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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46566/psn-pdf
    June 25, 2018 - A systematic review of interventions to follow-up test results pending at discharge. June 25, 2018 Darragh PJ, Bodley T, Orchanian-Cheff A, et al. A Systematic Review of Interventions to Follow-Up Test Results Pending at Discharge. J Gen Intern Med. 2018;33(5):750-758. doi:10.1007/s11606-017-4290-9. https://psnet.…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50376/psn-pdf
    September 25, 2019 - Stakeholder perceptions of smart infusion pumps and drug library updates: a multisite, interdisciplinary study. September 25, 2019 DeLaurentis P, Walroth TA, Fritschle AC, et al. Stakeholder perceptions of smart infusion pumps and drug library updates: A multisite, interdisciplinary study. Am J Health Syst Pharm. 2…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48024/psn-pdf
    January 01, 2021 - The mental health trigger tool: development and testing of a specialized trigger tool for mental health settings. July 10, 2019 Sajith SG, Fung D, Chua HC. The Mental Health Trigger Tool: Development and Testing of a Specialized Trigger Tool for Mental Health Settings. J Patient Saf. 2021;17(4):e306-e312. doi:10.1…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45256/psn-pdf
    July 01, 2017 - Applied use of safety event occurrence control charts of harm and non-harm events: a case study. July 1, 2017 Robinson SN, Neyens DM, Diller T. Applied Use of Safety Event Occurrence Control Charts of Harm and Non-Harm Events: A Case Study. Am J Med Qual. 2017;32(3):285-291. doi:10.1177/1062860616646197. https://p…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44754/psn-pdf
    March 23, 2016 - Use of failure mode and effects analysis to improve emergency department handoff processes. March 23, 2016 Sorrentino P. Use of Failure Mode and Effects Analysis to Improve Emergency Department Handoff Processes. Clin Nurse Spec. 2016;30(1):28-37. doi:10.1097/NUR.0000000000000169. https://psnet.ahrq.gov/issue/use-…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44257/psn-pdf
    November 06, 2015 - A systems approach to evaluating ionizing radiation: six focus areas to improve quality, efficiency, and patient safety. November 6, 2015 Perlin JB, Mower L, Bushe C. A systems approach to evaluating ionizing radiation: six focus areas to improve quality, efficiency, and patient safety. J Healthc Qual. 2015;37(3):…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73218/psn-pdf
    January 01, 2022 - Work-related factors, cognitive skills, unsafe behavior and safety incident involvement among emergency medical services crew members: relationships and indirect effects. May 5, 2021 Sedlár M. Work-related factors, cognitive skills, unsafe behavior and safety incident involvement among emergency medical services …

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848813/psn-pdf
    May 10, 2023 - Blood and blood products transfusion errors: what can we do to improve patient safety. May 10, 2023 Brown C, Brown M. Blood and blood products transfusion errors: what can we do to improve patient safety? Br J Nurs. 2023;32(7):326-332. doi:10.12968/bjon.2023.32.7.326. https://psnet.ahrq.gov/issue/blood-and-blood-p…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45214/psn-pdf
    July 13, 2016 - Recognizing quality improvement and patient safety activities in academic promotion in departments of medicine: innovative language in promotion criteria. July 13, 2016 Staiger TO, Mills LM, Wong BM, et al. Recognizing Quality Improvement and Patient Safety Activities in Academic Promotion in Departments of Medici…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45774/psn-pdf
    October 11, 2017 - Patient safety in community dementia services: what can we learn from the experiences of caregivers and healthcare professionals? October 11, 2017 Behrman S, Wilkinson P, Lloyd H, et al. Patient safety in community dementia services: what can we learn from the experiences of caregivers and healthcare professionals…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/844754/psn-pdf
    September 18, 2019 - How do stakeholders experience the adoption of electronic prescribing systems in hospitals? A systematic review and thematic synthesis of qualitative studies. September 18, 2019 Farre A, Heath G, Shaw K, et al. How do stakeholders experience the adoption of electronic prescribing systems in hospitals? A systematic…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851450/psn-pdf
    July 19, 2023 - Patient safety for people experiencing advanced dementia in hospital: a video reflexive ethnography. July 19, 2023 Dadich A, Rodrigues J, De Bellis A, et al. Patient safety for people experiencing advanced dementia in hospital: a video reflexive ethnography. Dementia (London). 2023;22(5):1057-1076. doi:10.1177/147…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/861289/psn-pdf
    January 01, 2025 - Assessing the impact of an electronic chemotherapy order verification checklist on pharmacist reported errors in oncology infusion centers of a health-system. January 24, 2024 Wat SK (S), Wesolowski B, Cierniak K, et al. Assessing the impact of an electronic chemotherapy order verification checklist on pharmacist …

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43281/psn-pdf
    May 28, 2015 - A method for prioritizing interventions following root cause analysis (RCA): lessons from philosophy. May 28, 2015 Boyd M. A method for prioritizing interventions following root cause analysis (RCA): lessons from philosophy. J Eval Clin Pract. 2015;21(3):461-9. doi:10.1111/jep.12272. https://psnet.ahrq.gov/issue/m…

  15. Communication Error in a Closed ICU | PSNet

    psnet.ahrq.gov/web-mm/communication-error-closed-icu
    July 01, 2016 - Communication Error in a Closed ICU Citation Text: Haas B, Conn LG. Communication Error in a Closed ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML En…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49829/psn-pdf
    May 01, 2018 - Root Cause Analysis Gone Wrong May 1, 2018 Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong The Case A 42-year-old man with history of end-stage renal disease on hemodialysis was awaiting a kidney transplant. A suitabl…

  17. The Unhappy Patient Leaves Against Medical Advice. | PSNet

    psnet.ahrq.gov/web-mm/unhappy-patient-leaves-against-medical-advice
    January 31, 2024 - The Unhappy Patient Leaves Against Medical Advice. Citation Text: Nichols A. The Unhappy Patient Leaves Against Medical Advice.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: Google Scholar …

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50392/psn-pdf
    September 01, 2019 - In Conversation With… Shantanu Agrawal, MD, MPhil September 1, 2019 In Conversation With… Shantanu Agrawal, MD, MPhil. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-shantanu-agrawal-md-mphil Editor's note: Dr. Agrawal is president and CEO of the National Quality Forum (NQF). He is the form…

  19. Getting Into Patient Safety: A Personal Story | PSNet

    psnet.ahrq.gov/perspective/getting-patient-safety-personal-story
    August 01, 2006 - It seemed to me that this was another systems challenge—that we don't have good systems for identifying … Starting with the great work that you all did a few years ago identifying those practices with good

  20. Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome | PSNet

    psnet.ahrq.gov/web-mm/dangers-missing-epidural-abscess-multiple-visits-and-delayed-diagnosis-severely-negative
    April 27, 2022 - patients with at least one SEA risk factor, ESR has been shown to be 100% sensitive and 67% specific for identifying … have poor sensitivity and can miss SEA. 13 , 28 Historically, CT myelography was performed to aid in identifying
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