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psnet.ahrq.gov/node/44094/psn-pdf
November 03, 2015 - Intended and unintended effects of large-scale adverse
event disclosure: a controlled before-after analysis of five
large-scale notifications.
November 3, 2015
Wagner TH, Taylor T, Cowgill E, et al. Intended and unintended effects of large-scale adverse event
disclosure: a controlled before-after analysis of five …
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psnet.ahrq.gov/node/44571/psn-pdf
June 21, 2016 - One size fits all? Mixed methods evaluation of the impact
of 100% single-room accommodation on staff and patient
experience, safety and costs.
June 21, 2016
Maben J, Griffiths P, Penfold C, et al. One size fits all? Mixed methods evaluation of the impact of 100%
single-room accommodation on staff and patient exper…
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psnet.ahrq.gov/node/47666/psn-pdf
January 01, 2020 - A partially structured postoperative handoff protocol
improves communication in 2 mixed surgical intensive
care units: findings from the Handoffs and Transitions in
Critical Care (HATRICC) prospective cohort study.
February 6, 2019
Lane-Fall MB, Pascual JL, Peifer HG, et al. A Partially Structured Postoperative Ha…
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psnet.ahrq.gov/node/48030/psn-pdf
May 22, 2019 - A culture of openness is associated with lower mortality
rates among 137 English National Health Service acute
trusts.
May 22, 2019
Toffolutti V, Stuckler D. A Culture Of Openness Is Associated With Lower Mortality Rates Among 137
English National Health Service Acute Trusts. Health Aff (Millwood). 2019;38(5):844-…
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psnet.ahrq.gov/node/46829/psn-pdf
July 23, 2018 - Quality and variability of patient directions in electronic
prescriptions in the ambulatory care setting.
July 23, 2018
Yang Y, Ward-Charlerie S, Dhavle AA, et al. Quality and Variability of Patient Directions in Electronic
Prescriptions in the Ambulatory Care Setting. J Manag Care Spec Pharm. 2018;24(7):691-699.
…
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psnet.ahrq.gov/node/43590/psn-pdf
October 08, 2014 - Disentangling quality and safety indicator data: a
longitudinal, comparative study of hand hygiene
compliance and accreditation outcomes in 96 Australian
hospitals.
October 8, 2014
Mumford V, Greenfield D, Hogden A, et al. Disentangling quality and safety indicator data: a longitudinal,
comparative study of hand …
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psnet.ahrq.gov/node/46012/psn-pdf
December 21, 2017 - Mortality risks associated with emergency admissions
during weekends and public holidays: an analysis of
electronic health records.
December 21, 2017
Walker S, Mason A, Quan P, et al. Mortality risks associated with emergency admissions during weekends
and public holidays: an analysis of electronic health records.…
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psnet.ahrq.gov/node/47752/psn-pdf
May 29, 2019 - How do nurses use early warning scoring systems to
detect and act on patient deterioration to ensure patient
safety? A scoping review.
May 29, 2019
Wood C, Chaboyer W, Carr P. How do nurses use early warning scoring systems to detect and act on
patient deterioration to ensure patient safety? A scoping review. Int …
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psnet.ahrq.gov/node/45279/psn-pdf
September 27, 2016 - Does clinical supervision of health professionals improve
patient safety? A systematic review and meta-analysis.
September 27, 2016
Snowdon DA, Hau R, Leggat SG, et al. Does clinical supervision of health professionals improve patient
safety? A systematic review and meta-analysis. Int J Qual Health Care. 2016;28(4)…
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psnet.ahrq.gov/node/42454/psn-pdf
September 09, 2013 - A perinatal care quality and safety initiative: are there
financial rewards for improved quality?
September 9, 2013
Kozhimannil KB, Sommerness SA, Rauk P, et al. A perinatal care quality and safety initiative: are there
financial rewards for improved quality? Jt Comm J Qual Patient Saf. 2013;39(8):339-48.
https://…
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psnet.ahrq.gov/node/47407/psn-pdf
January 01, 2020 - Resource-based view on safety culture's influence on
hospital performance: the moderating role of electronic
health record implementation.
September 19, 2018
Upadhyay S, Weech-Maldonado R, Lemak CH, et al. Resource-based view on safety culture’s influence on
hospital performance: The moderating role of electronic …
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psnet.ahrq.gov/node/47875/psn-pdf
July 19, 2019 - Observer-based tools for non-technical skills assessment
in simulated and real clinical environments in healthcare:
a systematic review.
July 19, 2019
Higham H, Greig PR, Rutherford J, et al. Observer-based tools for non-technical skills assessment in
simulated and real clinical environments in healthcare: a syste…
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psnet.ahrq.gov/node/44369/psn-pdf
July 16, 2018 - The impact of a computerized physician order entry
system on medical errors with antineoplastic drugs 5
years after its implementation.
July 16, 2018
Cuervo S, Sanchis R, Lopez P, et al. The impact of a computerized physician order entry system on
medical errors with antineoplastic drugs 5 years after its implemen…
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psnet.ahrq.gov/node/43652/psn-pdf
August 04, 2015 - Do clinicians know which of their patients have central
venous catheters?: A multicenter observational study.
August 4, 2015
Chopra V, Govindan S, Kuhn L, et al. Do clinicians know which of their patients have central venous
catheters?: a multicenter observational study. Ann Intern Med. 2014;161(8):562-7. doi:10.73…
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psnet.ahrq.gov/node/46277/psn-pdf
August 15, 2017 - Randomized trial of reducing ambulatory malpractice and
safety risk: results of the Massachusetts PROMISES
Project.
August 15, 2017
Schiff G, Nieva HR, Griswold P, et al. Randomized Trial of Reducing Ambulatory Malpractice and Safety
Risk: Results of the Massachusetts PROMISES Project. Med Care. 2017;55(8):797-805…
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psnet.ahrq.gov/node/45911/psn-pdf
June 27, 2018 - Use of unsolicited patient observations to identify
surgeons with increased risk for postoperative
complications.
June 27, 2018
Cooper WO, Guillamondegui O, Hines J, et al. Use of Unsolicited Patient Observations to Identify
Surgeons With Increased Risk for Postoperative Complications. JAMA Surg. 2017;152(6):522-5…
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psnet.ahrq.gov/node/46515/psn-pdf
December 22, 2018 - A contemporary medicolegal analysis of outpatient
medication management in chronic pain.
December 22, 2018
Abrecht CR, Brovman EY, Greenberg P, et al. A Contemporary Medicolegal Analysis of Outpatient
Medication Management in Chronic Pain. Anesth Analg. 2017;125(5):1761-1768.
doi:10.1213/ANE.0000000000002499.
htt…
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psnet.ahrq.gov/node/42361/psn-pdf
September 19, 2013 - Involvement of patients with cancer in patient safety: a
qualitative study of current practices, potentials and
barriers.
September 19, 2013
Martin HM, Navne LE, Lipczak H. Involvement of patients with cancer in patient safety: a qualitative study
of current practices, potentials and barriers. BMJ Qual Saf. 2013;2…
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psnet.ahrq.gov/node/49564/psn-pdf
July 01, 2008 - Dependence vs. Pain
July 1, 2008
Gordon AJ. Dependence vs. Pain . PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/dependence-vs-pain
Case Objectives
Define opioid dependence and opioid withdrawal syndrome.
Describe the treatment of opioid withdrawal syndrome including the use of the Clinical Opioid
Withdra…
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psnet.ahrq.gov/node/49849/psn-pdf
January 01, 2019 - Spotlight: Mistaken Attribution, Diagnostic Misstep
January 1, 2019
Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
Case Objectives
List the patient safety events that are unique to in…