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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…
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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…
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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…
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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…
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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.
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Format: …
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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.
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Format:
Google Scholar BibTeX EndNote X3 …
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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 …
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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…
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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…
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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/…
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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.
…
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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…
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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…