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psnet.ahrq.gov/node/848108/psn-pdf
April 26, 2023 - Specifically, it a
highlights the value of implementing system-wide safety protocols and practices to
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psnet.ahrq.gov/node/836841/psn-pdf
June 01, 2020 - The Cleveland Clinic Pairs Advanced Practice Registered
Nurses and Paramedics To Provide Home Visits to
Recently Discharged Patients at Highest Risk for Hospital
Readmission
April 7, 2022
https://psnet.ahrq.gov/innovation/cleveland-clinic-pairs-advanced-practice-registered-nurses-and-
paramedics-provide-home
Sum…
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psnet.ahrq.gov/node/49857/psn-pdf
March 01, 2019 - Duplicate Insulin Order
March 1, 2019
Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/duplicate-insulin-order
The Case
A 45-year-old man with a history of insulin-dependent diabetes mellitus was seen in the emergency
department (ED) for complaints of letharg…
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psnet.ahrq.gov/node/49725/psn-pdf
January 01, 2015 - Haste Makes Care Unsafe
January 1, 2015
Eichhorn JH. Haste Makes Care Unsafe. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/haste-makes-care-unsafe
The Case
An 80-year-old man with a history of coronary artery disease and atrial fibrillation underwent a combined
elective coronary artery bypass graft (CABG…
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psnet.ahrq.gov/issue/safety-considerations-learning-new-procedures-survey-surgeons
January 23, 2017 - Study
Safety considerations in learning new procedures: a survey of surgeons.
Citation Text:
Jaffe TA, Hasday SJ, Knol M, et al. Safety considerations in learning new procedures: a survey of surgeons. J Surg Res. 2017;218:361-366. doi:10.1016/j.jss.2017.06.058.
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psnet.ahrq.gov/issue/correlates-third-victim-phenomenon
September 18, 2019 - Review
Correlates of the third victim phenomenon.
Citation Text:
Russ MJ. Correlates of the Third Victim Phenomenon. Psychiatr Q. 2017;88(4):917-920. doi:10.1007/s11126-017-9511-1.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote t…
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psnet.ahrq.gov/issue/driving-improvement-patient-care-lessons-toyota
September 24, 2016 - Study
Classic
Driving improvement in patient care: lessons from Toyota.
Citation Text:
Thompson DN, Wolf GA, Spear SJ. Driving improvement in patient care: lessons from Toyota. J Nurs Adm. 2003;33(11):585-595.
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psnet.ahrq.gov/issue/development-national-reporting-and-learning-system-england-and-wales-2001-2005
September 14, 2022 - Commentary
The development of the National Reporting and Learning System in England and Wales, 2001-2005.
Citation Text:
Williams SK, Osborn SS. The development of the National Reporting and Learning System in England and Wales, 2001–2005. Med J Aust. 2019;184(S10) (S10):s65-s68. doi:1…
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psnet.ahrq.gov/issue/effect-drug-concentration-expression-epinephrine-dosing-errors-randomized-trial
August 27, 2008 - Study
The effect of drug concentration expression on epinephrine dosing errors: a randomized trial.
Citation Text:
Wheeler DW, Carter JJ, Murray LJ, et al. The effect of drug concentration expression on epinephrine dosing errors: a randomized trial. Ann Intern Med. 2008;148(1):11-4.
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psnet.ahrq.gov/issue/wrong-site-craniotomy-analysis-35-cases-and-systems-prevention
November 16, 2022 - Study
Wrong-site craniotomy: analysis of 35 cases and systems for prevention.
Citation Text:
Cohen FL, Mendelsohn D, Bernstein M. Wrong-site craniotomy: analysis of 35 cases and systems for prevention. J Neurosurg. 2010;113(3):461-73. doi:10.3171/2009.10.JNS091282.
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…
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psnet.ahrq.gov/issue/cognitive-bias-clinical-medicine
February 20, 2019 - Commentary
Classic
Cognitive bias in clinical medicine.
Citation Text:
O'Sullivan ED, Schofield SJ. Cognitive bias in clinical medicine. J R Coll Physicians Edinb. 2018;48(3):225-232. doi:10.4997/JRCPE.2018.306.
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DOI Google Sch…
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psnet.ahrq.gov/issue/time-trends-pulmonary-embolism-united-states-evidence-overdiagnosis
February 18, 2011 - Study
Time trends in pulmonary embolism in the United States: evidence of overdiagnosis.
Citation Text:
Wiener RS, Schwartz LM, Woloshin S. Time trends in pulmonary embolism in the United States: evidence of overdiagnosis. Arch Intern Med. 2011;171(9):831-7. doi:10.1001/archinternmed.20…
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psnet.ahrq.gov/issue/homecare-safety-virtual-quality-improvement-collaboratives
January 24, 2024 - Study
Homecare safety virtual quality improvement collaboratives
Citation Text:
Miller W, Asselbergs M, Bank J, et al. Homecare safety virtual quality improvement collaboratives. Healthc Q. 2020;22(SP). doi:10.12927/hcq.2020.26042.
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DOI Google Scholar B…
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psnet.ahrq.gov/issue/concept-analysis-situational-awareness-nursing
August 12, 2015 - Review
A concept analysis of situational awareness in nursing.
Citation Text:
Fore AM, Sculli GL. A concept analysis of situational awareness in nursing. J Adv Nurs. 2013;69(12):2613-21. doi:10.1111/jan.12130.
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DOI Google Scholar PubMed BibTeX EndNote…
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psnet.ahrq.gov/issue/why-dont-nurses-consistently-take-patient-respiratory-rates
October 10, 2012 - Study
Why don't nurses consistently take patient respiratory rates?
Citation Text:
Ansell H, Meyer A, Thompson S. Why don't nurses consistently take patient respiratory rates? Br J Nurs. 2014;23(8):414-8.
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Google Scholar PubMed BibTeX EndNote X3 XML End…
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psnet.ahrq.gov/issue/ahrq-announces-interest-research-about-epidemiology-patient-safety-risks-and-harms-ambulatory
August 15, 2018 - Government Resource
AHRQ Announces Interest in Research About the Epidemiology of Patient Safety Risks and Harms in Ambulatory Health Care Settings.
Citation Text:
AHRQ Announces Interest in Research About the Epidemiology of Patient Safety Risks and Harms in Ambulatory Health Care Setti…
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psnet.ahrq.gov/issue/medication-safety-issue-brief-small-and-rural-hospitals-unique-challenges-unique-solutions
June 17, 2014 - Fact Sheet/FAQs
Medication safety issue brief. Small and rural hospitals—unique challenges, unique solutions.
Citation Text:
Association AH, Pharmacists AS of H-S, Networks H & H. Medication Safety Issue Brief. Small and rural hospitals--unique challenges, unique solutions. Hospitals & h…
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psnet.ahrq.gov/issue/patient-safety-nicu-comprehensive-review
September 12, 2016 - Review
Patient safety in the NICU: a comprehensive review.
Citation Text:
Samra HA, McGrath JM, Rollins W. Patient safety in the NICU: a comprehensive review. J Perinat Neonatal Nurs. 2011;25(2):123-132. doi:10.1097/JPN.0b013e31821693b2.
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DOI Google S…
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psnet.ahrq.gov/issue/enotss-platform-surgeons-nontechnical-skills-performance-improvement
July 01, 2017 - Commentary
The eNOTSS platform for surgeons’ nontechnical skills performance improvement.
Citation Text:
Pradarelli JC, Yule S, Smink DS. The eNOTSS Platform for Surgeons’ Nontechnical Skills Performance Improvement. JAMA Surg. 2020;155(5):438-439. doi:10.1001/jamasurg.2019.5880.
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psnet.ahrq.gov/issue/detection-and-prevention-medication-errors-using-real-time-bedside-nurse-charting
September 27, 2017 - Study
Detection and prevention of medication errors using real-time bedside nurse charting.
Citation Text:
Nelson NC, Evans RS, Samore MH, et al. Detection and Prevention of Medication Errors Using Real-Time Bedside Nurse Charting. Journal of the American Medical Informatics Associatio…