts.0000000000001243.
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psnet.ahrq.gov/issue/beliefs-ambulatory-care-physicians-about-accuracy-patient-medication-records-and-technology
December 03, 2014 - Study
Beliefs of ambulatory care physicians about accuracy of patient medication records and technology-enhanced solutions to improve accuracy.
Citation Text:
Weeks DL, Corbett CF, Stream G. Beliefs of ambulatory care physicians about accuracy of patient medication records and technolo…
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psnet.ahrq.gov/issue/blood-sampling-guidelines-focus-patient-safety-and-identification-review
August 10, 2016 - Review
Blood sampling guidelines with focus on patient safety and identification—a review.
Citation Text:
Cornes M, Ibarz M, Ivanov H, et al. Blood sampling guidelines with focus on patient safety and identification - a review. Diagnosis (Berl). 2019;6(1):33-37. doi:10.1515/dx-2018-0042.…
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psnet.ahrq.gov/issue/improving-patient-safety-avoiding-unread-imaging-exams-national-va-enterprise-electronic
March 12, 2025 - Study
Improving patient safety: avoiding unread imaging exams in the National VA enterprise electronic health record.
Citation Text:
Bastawrous S, Carney B. Improving Patient Safety: Avoiding Unread Imaging Exams in the National VA Enterprise Electronic Health Record. J Digit Imaging. 20…
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psnet.ahrq.gov/issue/international-perspectives-modifications-surgical-safety-checklist
November 17, 2021 - Study
International perspectives on modifications to the surgical safety checklist.
Citation Text:
Turley N, Elam M, Brindle ME. International perspectives on modifications to the surgical safety checklist. JAMA Netw Open. 2023;6(6):e2317183. doi:10.1001/jamanetworkopen.2023.17183.
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psnet.ahrq.gov/issue/identifying-discrepancies-electronic-medical-records-through-pharmacist-medication
August 03, 2022 - Study
Identifying discrepancies in electronic medical records through pharmacist medication reconciliation.
Citation Text:
Stewart AL, Lynch KJ. Identifying discrepancies in electronic medical records through pharmacist medication reconciliation. J Am Pharm Assoc (2003). 2012;52(1):59-…