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psnet.ahrq.gov/node/867097/psn-pdf
November 06, 2024 - Recommendations but no Action: Improving the
Effectiveness of Quality and Safety Recommendations in
Healthcare.
November 6, 2024
Recommendations But No Action: Improving The Effectiveness Of Quality And Safety Recommendations
In Healthcare. Dorset, UK: Health Services Safety Investigations Body; September 2024.
h…
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psnet.ahrq.gov/node/50848/psn-pdf
January 29, 2020 - Deficiencies in Care Coordination and Facility Response
to a Patient Suicide at the Minneapolis VA Health Care
System, Minnesota.
January 29, 2020
Washington, DC: Department of Veterans Affairs, Office of Inspector General. January 7, 2020. Report No.
19-00468-67.
https://psnet.ahrq.gov/issue/deficiencies-care-co…
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psnet.ahrq.gov/node/43021/psn-pdf
November 04, 2014 - Patient safety culture transformation in a children's
hospital: an interprofessional approach.
November 4, 2014
Nagelkerk J, Peterson T, Pawl BL, et al. Patient safety culture transformation in a children's hospital: an
interprofessional approach. J Interprof Care. 2014;28(4):358-64. doi:10.3109/13561820.2014.88593…
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psnet.ahrq.gov/node/837901/psn-pdf
August 24, 2022 - Trial and error: learning from malpractice claims in
childhood surgery.
August 24, 2022
Prieto JM, Falcone B, Greenberg P, et al. Trial and error: learning from malpractice claims in childhood
surgery. J Surg Res. 2022;279:84-88. doi:10.1016/j.jss.2022.05.033.
https://psnet.ahrq.gov/issue/trial-and-error-learning-…
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psnet.ahrq.gov/node/74102/psn-pdf
January 01, 2022 - Workforce planning and safe workload in sterile
compounding hospital pharmacy services.
November 24, 2021
Chaker A, Omair I, Mohamed WH, et al. Workforce planning and safe workload in sterile compounding
hospital pharmacy services. Am J Health Syst Pharm. 2022;79(3):187–192. doi:10.1093/ajhp/zxab379.
https://psnet…
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psnet.ahrq.gov/node/39088/psn-pdf
September 01, 2015 - Laboratory session to improve first-year pharmacy
students' knowledge and confidence concerning the
prevention of medication errors.
September 1, 2015
Kiersma ME, Darbishire PL, Plake KS, et al. Laboratory session to improve first-year pharmacy students'
knowledge and confidence concerning the prevention of medica…
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psnet.ahrq.gov/node/866728/psn-pdf
September 18, 2024 - ROI for a fall prevention intervention: invest a little, save a
lot.
September 18, 2024
Cooper AS. ROI for a fall prevention intervention: invest a little, save a lot. Nurs Adm Q. 2024;48(3):248-
252. doi:10.1097/naq.0000000000000647.
https://psnet.ahrq.gov/issue/roi-fall-prevention-intervention-invest-little-save…
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psnet.ahrq.gov/node/50569/psn-pdf
October 23, 2019 - Design and implementation of a tool for pharmacists to
register potential errors in prescribed medication.
October 23, 2019
Frid S, Zapico V, Mansilla A, et al. Design and Implementation of a Tool for Pharmacists to Register
Potential Errors in Prescribed Medication. Stud Health Technol Inform. 2019;264:581-585.
d…
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psnet.ahrq.gov/node/46047/psn-pdf
May 17, 2017 - Medicare failed to investigate suspicious infection cases
from 96 hospitals.
May 17, 2017
Jewett C. Kaiser Health News. May 9, 2017.
https://psnet.ahrq.gov/issue/medicare-failed-investigate-suspicious-infection-cases-96-hospitals
The Centers for Medicare and Medicaid Services decision to withhold payment for certa…
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psnet.ahrq.gov/node/43665/psn-pdf
November 20, 2015 - Patient safety education to change medical students'
attitudes and sense of responsibility.
November 20, 2015
Roh H, Park SJ, Kim T. Patient safety education to change medical students' attitudes and sense of
responsibility. Med Teach. 2015;37(10):908-14. doi:10.3109/0142159X.2014.970988.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/44195/psn-pdf
June 06, 2018 - An assessment of basic patient safety skills in residents
entering the first year of clinical training.
June 6, 2018
Comunale ME, Sandoval M, Broussard LT. An Assessment of Basic Patient Safety Skills in Residents
Entering the First Year of Clinical Training. J Patient Saf. 2018;14(2):112-114.
doi:10.1097/PTS.0000…
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psnet.ahrq.gov/web-mm/do-not-miss-sepsis-needles-viral-haystacks
March 27, 2024 - SPOTLIGHT CASE
Do Not Miss Sepsis Needles in Viral Haystacks!
Citation Text:
Hamline M, Shaikh U. Do Not Miss Sepsis Needles in Viral Haystacks!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
Copy Citation
For…
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psnet.ahrq.gov/web-mm/failure-adhere-dietary-restrictions-leading-complications-and-poor-follow
September 27, 2023 - Failure to Adhere to Dietary Restrictions Leading to Complications and Poor Follow-up
Citation Text:
Bohringer C, Bourgeois J, Xiong G, et al. Failure to adhere to dietary restrictions leading to complications and poor follow-up.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…
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psnet.ahrq.gov/issue/characteristics-initial-prescription-episodes-and-likelihood-long-term-opioid-use-united
April 24, 2018 - Study
Classic
Characteristics of initial prescription episodes and likelihood of long-term opioid use—United States, 2006–2015.
Citation Text:
Shah A, Hayes CJ, Martin BC. Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use - …
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psnet.ahrq.gov/issue/national-implementation-project-prevent-catheter-associated-urinary-tract-infection-nursing
April 05, 2017 - Study
Classic
A national implementation project to prevent catheter-associated urinary tract infection in nursing home residents.
Citation Text:
Mody L, Greene T, Meddings J, et al. A National Implementation Project to Prevent Catheter-Associated Urinary Tract I…
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psnet.ahrq.gov/issue/clinical-pharmacist-led-transitions-care-program-veterans-two-planned-care-transitions
December 23, 2011 - Study
A clinical pharmacist-led transitions of care program for veterans with two planned care transitions (hospital to skilled care and skilled care to home) amid the COVID-19 pandemic.
Citation Text:
Scannell GA, Bevan DJ, Cowan A, et al. A clinical pharmacist-led transitions of care p…
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psnet.ahrq.gov/issue/exploring-roots-unintended-safety-threats-associated-introduction-hospital-eprescribing
December 21, 2022 - Study
Exploring the roots of unintended safety threats associated with the introduction of hospital ePrescribing systems and candidate avoidance and/or mitigation strategies: a qualitative study.
Citation Text:
Mozaffar H, Cresswell K, Williams R, et al. Exploring the roots of unintended…
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psnet.ahrq.gov/issue/patient-doctor-continuity-and-diagnosis-cancer-electronic-medical-records-study-general
September 11, 2019 - Study
Patient–doctor continuity and diagnosis of cancer: electronic medical records study in general practice.
Citation Text:
Ridd MJ, Ferreira DLS, Montgomery AA, et al. Patient-doctor continuity and diagnosis of cancer: electronic medical records study in general practice. Br J Gen Pra…
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psnet.ahrq.gov/issue/methods-studying-medication-safety-following-electronic-health-record-implementation-acute
February 03, 2011 - Review
Methods for studying medication safety following electronic health record implementation in acute care: a scoping review.
Citation Text:
Pereira N, Duff JP, Hayward T, et al. Methods for studying medication safety following electronic health record implementation in acute care: a …
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psnet.ahrq.gov/issue/what-can-patients-tell-us-about-quality-and-safety-hospital-care-findings-uk-multicentre
July 21, 2017 - Study
Emerging Classic
What can patients tell us about the quality and safety of hospital care? Findings from a UK multicentre survey study.
Citation Text:
O'Hara JK, Reynolds C, Moore S, et al. What can patients tell us about the quality and safety of hospital …