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psnet.ahrq.gov/node/47279/psn-pdf
July 23, 2018 - No Place Like Home: Advancing the Safety of Care in the
Home.
July 23, 2018
Boston, MA: Institute for Healthcare Improvement; 2018.
https://psnet.ahrq.gov/issue/no-place-home-advancing-safety-care-home
The home care setting harbors unique challenges to patient safety. This report builds on a previous
evidence ass…
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psnet.ahrq.gov/node/866857/psn-pdf
October 02, 2024 - Reducing falls in hospitalized children and adolescents
with cancer and blood disorders: a quality improvement
journey.
October 2, 2024
Morrissey LK, Ho P, Ilowite M, et al. Reducing falls in hospitalized children and adolescents with cancer
and blood disorders: a quality improvement journey. Pediatr Qual Saf. 202…
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psnet.ahrq.gov/web-mm/transitions-adolescent-medicine
August 04, 2021 - Transitions in Adolescent Medicine
Citation Text:
Okumura MJ, Williams RG. Transitions in Adolescent Medicine. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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Format:
Google Scholar BibTeX EndNote X3 …
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psnet.ahrq.gov/node/846170/psn-pdf
March 15, 2023 - Duplicate Therapies in Retail Pharmacy
March 15, 2023
Punatar N, Molla M, Lee S. Duplicate Therapies in Retail Pharmacy. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/duplicate-therapies-retail-pharmacy
The Cases
Case 1: A middle-aged man with a past medical history of heart failure with reduced ejection f…
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psnet.ahrq.gov/web-mm/transfer-troubles
December 29, 2014 - SPOTLIGHT CASE
Transfer Troubles
Citation Text:
Hains IM. Transfer Troubles. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_case_mesenteric_ischemia_08.05.2022.pdf
January 01, 2022 - Spotlight
Spotlight
Delayed Diagnosis of Mesenteric Ischemia
Source and Credits
• This presentation is based on the August 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Anamaria Robles, MD, and Garth Utter, MD, MSc
o AHRQ WebM&M…
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psnet.ahrq.gov/issue/implementation-custom-alert-prevent-medication-timing-errors-associated-computerized
April 25, 2016 - Study
Implementation of a custom alert to prevent medication-timing errors associated with computerized prescriber order entry.
Citation Text:
Idemoto LM, Williams BL, Ching JM, et al. Implementation of a custom alert to prevent medication-timing errors associated with computerized presc…
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psnet.ahrq.gov/issue/designing-distractions-human-factors-approach-decreasing-interruptions-centralised-medication
July 27, 2018 - Study
Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication station.
Citation Text:
Colligan L, Guerlain S, Steck SE, et al. Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication…
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psnet.ahrq.gov/issue/advancing-science-patient-safety
March 13, 2013 - Commentary
Classic
Advancing the science of patient safety.
Citation Text:
Shekelle PG, Pronovost P, Wachter R, et al. Advancing the science of patient safety. Ann Intern Med. 2011;154(10):693-6. doi:10.7326/0003-4819-154-10-201105170-00011.
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…
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psnet.ahrq.gov/issue/evaluation-problem-specific-sbar-tool-improve-after-hours-nurse-physician-phone-communication
December 30, 2014 - Study
Evaluation of a problem-specific SBAR tool to improve after-hours nurse-physician phone communication: a randomized trial.
Citation Text:
Joffe E, Turley JP, Hwang KO, et al. Evaluation of a problem-specific SBAR tool to improve after-hours nurse-physician phone communication: a ra…
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psnet.ahrq.gov/issue/accurate-measurement-californias-safety-net-health-systems-has-gaps-and-barriers
April 04, 2018 - Study
Accurate measurement in California's safety-net health systems has gaps and barriers.
Citation Text:
Khoong EC, Cherian R, Rivadeneira NA, et al. Accurate Measurement In California's Safety-Net Health Systems Has Gaps And Barriers. Health Aff (Millwood). 2018;37(11):1760-1769. doi:…
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psnet.ahrq.gov/issue/mixed-methods-study-exploring-patient-safety-culture-4-vha-hospitals
September 25, 2019 - Study
A mixed methods study exploring patient safety culture at 4 VHA Hospitals.
Citation Text:
Sullivan JL, Shin MH, Ranusch A, et al. A mixed methods study exploring patient safety culture at 4 VHA Hospitals. Jt Comm J Qual Patient Saf. 2024;50(11):791-800. doi:10.1016/j.jcjq.2024.07.0…
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psnet.ahrq.gov/issue/assessing-clinical-economic-and-health-resource-utilization-impacts-prefilled-syringes-versus
August 15, 2018 - Review
Assessing the clinical, economic, and health resource utilization impacts of prefilled syringes versus conventional medication administration methods: results from a systematic literature review.
Citation Text:
Benhamou D, Weiss M, Borms M, et al. Assessing the clinical, economic,…
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psnet.ahrq.gov/issue/theory-policy-resilient-health-care-policy-recommendations-and-lessons-learnt-resilience
July 19, 2023 - Commentary
From theory to policy in resilient health care: policy recommendations and lessons learnt from the Resilience in Healthcare Research Program.
Citation Text:
Wiig S, Lyng HB, Guise V, et al. From theory to policy in resilient health care: policy recommendations and lessons lear…
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psnet.ahrq.gov/issue/family-participation-during-intensive-care-unit-rounds-goals-and-expectations-parents-and
June 12, 2019 - Study
Family participation during intensive care unit rounds: goals and expectations of parents and health care providers in a tertiary pediatric intensive care unit.
Citation Text:
Stickney CA, Ziniel SI, Brett MS, et al. Family participation during intensive care unit rounds: goals and…
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psnet.ahrq.gov/issue/using-inpatient-portal-engage-families-pediatric-hospital-care
September 13, 2023 - Study
Using an inpatient portal to engage families in pediatric hospital care.
Citation Text:
Kelly MM, Hoonakker P, Dean SM. Using an inpatient portal to engage families in pediatric hospital care. J Am Med Inform Assoc. 2017;24(1):153-161. doi:10.1093/jamia/ocw070.
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psnet.ahrq.gov/issue/implementing-patient-and-family-involvement-interventions-promoting-patient-safety-systematic
February 02, 2022 - Review
Implementing patient and family involvement interventions for promoting patient safety: a systematic review and meta-analysis.
Citation Text:
Giap T-T-T, Park M. Implementing patient and family involvement interventions for promoting patient safety. J Patient Saf. 2021;17(2):131-1…
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psnet.ahrq.gov/issue/fifth-vital-sign-nurse-worry-predicts-inpatient-deterioration-within-24-hours
October 14, 2015 - Study
The fifth vital sign? Nurse worry predicts inpatient deterioration within 24 hours.
Citation Text:
The fifth vital sign? Nurse worry predicts inpatient deterioration within 24 hours. Romero-Brufau S, Gaines K, Nicolas CT, et al. JAMIA Open. 2019;2(4):465-470.
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…
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psnet.ahrq.gov/issue/impact-regionalized-care-concordance-plan-and-preventable-adverse-events-general-medicine
November 16, 2022 - Study
Impact of regionalized care on concordance of plan and preventable adverse events on general medicine services.
Citation Text:
Mueller SK, Schnipper JL, Giannelli K, et al. Impact of regionalized care on concordance of plan and preventable adverse events on general medicine service…
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psnet.ahrq.gov/issue/avoiding-potential-harm-improving-appropriateness-urinary-catheter-use-18-emergency
June 08, 2016 - Study
Avoiding potential harm by improving appropriateness of urinary catheter use in 18 emergency departments.
Citation Text:
Fakih MG, Heavens M, Grotemeyer J, et al. Avoiding potential harm by improving appropriateness of urinary catheter use in 18 emergency departments. Ann Emerg Med…