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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/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/node/33600/psn-pdf
June 16, 2024 - less harmful if care
had been different;
Adverse events due to negligence: those due to care that falls
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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/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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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagg…
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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/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/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/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/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/clinical-characteristics-and-short-term-outcomes-acute-kidney-injury-missed-diagnosis-older
April 20, 2022 - Study
Clinical characteristics and short-term outcomes of acute kidney injury missed diagnosis in older patients with severe COVID-19 in intensive care unit.
Citation Text:
Li Q, Hu P, Kang H, et al. Clinical characteristics and short-term outcomes of acute kidney injury missed diagnosis…
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psnet.ahrq.gov/issue/evaluation-policies-limiting-opioid-exposure-opioid-prescribing-and-patient-pain-opioid-naive
May 18, 2022 - Study
Evaluation of policies limiting opioid exposure on opioid prescribing and patient pain in opioid-naive patients undergoing elective surgery in a large American health system.
Citation Text:
Rennert L, Howard KA, Walker KB, et al. Evaluation of policies limiting opioid exposure on o…
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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/development-and-applications-veterans-health-administrations-stratification-tool-opioid-risk
April 01, 2020 - Study
Development and applications of the Veterans Health Administration's Stratification Tool for Opioid Risk Mitigation (STORM) to improve opioid safety and prevent overdose and suicide.
Citation Text:
Oliva EM, Bowe T, Tavakoli S, et al. Development and applications of the Veterans He…
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psnet.ahrq.gov/issue/effect-standardized-handoff-curriculum-improved-clinician-preparedness-intensive-care-unit
October 19, 2022 - Study
Classic
Effect of standardized handoff curriculum on improved clinician preparedness in the intensive care unit: a stepped-wedge cluster randomized clinical trial.
Citation Text:
Parent B, LaGrone LN, Albirair MT, et al. Effect of Standardized Handoff Curr…
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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/perceptions-pediatric-hospital-safety-culture-united-states-analysis-2016-hospital-survey
January 19, 2022 - Study
Perceptions of pediatric hospital safety culture in the United States: an analysis of the 2016 Hospital Survey on Patient Safety Culture.
Citation Text:
Gampetro PJ, Segvich JP, Jordan N, et al. Perceptions of Pediatric Hospital Safety Culture in the United States: An Analysis of t…