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psnet.ahrq.gov/node/49470/psn-pdf
December 01, 2004 - Discharge Fumbles
December 1, 2004
Forster AJ. Discharge Fumbles. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/discharge-fumbles
Case Objectives
List the types of adverse events that occur at discharge
Identify the characteristics that identify patients at high risk for errors at discharge
Understand th…
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psnet.ahrq.gov/web-mm/no-bp-during-nibp
March 01, 2011 - No BP During NIBP
Citation Text:
Görges M, Ansermino MJ. No BP During NIBP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…
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psnet.ahrq.gov/web-mm/lost-sign-out-and-documentation
January 31, 2011 - Lost in Sign Out and Documentation
Citation Text:
Detsky ME. Lost in Sign Out and Documentation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 …
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psnet.ahrq.gov/node/49806/psn-pdf
September 01, 2017 - Failed Interpretation of Screening Tool: Delayed
Treatment
September 1, 2017
Cable CA, Murphy DJ, Martin GS. Failed Interpretation of Screening Tool: Delayed Treatment. PSNet
[internet]. 2017.
https://psnet.ahrq.gov/web-mm/failed-interpretation-screening-tool-delayed-treatment
The Case
An 88-year-old man present…
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psnet.ahrq.gov/node/33662/psn-pdf
January 01, 2008 - In Conversation with…Jennifer Daley, MD
January 1, 2008
In Conversation with…Jennifer Daley, MD. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/conversation-withjennifer-daley-md
Editor's note: Jennifer Daley, MD, is the Chief Medical Officer of Partners Community Healthcare Inc., the
organization for …
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psnet.ahrq.gov/sites/default/files/2021-02/final_feb_2021_spotlight_delay_in_appropriate_dx.pdf
January 01, 2021 - • Information technology may improve communication by identifying
and locating ordering providers
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psnet.ahrq.gov/issue/application-system-dynamics-modelling-system-safety-improvement-present-use-and-future
October 27, 2021 - Review
Emerging Classic
The application of system dynamics modelling to system safety improvement: present use and future potential.
Citation Text:
The application of system dynamics modelling to system safety improvement: present use and future potential. Ibrah…
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psnet.ahrq.gov/issue/are-agency-healthcare-research-and-quality-obstetric-trauma-indicators-valid-measures
April 30, 2014 - Study
Are the Agency for Healthcare Research and Quality obstetric trauma indicators valid measures of hospital safety?
Citation Text:
Grobman WA, Feinglass J, Murthy S. Are the Agency for Healthcare Research and Quality obstetric trauma indicators valid measures of hospital safety? Am…
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psnet.ahrq.gov/issue/eight-rights-safe-electronic-health-record-use
December 06, 2023 - Commentary
Eight rights of safe electronic health record use.
Citation Text:
Sittig DF, Singh H. Eight rights of safe electronic health record use. JAMA. 2009;302(10):1111-3. doi:10.1001/jama.2009.1311.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML…
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psnet.ahrq.gov/issue/healthcare-systems-ergonomics-and-patient-safety-triennial-conference
February 10, 2015 - Meeting/Conference
Healthcare Systems Ergonomics and Patient Safety Triennial Conference.
Citation Text:
Healthcare Systems Ergonomics and Patient Safety Triennial Conference. Delft University of Technology. Faculty Industrial Design Engineering. Delft, The Netherlands, November 2-4, 202…
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psnet.ahrq.gov/issue/faces-errors-case-based-approach-educating-providers-policy-makers-and-public-about-patient
March 13, 2013 - Commentary
The faces of errors: a case-based approach to educating providers, policy makers, and the public about patient safety.
Citation Text:
Wachter R, Shojania KG. The faces of errors: a case-based approach to educating providers, policymakers, and the public about patient safety. J…
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psnet.ahrq.gov/issue/scientific-inquiry-100000-lives-campaign-and-application-children
April 05, 2017 - Commentary
Scientific inquiry. 100,000 lives campaign and the application to children.
Citation Text:
Edson BS, Williams MC. Scientific Inquiry . 100,000 Lives Campaign and the Application to Children. Journal for Specialists in Pediatric Nursing. 2006;11(2). doi:10.1111/j.1744-6155.20…
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psnet.ahrq.gov/issue/functional-health-literacy-and-understanding-medications-discharge
April 24, 2018 - Study
Functional health literacy and understanding of medications at discharge.
Citation Text:
Maniaci MJ, Heckman MG, Dawson NL. Functional health literacy and understanding of medications at discharge. Mayo Clin Proc. 2008;83(5):554-8. doi:10.4065/83.5.554.
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psnet.ahrq.gov/issue/serious-hazards-transfusion-shot-haemovigilance-and-progress-improving-transfusion-safety
April 27, 2019 - Review
Serious hazards of transfusion (SHOT) haemovigilance and progress is improving transfusion safety.
Citation Text:
Bolton-Maggs PHB, Cohen H. Serious Hazards of Transfusion (SHOT) haemovigilance and progress is improving transfusion safety. Br J Haematol. 2013;163(3):303-14. doi…
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psnet.ahrq.gov/issue/objective-medical-emergency-team-activation-criteria-case-control-study
June 22, 2009 - Study
The objective medical emergency team activation criteria: a case-control study.
Citation Text:
Cretikos M, Chen J, Hillman K, et al. The objective medical emergency team activation criteria: a case-control study. Resuscitation. 2007;73(1):62-72.
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…
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psnet.ahrq.gov/issue/building-cultures-high-reliability-lessons-high-reliability-organization-paradigm
September 05, 2018 - Review
Building cultures of high reliability: lessons from the high reliability organization paradigm.
Citation Text:
Sutcliffe KM. Building cultures of high reliability: lessons from the high reliability organization paradigm. Anesthesiol Clin. 2023;41(4):707-717. doi:10.1016/j.anclin.2…
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psnet.ahrq.gov/issue/evidence-brief-implementation-high-reliability-organization-principles
November 11, 2020 - Book/Report
Evidence Brief: Implementation of High Reliability Organization Principles.
Citation Text:
Evidence Brief: Implementation of High Reliability Organization Principles. Veazie S, Peterson K, Bourne D. Washington DC: United States Department of Veterans Affairs; May 2019.
…
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psnet.ahrq.gov/issue/obstetric-practice-guidelines-labors-love-lost
April 30, 2014 - Commentary
Obstetric practice guidelines: labor's love lost?
Citation Text:
Cohen WR, Friedman EA. Obstetric practice guidelines: labor's love lost? J Matern Fetal Neonatal Med. 2019;32(9):1567-1570. doi:10.1080/14767058.2017.1406474.
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DOI Google Schola…
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psnet.ahrq.gov/issue/restorative-just-culture-exploration-enabling-conditions-successful-implementation
February 08, 2023 - Study
Restorative just culture: an exploration of the enabling conditions for successful implementation.
Citation Text:
Boskeljon-Horst L, Steinmetz V, Dekker SWA. Restorative just culture: an exploration of the enabling conditions for successful implementation. Healthcare (Basel). 2024;…
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psnet.ahrq.gov/issue/patient-experience-source-understanding-origins-impact-and-remediation-diagnostic-errors
August 16, 2023 - Book/Report
Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors.
Citation Text:
Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors. Schlesinger M, Grob R, Gleason K, et al. Rock…