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psnet.ahrq.gov/node/33724/psn-pdf
February 01, 2012 - In Conversation With… Lawrence Smith, MD
February 1, 2012
In Conversation With… Lawrence Smith, MD. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-lawrence-smith-md
Editor's note: Lawrence G. Smith, MD, is the founding Dean of Hofstra North Shore-LIJ School of
Medicine and Executive Vice P…
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psnet.ahrq.gov/web-mm/environmental-safety-or
May 19, 2015 - Environmental Safety in the OR
Citation Text:
Linkin DR, Lautenbach E. Environmental Safety in the OR . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
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psnet.ahrq.gov/node/50769/psn-pdf
February 15, 2017 - Cultural Competence and Patient Safety
December 27, 2019
Brach C, Hall KK, Fitall E. Cultural Competence and Patient Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/cultural-competence-and-patient-safety
Background
Culture can be defined as the “personal identification, language, thoughts, co…
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psnet.ahrq.gov/node/49513/psn-pdf
July 01, 2006 - Moving Pains
July 1, 2006
Schell H, Wachter R. Moving Pains. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/moving-pains
Case Objectives
Appreciate the risk posed by intrahospital transport
Identify key features of current transport practice and policies
Propose interventions that might improve safety of …
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psnet.ahrq.gov/node/49679/psn-pdf
March 01, 2013 - The Unfamiliar Catheter
March 1, 2013
Swayze SC, James A. The Unfamiliar Catheter. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/unfamiliar-catheter
The Case
A 28-year-old woman, 20 months post–bilateral lung transplant, presented to the emergency department
with sudden onset of severe shortness of breath…
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psnet.ahrq.gov/node/49747/psn-pdf
December 01, 2015 - Harm From Alarm Fatigue
December 1, 2015
Pelter MM, Drew BJ. Harm From Alarm Fatigue. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/harm-alarm-fatigue
Case Objectives
Define alarm fatigue and describe potential errors that can occur due to alarm fatigue.
Identify federal and national agencies focusing on …
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psnet.ahrq.gov/node/867533/psn-pdf
January 15, 2025 - AHRQ announces interest in health services research to
reduce emergency department boarding and hospital
crowding.
January 15, 2025
AHRQ announces interest in health services research to reduce emergency department boarding and
hospital crowding. Agency for Healthcare Quality and Research. Special Emphasis Notice.…
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psnet.ahrq.gov/node/47158/psn-pdf
August 15, 2018 - A standardized handoff simulation promotes recovery
from auditory distractions in resident physicians.
August 15, 2018
Matern LH, Farnan JM, Hirsch KW, et al. A Standardized Handoff Simulation Promotes Recovery From
Auditory Distractions in Resident Physicians. Simul Healthc. 2018;13(4):233-238.
doi:10.1097/SIH.00…
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psnet.ahrq.gov/node/44801/psn-pdf
June 22, 2016 - Safety for all: integrated design for inpatient units.
June 22, 2016
Hunt JM, Sine DM. Patient Saf Qual Healthc. May/June 2016;13:20-28.
https://psnet.ahrq.gov/issue/safety-all-integrated-design-inpatient-units
Design is emerging as an important tactic to augment safe care delivery. Hospitals that provide care for
…
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psnet.ahrq.gov/node/44968/psn-pdf
January 23, 2017 - Financial incentives and mortality: taking pay for
performance a step too far.
January 23, 2017
Gupta K, Wachter R, Kachalia A. Financial incentives and mortality: taking pay for performance a step too
far. BMJ Qual Saf. 2017;26(2):164-168. doi:10.1136/bmjqs-2015-004835.
https://psnet.ahrq.gov/issue/financial-ince…
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psnet.ahrq.gov/node/45349/psn-pdf
July 27, 2016 - An insurer's care transition program emphasizes
medication reconciliation, reduces readmissions and
costs.
July 27, 2016
Polinski JM, Moore JM, Kyrychenko P, et al. An Insurer's Care Transition Program Emphasizes Medication
Reconciliation, Reduces Readmissions And Costs. Health Aff (Millwood). 2016;35(7):1222-9.
…
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psnet.ahrq.gov/node/74256/psn-pdf
January 19, 2022 - Potentially severe incidents during interhospital transport
of critically ill patients, frequently occurring but rarely
reported: a prospective study.
January 19, 2022
Eiding H, Røise O, Kongsgaard UE. Potentially severe incidents during interhospital transport of critically ill
patients, frequently occurring but …
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psnet.ahrq.gov/node/73372/psn-pdf
June 09, 2021 - Impact of COVID-19 on inpatient clinical emergencies: a
single-center experience.
June 9, 2021
Mitchell OJL, Neefe S, Ginestra JC, et al. Impact of COVID-19 on inpatient clinical emergencies: a single-
center experience. Resusc Plus. 2021;6:100135. doi:10.1016/j.resplu.2021.100135.
https://psnet.ahrq.gov/issue/imp…
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psnet.ahrq.gov/node/45341/psn-pdf
July 27, 2016 - How to avoid catastrophic events on the ward.
July 27, 2016
Bein B, Seewald S, Gräsner J-T. How to avoid catastrophic events on the ward. Best Pract Res Clin
Anaesthesiol. 2016;30(2):237-45. doi:10.1016/j.bpa.2016.04.003.
https://psnet.ahrq.gov/issue/how-avoid-catastrophic-events-ward
Hospitals require robust esca…
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psnet.ahrq.gov/node/40427/psn-pdf
May 04, 2011 - Development of a tool within the electronic medical
record to facilitate medication reconciliation after hospital
discharge.
May 4, 2011
Schnipper JL, Liang CL, Hamann C, et al. Development of a tool within the electronic medical record to
facilitate medication reconciliation after hospital discharge. J Am Med Inf…
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psnet.ahrq.gov/node/46957/psn-pdf
May 17, 2018 - Improving communication with patients with limited
English proficiency.
May 17, 2018
Taira BR. Improving Communication With Patients With Limited English Proficiency. JAMA Int Med.
2018;178(5):605-606. doi:10.1001/jamainternmed.2018.0373.
https://psnet.ahrq.gov/issue/improving-communication-patients-limited-englis…
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psnet.ahrq.gov/node/50703/psn-pdf
December 04, 2019 - A systematic review of clinical outcomes associated with
intrahospital transitions
December 4, 2019
Bristol AA, Schneider CE, Lin S-Y, et al. A Systematic Review of Clinical Outcomes Associated With
Intrahospital Transitions. J Healthc Qual. 2019. doi:10.1097/JHQ.0000000000000232.
https://psnet.ahrq.gov/issue/syst…
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psnet.ahrq.gov/node/837597/psn-pdf
June 29, 2022 - Patient safety informatics: criteria development for
assessing the maturity of digital patient safety in
hospitals.
June 29, 2022
Kutza J-O, Hübner U, Holmgren AJ, et al. Patient safety informatics: criteria development for assessing the
maturity of digital patient safety in hospitals. Stud Health Technol Inform. …
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psnet.ahrq.gov/node/73092/psn-pdf
March 31, 2021 - SAFER Care: improving caregiver comprehension of
discharge instructions.
March 31, 2021
Uong A, Philips K, Hametz P, et al. SAFER care: improving caregiver comprehension of discharge
instructions. Pediatrics. 2021;147(4):e20200031. doi:10.1542/peds.2020-0031.
https://psnet.ahrq.gov/issue/safer-care-improving-careg…
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psnet.ahrq.gov/node/44253/psn-pdf
August 24, 2015 - Acceptability and feasibility of the Leapfrog computerized
physician order entry evaluation tool for hospitals outside
the United States.
August 24, 2015
Cho IS, Lee J-H, Choi S-K, et al. Acceptability and feasibility of the Leapfrog computerized physician order
entry evaluation tool for hospitals outside the Unit…