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psnet.ahrq.gov/node/33581/psn-pdf
December 15, 2024 - generally the responsibility of nurses or other trained staff;
in ambulatory care the responsibility falls
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psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles
December 15, 2024 - Examples include patients who may be on medications that could increase their risk of falls or bleeding
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psnet.ahrq.gov/perspective/patient-safety-and-opioid-medications
January 01, 2015 - In this sense, the opioid epidemic is iatrogenic, and thus falls within the scope of patient safety.
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psnet.ahrq.gov/web-mm/hard-swallow
April 26, 2023 - However, the responsibility hardly falls on the speech therapist alone.
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psnet.ahrq.gov/node/49568/psn-pdf
September 01, 2008 - However, this proportion falls rapidly over the first few weeks of life, and by 6 months less than 40%
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psnet.ahrq.gov/node/845472/psn-pdf
March 15, 2023 - , which could reduce the risk of
heart attack and stroke that may lead to potential disability and falls … augment that with telehealth where you get a view into someone's home and see if there are
tripping or falling
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psnet.ahrq.gov/node/49572/psn-pdf
October 01, 2008 - Mistaken Identity
October 1, 2008
Hall LW. Mistaken Identity. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/mistaken-identity
The Case
An 85-year-old Cantonese-speaking woman was admitted to the medical service with altered mental status
and a reported fall. After finding tenderness in her left hip, the p…
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psnet.ahrq.gov/web-mm/overriding-considerations
March 09, 2009 - Overriding Considerations
Citation Text:
Holtzman NA. Overriding Considerations. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/node/865697/psn-pdf
April 24, 2024 - In Conversation with...Katie Boston-Leary about Patient
Safety Amid Nursing Workforce Challenges
April 24, 2024
Leary KB. In Conversation with..Katie Boston-Leary about Patient Safety Amid Nursing Workforce
Challenges. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/conversation-withkatie-boston-leary-a…
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psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary
September 23, 2024 - Rescue Improvement Conference Innovation Summary
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July 23, 2024
View more articles from the same authors.
Innovation
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psnet.ahrq.gov/node/49525/psn-pdf
December 01, 2006 - Hidden Heparins: HIT Happens
December 1, 2006
Fogarty PF. Hidden Heparins: HIT Happens. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/hidden-heparins-hit-happens
Case Objectives
Review the presentation of heparin-induced thrombocytopenia (HIT) and its primary complication,
thrombosis.
Discuss the managem…
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psnet.ahrq.gov/sites/default/files/2022-02/final_cme_reviewed_spotlight_loss_of_trust_and_a_missed_diagnosis_02.14.20221_-_clean_-_revised.pdf
January 01, 2022 - Microsoft PowerPoint - FINAL CME Reviewed Spotlight_Loss of Trust and a Missed Diagnosis_02.14.20221 - clean - REVISED.pptx
Spotlight
A Loss of Trust and a Missed Diagnosis
Source and Credits
• This presentation is based on the February 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.…
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psnet.ahrq.gov/web-mm/hidden-heparins-hit-happens
March 27, 2024 - SPOTLIGHT CASE
Hidden Heparins: HIT Happens
Citation Text:
Fogarty PF. Hidden Heparins: HIT Happens. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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Google Scholar BibTeX EndNote X3…
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psnet.ahrq.gov/web-mm/hurried-team-huddle-and-poor-communication-unsafe-practice-during-anesthesia-emergency
September 27, 2023 - August 9, 2023
Cost of inpatient falls and cost-benefit analysis of implementation of
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psnet.ahrq.gov/issue/feasibility-and-added-value-executive-walkrounds-long-term-care-organizations-netherlands
January 07, 2015 - Study
Feasibility and added value of Executive WalkRounds in long term care organizations in the Netherlands.
Citation Text:
van Dusseldorp L, de Waal GH-, Hamers H, et al. Feasibility and Added Value of Executive WalkRounds in Long Term Care Organizations in the Netherlands. Jt Comm J Q…
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psnet.ahrq.gov/issue/understanding-differences-electronic-health-record-ehr-use-linking-individual-physicians
November 17, 2015 - Study
Understanding differences in electronic health record (EHR) use: linking individual physicians' perceptions of uncertainty and EHR use patterns in ambulatory care.
Citation Text:
Lanham HJ, Sittig DF, Leykum LK, et al. Understanding differences in electronic health record (EHR) u…
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psnet.ahrq.gov/issue/safe-practice-recommendations-use-copy-forward-nursing-flow-sheets-hospital-settings
May 18, 2022 - Study
Safe practice recommendations for the use of copy-forward with nursing flow sheets in hospital settings.
Citation Text:
Patterson ES, Sillars DM, Staggers N, et al. Safe Practice Recommendations for the Use of Copy-Forward with Nursing Flow Sheets in Hospital Settings. Jt Comm J Qu…
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psnet.ahrq.gov/issue/what-stops-hospital-clinical-staff-following-protocols-analysis-incidence-and-factors-behind
September 09, 2015 - Study
What stops hospital clinical staff from following protocols? An analysis of the incidence and factors behind the failure of bedside clinical staff to activate the rapid response system in a multi-campus Australian metropolitan healthcare service.
Citation Text:
Shearer B, Marshal…
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psnet.ahrq.gov/issue/long-term-outcomes-medication-intervention-using-screening-tool-older-persons-potentially
July 31, 2024 - Study
Long-term outcomes of medication intervention using the screening tool of older persons potentially inappropriate prescriptions screening tool to alert doctors to right treatment criteria.
Citation Text:
Frankenthal D, Israeli A, Caraco Y, et al. Long-Term Outcomes of Medication In…
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psnet.ahrq.gov/issue/swarming-improve-patient-care-novel-approach-root-cause-analysis
September 23, 2020 - Study
"SWARMing" to improve patient care: a novel approach to root cause analysis.
Citation Text:
Li J, Boulanger B, Norton J, et al. "SWARMing" to Improve Patient Care: A Novel Approach to Root Cause Analysis. Jt Comm J Qual Patient Saf. 2015;41(11):494-501.
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