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psnet.ahrq.gov/issue/how-do-hospitalized-patients-feel-about-resident-work-hours-fatigue-and-discontinuity-care
July 02, 2008 - Study
How do hospitalized patients feel about resident work hours, fatigue, and discontinuity of care?
Citation Text:
Fletcher KE, Wiest FC, Halasyamani L, et al. How do hospitalized patients feel about resident work hours, fatigue, and discontinuity of care? J Gen Intern Med. 2008;23(…
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psnet.ahrq.gov/issue/ambulance-diversion-associated-reduced-access-cardiac-technology-and-increased-one-year
October 27, 2016 - Study
Ambulance diversion associated with reduced access to cardiac technology and increased one-year mortality.
Citation Text:
Shen Y-C, Hsia RY. Ambulance diversion associated with reduced access to cardiac technology and increased one-year mortality. Health Aff (Millwood). 2015;34(8):…
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psnet.ahrq.gov/issue/eliminating-explicit-and-implicit-biases-health-care-evidence-and-research-needs
May 11, 2016 - Review
Eliminating explicit and implicit biases in health care: evidence and research needs.
Citation Text:
Vela MB, Erondu AI, Smith NA, et al. Eliminating explicit and implicit biases in health care: evidence and research needs. Annu Rev Public Health. 2022;43(1):477-501. doi:10.1146/…
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psnet.ahrq.gov/issue/accuracy-trigger-tools-detect-preventable-adverse-events-primary-care-systematic-review
January 22, 2016 - Review
The accuracy of trigger tools to detect preventable adverse events in primary care: a systematic review.
Citation Text:
Davis JJ, Harrington N, Fagan HB, et al. The Accuracy of Trigger Tools to Detect Preventable Adverse Events in Primary Care: A Systematic Review. J Am Board Fam …
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psnet.ahrq.gov/issue/do-professionalism-lapses-medical-school-predict-problems-residency-and-clinical-practice
February 15, 2017 - Study
Do professionalism lapses in medical school predict problems in residency and clinical practice?
Citation Text:
Krupat E, Dienstag JL, Padrino SL, et al. Do professionalism lapses in medical school predict problems in residency and clinical practice? Acad Med. 2020;95(6):888-895. d…
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psnet.ahrq.gov/issue/medication-error-prevention-survey-five-years-results
March 26, 2015 - Study
A medication error prevention survey: five years of results.
Citation Text:
Cusano FL, Chambers C, Summach L. A medication error prevention survey: five years of results. J Oncol Pharm Pract. 2009;15(2):87-93. doi:10.1177/1078155208099284.
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Format:
DOI …
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psnet.ahrq.gov/issue/competencies-improving-diagnosis-interprofessional-framework-education-and-training-health
September 12, 2018 - Study
Competencies for improving diagnosis: an interprofessional framework for education and training in health care.
Citation Text:
Olson A, Rencic J, Cosby K, et al. Competencies for improving diagnosis: an interprofessional framework for education and training in health care. Diagnosi…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.266_slideshow.ppt
May 01, 2012 - Spotlight Case July 2008
Spotlight Case
The Perils of Cross Coverage
*
*
Source and Credits
This presentation is based on the May 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Jeanne M. Farnan, MD, MHPE, and Vineet M. Arora, MD, MAPP, …
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psnet.ahrq.gov/issue/strategic-approach-managing-conflict-hospitals-responding-joint-commission-leadership
December 01, 2007 - Commentary
A strategic approach for managing conflict in hospitals: responding to The Joint Commission leadership standard—part 1 and part 2.
Citation Text:
Scott C, Gerardi D. A strategic approach for managing conflict in hospitals: responding to the Joint Commission leadership standard…
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psnet.ahrq.gov/issue/july-spike-fatal-medication-errors-possible-effect-new-medical-residents
February 15, 2011 - Study
Classic
A July spike in fatal medication errors: a possible effect of new medical residents.
Citation Text:
Phillips DP, Barker GEC. A July spike in fatal medication errors: a possible effect of new medical residents. J Gen Intern Med. 2010;25(8):774-9. …
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psnet.ahrq.gov/issue/comparative-effectiveness-serious-game-and-e-module-support-patient-safety-knowledge-and
September 08, 2010 - Study
Comparative effectiveness of a serious game and an e-module to support patient safety knowledge and awareness.
Citation Text:
Dankbaar MEW, Richters O, Kalkman CJ, et al. Comparative effectiveness of a serious game and an e-module to support patient safety knowledge and awareness. …
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psnet.ahrq.gov/node/840174/psn-pdf
August 28, 2024 - If the patient’s income was supporting their family, the family may have a right to that lost income.
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psnet.ahrq.gov/web-mm/perils-cross-coverage
September 22, 2010 - SPOTLIGHT CASE
The Perils of Cross Coverage
Citation Text:
Farnan JM, Arora V. The Perils of Cross Coverage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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Format:
Google Scholar BibTeX En…
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psnet.ahrq.gov/web-mm/missed-candor-implementation-opportunities
November 11, 2020 - If the patient’s income was supporting their family, the family may have a right to that lost income.
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psnet.ahrq.gov/innovation/echo-care-transitions-successfully-reduces-patient-readmissions-skilled-nursing
October 30, 2024 - rate of hospital readmissions (P = 0.034), reduction in SNF length of stay (P = 0.01), and significant savings … Workers and Nurse Practitioners Result in Better Outcomes and Reduced Acute Care Utilization in Low-Income
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psnet.ahrq.gov/innovation/system-approaches-social-determinants-health-screening-and-intervention-innovation
July 23, 2024 - Shaheen reports that UNC Health funds this innovation with shared savings from its value-based contracts … Workers and Nurse Practitioners Result in Better Outcomes and Reduced Acute Care Utilization in Low-Income
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psnet.ahrq.gov/innovation/missouri-quality-initiative-moqi-reduces-hospitalizations-among-nursing-home-residents
July 23, 2024 - These savings offset the expense associated with a full-time APRN:
Reduction of $1,241 (6.3%) for … notes that this fee is based on the degree of support the nursing home will require and the expected savings … Moving forward, the cost savings associated with a reduction in avoidable hospitalizations provide a … Workers and Nurse Practitioners Result in Better Outcomes and Reduced Acute Care Utilization in Low-Income
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psnet.ahrq.gov/node/33870/psn-pdf
November 01, 2018 - costs, supporting a strong
economic rationale for the new model.(5,6) In fact, a portion of these savings … her inpatients.(1) One can do the math: if the average PCP has a panel of 1800 patients to
create an income
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psnet.ahrq.gov/node/865540/psn-pdf
April 11, 2024 - Misplaced Nasogastric Tube Resulting in Aspiration
April 11, 2024
Singh A, Huang C. Misplaced Nasogastric Tube Resulting in Aspiration. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
The Case
An 82-year-old woman presented to the Emergency Department (ED) for …
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psnet.ahrq.gov/node/33574/psn-pdf
March 15, 2025 - Ambulatory Care Safety
March 15, 2025
Ambulatory Care Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/ambulatory-care-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Las…