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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47193/psn-pdf
    September 05, 2018 - Situation, background, assessment, recommendation (SBAR) communication tool for handoff in health care- a narrative review. September 5, 2018 Shahid S, Thomas S. Situation, background, assessment, recommendation (SBAR) communication tool for handoff in health care; a narrative review. Saf Health. 2018;4(7). doi:10…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/847543/psn-pdf
    April 12, 2023 - What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study. April 12, 2023 Schnipper JL, Reyes Nieva H, Yoon CS, et al. What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study. BMJ Qual Saf. 2023;32(8):457-469. doi:10.1136/bmjqs-2022- 0…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60045/psn-pdf
    March 18, 2020 - Making Healthcare Safer III. March 18, 2020 Holmes A, Long A, Wyant B, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0029-EF. https://psnet.ahrq.gov/issue/making-healthcare-safer-iii This newly issued follow up to the seminal AHRQ Making Health Care Safer rep…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46588/psn-pdf
    February 28, 2018 - The relationship between resident burnout and safety- related and acceptability-related quality of healthcare: a systematic literature review. February 28, 2018 Dewa CS, Loong D, Bonato S, et al. The relationship between resident burnout and safety-related and acceptability-related quality of healthcare: a systema…
  5. psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
    September 16, 2015 - SPOTLIGHT CASE Which Line: Ordering Provider or Proceduralist? Citation Text: Blackmore CC. Which Line: Ordering Provider or Proceduralist?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: …
  6. psnet.ahrq.gov/web-mm/dissecting-presentation
    May 05, 2021 - SPOTLIGHT CASE Dissecting the Presentation Citation Text: Suat-Ooi SB. Dissecting the Presentation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 …
  7. psnet.ahrq.gov/sites/default/files/2024-09/final_spotlight_case_open_wound_of_the_elbow_slides_09.19.2024.pptx
    January 01, 2024 - Spotlight Spotlight Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations 1 Source and Credits This presentation is based on the September 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: David…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866839/psn-pdf
    September 25, 2024 - Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations September 25, 2024 Barnes DK, Utter GH. Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/errors-managing-open-wound-elb…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50427/psn-pdf
    September 04, 2019 - Correlation between hospital finances and quality and safety of patient care. September 4, 2019 Akinleye DD, McNutt L-A, Lazariu V, et al. Correlation between hospital finances and quality and safety of patient care. PLoS One. 2019;14(8):e0219124. doi:10.1371/journal.pone.0219124. https://psnet.ahrq.gov/issue/corr…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/845297/psn-pdf
    January 01, 2024 - An analysis of prehospital pediatric medication dosing errors after implementation of a state-wide EMS pediatric drug dosing reference. March 1, 2023 Kazi R, Hoyle JD, Huffman C, et al. An analysis of prehospital pediatric medication dosing errors after implementation of a state-wide EMS pediatric drug dosing refe…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46472/psn-pdf
    August 20, 2018 - Wide variation and overprescription of opioids after elective surgery. August 20, 2018 Thiels CA, Anderson SS, Ubl DS, et al. Wide Variation and Overprescription of Opioids After Elective Surgery. Ann Surg. 2017;266(4):564-573. doi:10.1097/SLA.0000000000002365. https://psnet.ahrq.gov/issue/wide-variation-and-overp…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45317/psn-pdf
    August 17, 2016 - Partnered pharmacist charting on admission in the general medical and emergency short-stay unit—a cluster-randomised controlled trial in patients with complex medication regimens. August 17, 2016 Tong EY, Roman C, Mitra B, et al. Partnered pharmacist charting on admission in the General Medical and Emergency Shor…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46889/psn-pdf
    October 13, 2018 - Evaluation of reasons why surgical residents exceeded 2011 duty hour requirements when offered flexibility. October 13, 2018 Blay E, Engelhardt KE, Hewitt B, et al. Evaluation of Reasons Why Surgical Residents Exceeded 2011 Duty Hour Requirements When Offered Flexibility: A FIRST Trial Analysis. JAMA Surg. 2018;153…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/844051/psn-pdf
    February 08, 2023 - Insurance claims for wrong-side, wrong-organ, wrong- procedure, or wrong-person surgical errors: a retrospective study for 10 years. February 8, 2023 Vacheron C-H, Acker A, Autran M, et al. Insurance claims for wrong-side, wrong-organ, wrong-procedure, or wrong-person surgical errors: a retrospective study for 10 …
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/842772/psn-pdf
    January 18, 2023 - Short- and long-term effects of an electronic medication management system on paediatric prescribing errors. January 18, 2023 Westbrook JI, Li L, Raban MZ, et al. Short- and long-term effects of an electronic medication management system on paediatric prescribing errors. NPJ Digit Med. 2022;5(1):179. doi:10.1038/s4…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47448/psn-pdf
    October 10, 2018 - Ten principles for more conservative, care-full diagnosis. October 10, 2018 Schiff G, Martin SA, Eidelman DH, et al. Ten Principles for More Conservative, Care-Full Diagnosis. Ann Intern Med. 2018;169(9):643-645. doi:10.7326/M18-1468. https://psnet.ahrq.gov/issue/ten-principles-more-conservative-care-full-diagnosis…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/844769/psn-pdf
    January 01, 2020 - Failure to administer recommended chemotherapy: acceptable variation or cancer care quality blind spot? September 18, 2019 Ellis RJ, Schlick CJR, Feinglass J, et al. Failure to administer recommended chemotherapy: acceptable variation or cancer care quality blind spot? BMJ Qual Saf. 2020;29(2):103-112. doi:10.1136/…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867045/psn-pdf
    October 30, 2024 - The burden of healthcare utilization, cost, and mortality associated with select surgical site infections. October 30, 2024 Shambhu S, Gordon AS, Liu Y, et al. The burden of healthcare utilization, cost, and mortality associated with select surgical site infections. Jt Comm J Qual Patient Saf. 2024;50(12):857-866. …
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849334/psn-pdf
    May 24, 2023 - I like what you are saying, but only if I feel safe: psychological safety moderates the relationship between voice and perceived contribution to healthcare team effectiveness. May 24, 2023 Weiss M, Morrison EW, Szyld D. I like what you are saying, but only if I feel safe: psychological safety moderates the relati…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74692/psn-pdf
    January 26, 2022 - Changes made to orders placed by overnight admitting residents on teaching rounds the next day. January 26, 2022 Chiel L, Freiman E, Yarahuan J, et al. Changes made to orders placed by overnight admitting residents on teaching rounds the next day. Hosp Pediatr. 2021;12(1):e35-e38. doi:10.1542/hpeds.2021-005823. ht…

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