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psnet.ahrq.gov/node/33596/psn-pdf
June 01, 2025 - Failure to Rescue
January 29, 2025
Tokareva I, Romano P. Failure to Rescue. PSNet [internet]. 2025.
https://psnet.ahrq.gov/primer/failure-rescue
Updated in January 2025 by Irina Tokareva RN, BSN, MAS, CPHQ and Patrick Romano, MD, MPH. PSNet
primers are regularly reviewed and updated to ensure that they reflect cur…
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psnet.ahrq.gov/issue/best-practices-safe-handling-products-containing-concentrated-potassium
April 22, 2011 - Study
Best practices for safe handling of products containing concentrated potassium.
Citation Text:
Tubman M, Majumdar SR, Lee D, et al. Best practices for safe handling of products containing concentrated potassium. BMJ. 2005;331(7511):274-7.
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psnet.ahrq.gov/issue/uptake-quality-related-event-standards-practice-community-pharmacies
November 09, 2016 - Study
Uptake of quality-related event standards of practice by community pharmacies.
Citation Text:
Boyle TA, Bishop A, Overmars C, et al. Uptake of Quality-Related Event Standards of Practice by Community Pharmacies. J Pharm Pract. 2015;28(5):442-9. doi:10.1177/0897190014522066.
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psnet.ahrq.gov/issue/armstrong-institute-academic-institute-patient-safety-and-quality-improvement-research
September 27, 2017 - Commentary
The Armstrong Institute: an academic institute for patient safety and quality improvement, research, training, and practice.
Citation Text:
Pronovost P, Holzmueller CG, Molello NE, et al. The Armstrong Institute: An Academic Institute for Patient Safety and Quality Improvement…
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psnet.ahrq.gov/issue/findings-naloxone-database-and-its-utilization-improve-safety-and-education-tertiary-care
April 12, 2023 - Study
Findings of a naloxone database and its utilization to improve safety and education in a tertiary care medical center.
Citation Text:
Rosenfeld DM, Betcher JA, Shah RA, et al. Findings of a Naloxone Database and its Utilization to Improve Safety and Education in a Tertiary Care Med…
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psnet.ahrq.gov/issue/computerized-decision-support-medication-dosing-renal-insufficiency-randomized-controlled
September 30, 2009 - Study
Computerized decision support for medication dosing in renal insufficiency: a randomized, controlled trial.
Citation Text:
Terrell KM, Perkins AJ, Hui SL, et al. Computerized decision support for medication dosing in renal insufficiency: a randomized, controlled trial. Ann Emerg …
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psnet.ahrq.gov/issue/effects-work-hour-limitations-resident-well-being-patient-care-and-education-internal
January 13, 2021 - Study
The effects of work-hour limitations on resident well-being, patient care, and education in an internal medicine residency program.
Citation Text:
Goitein L, Shanafelt TD, Wipf JE, et al. The effects of work-hour limitations on resident well-being, patient care, and education in …
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psnet.ahrq.gov/issue/proactive-patient-safety-focusing-what-goes-right-perioperative-environment
April 26, 2023 - Study
Proactive patient safety: focusing on what goes right in the perioperative environment.
Citation Text:
Duffy C, Menon N, Horak D, et al. Proactive patient safety: focusing on what goes right in the perioperative environment. J Patient Saf. 2023;19(4):281-286. doi:10.1097/pts.000000…
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psnet.ahrq.gov/issue/outcomes-michigan-medicines-integrated-patient-safety-and-communication-and-resolution
April 24, 2018 - Study
Outcomes of Michigan Medicine's integrated patient safety and communication and resolution program, 2013–2022.
Citation Text:
Burney RE, Mckeown ES, Zhang Y, et al. Outcomes of Michigan Medicine's integrated patient safety and communication and resolution program, 2013–2022. J Pati…
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psnet.ahrq.gov/issue/nursing-crew-resource-management-follow-report-veterans-health-administration
September 27, 2016 - Commentary
Nursing crew resource management: a follow-up report from the Veterans Health Administration.
Citation Text:
Sculli GL, Fore AM, West P, et al. Nursing crew resource management: a follow-up report from the Veterans Health Administration. J Nurs Adm. 2013;43(3):122-6. doi:10.1…
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psnet.ahrq.gov/issue/electronic-health-record-adoption-childrens-hospitals-united-states
February 17, 2011 - Study
Electronic health record adoption by children's hospitals in the United States.
Citation Text:
Nakamura MM, Ferris T, DesRoches CM, et al. Electronic health record adoption by children's hospitals in the United States. Arch Pediatr Adolesc Med. 2010;164(12):1145-51. doi:10.1001/arc…
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psnet.ahrq.gov/issue/use-electronic-health-records-us-hospitals
February 17, 2011 - Meeting/Conference Proceedings
Use of electronic health records in US hospitals.
Citation Text:
Jha AK, DesRoches CM, Campbell EG, et al. Use of electronic health records in U.S. hospitals. doi:10.1056/NEJMsa0900592.
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psnet.ahrq.gov/issue/iatrogenic-disease-management-moderating-medication-errors-and-risks-pharmacy-benefit
February 13, 2019 - Commentary
Iatrogenic disease management: moderating medication errors and risks in a pharmacy benefit management environment.
Citation Text:
Nair V, Salmon JW, Kaul AF. Iatrogenic Disease Management: Moderating Medication Errors and Risks in a Pharmacy Benefit Management Environment…
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psnet.ahrq.gov/issue/family-caregiver-activation-transitions-fcat-tool-new-measure-family-caregiver-self-efficacy
September 10, 2014 - Study
The Family Caregiver Activation in Transitions (FCAT) tool: a new measure of family caregiver self-efficacy.
Citation Text:
Coleman EA, Ground KL, Maul A. The Family Caregiver Activation in Transitions (FCAT) Tool: A New Measure of Family Caregiver Self-Efficacy. Jt Comm J Qual Pat…
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psnet.ahrq.gov/issue/realist-synthesis-intentional-rounding-hospital-wards-exploring-evidence-what-works-whom-what
March 01, 2023 - Review
Realist synthesis of intentional rounding in hospital wards: exploring the evidence of what works, for whom, in what circumstances and why.
Citation Text:
Sims S, Leamy M, Davies N, et al. Realist synthesis of intentional rounding in hospital wards: exploring the evidence of what …
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psnet.ahrq.gov/issue/reducing-avoidable-readmissions-effectively-rare-campaign
January 31, 2018 - Award Recipient
Reducing Avoidable Readmissions Effectively campaign: a statewide collaborative.
Citation Text:
McCoy KA, Bear-Pfaffendorf K, Foreman JK, et al. Reducing Avoidable Hospital Readmissions Effectively: A Statewide Campaign. Joint Comm J Qual Patient Saf. 2016;40(5):198-204,…
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psnet.ahrq.gov/issue/nurse-decision-making-prearrest-period
July 29, 2020 - Study
Nurse decision making in the prearrest period.
Citation Text:
Gazarian PK, Henneman EA, Chandler GE. Nurse decision making in the prearrest period. Clin Nurs Res. 2010;19(1):21-37. doi:10.1177/1054773809353161.
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psnet.ahrq.gov/issue/medication-prescribing-errors-teaching-hospital
December 23, 2008 - Study
Classic
Medication prescribing errors in a teaching hospital.
Citation Text:
Lesar TS, Briceland LL, Delcoure K, et al. Medication prescribing errors in a teaching hospital. JAMA. 1990;263(17):2329-34.
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psnet.ahrq.gov/issue/clinical-validation-ahrq-postoperative-venous-thromboembolism-patient-safety-indicator
September 25, 2011 - Study
Clinical validation of the AHRQ postoperative venous thromboembolism patient safety indicator.
Citation Text:
Henderson KE, Recktenwald AJ, Reichley RM, et al. Clinical validation of the AHRQ postoperative venous thromboembolism patient safety indicator. Jt Comm J Qual Patient Saf.…
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psnet.ahrq.gov/issue/building-collaborative-teams-neonatal-intensive-care
August 14, 2019 - Study
Building collaborative teams in neonatal intensive care.
Citation Text:
Brodsky D, Gupta M, Quinn M, et al. Building collaborative teams in neonatal intensive care. BMJ Qual Saf. 2013;22(5):374-82. doi:10.1136/bmjqs-2012-000909.
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