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psnet.ahrq.gov/issue/quality-traditional-surveillance-public-reporting-nosocomial-bloodstream-infection-rates
August 20, 2018 - Study
Quality of traditional surveillance for public reporting of nosocomial bloodstream infection rates.
Citation Text:
Lin MY, Hota B, Khan YM, et al. Quality of traditional surveillance for public reporting of nosocomial bloodstream infection rates. JAMA. 2010;304(18):2035-41. doi:1…
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psnet.ahrq.gov/issue/respectful-maternity-care-dissemination-and-implementation-perinatal-safety-culture-improve
June 08, 2011 - Book/Report
Respectful Maternity Care: Dissemination and Implementation of Perinatal Safety Culture to Improve Equitable Maternal Healthcare Delivery and Outcomes.
Citation Text:
Respectful Maternity Care: Dissemination and Implementation of Perinatal Safety Culture To Improve Equitable …
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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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psnet.ahrq.gov/issue/development-huddle-observation-tool-structured-case-management-discussions-improve-situation
March 06, 2013 - Study
Development of the Huddle Observation Tool for structured case management discussions to improve situation awareness on inpatient clinical wards.
Citation Text:
Edbrooke-Childs J, Hayes J, Sharples E, et al. Development of the Huddle Observation Tool for structured case management …
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psnet.ahrq.gov/issue/sleep-sleepiness-fatigue-and-performance-12-hour-shift-nurses
July 22, 2010 - Study
Sleep, sleepiness, fatigue, and performance of 12-hour–shift nurses.
Citation Text:
Geiger-Brown J, Rogers VE, Trinkoff AM, et al. Sleep, Sleepiness, Fatigue, and Performance of 12-Hour-Shift Nurses. Chronobiol Int. 2012;29(2). doi:10.3109/07420528.2011.645752.
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psnet.ahrq.gov/issue/team-management-training-using-crisis-resource-management-results-perceived-benefits
October 03, 2011 - Study
Team management training using crisis resource management results in perceived benefits by healthcare workers.
Citation Text:
Rudy SJ, Polomano R, Murray WB, et al. Team management training using crisis resource management results in perceived benefits by healthcare workers. J Co…
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psnet.ahrq.gov/web-mm/central-line-clot
August 04, 2021 - SPOTLIGHT CASE
Central Line Clot
Citation Text:
Randolph AG. Central Line Clot. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/issue/attitudes-clinicians-and-patient-safety-culture-and-after-arrive-trial
November 20, 2024 - Study
Attitudes of clinicians and patient safety culture before and after the ARRIVE trial.
Citation Text:
White VanGompel E, Carlock F, Singh L, et al. Attitudes of clinicians and patient safety culture before and after the ARRIVE trial. J Obstet Gynecol Neonatal Nurs. 2023;52(3):211-22…
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psnet.ahrq.gov/node/49803/psn-pdf
January 01, 2018 - Point-of-care Mixup: 1 Shot Turns Into 3
August 1, 2017
Berberich RF. Point-of-care Mixup: 1 Shot Turns Into 3. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/point-care-mixup-1-shot-turns-3
The Case
A 2-month-old boy was brought in for a routine 2-month well-child visit. The exam was completed and the
app…
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psnet.ahrq.gov/issue/six-habits-enhance-met-performance-under-stress-discussion-paper-reviewing-team-mechanisms
December 12, 2018 - Commentary
Six habits to enhance MET performance under stress: a discussion paper reviewing team mechanisms for improved patient outcomes.
Citation Text:
Fein EC, Mackie B, Chernyak-Hai L, et al. Six habits to enhance MET performance under stress: A discussion paper reviewing team mechan…
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psnet.ahrq.gov/issue/impact-relocation-new-critical-care-building-pediatric-safety-events
May 27, 2020 - Study
Impact of a relocation to a new critical care building on pediatric safety events.
Citation Text:
Furthmiller A, Sahay R, Zhang B, et al. Impact of a relocation to a new critical care building on pediatric safety events. J Hosp Med. 2024;19(5):589-595. doi:10.1002/jhm.13324.
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psnet.ahrq.gov/issue/long-term-effects-teamwork-training-communication-and-teamwork-climate-ambulatory
May 01, 2019 - Study
Long-term effects of teamwork training on communication and teamwork climate in ambulatory reproductive health care.
Citation Text:
Dodge LE, Nippita S, Hacker MR, et al. Long‐term effects of teamwork training on communication and teamwork climate in ambulatory reproductive health …
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psnet.ahrq.gov/issue/just-culture-medication-error-prevention-and-second-victim-support-better-prescription
February 02, 2022 - Book/Report
Just Culture, Medication Error Prevention, and Second Victim Support: a Better Prescription for Preparing Nursing Students for Practices.
Citation Text:
Just Culture, Medication Error Prevention, and Second Victim Support: a Better Prescription for Preparing Nursing Students …
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psnet.ahrq.gov/issue/medical-record-review-deaths-unexpected-intensive-care-unit-admissions-and-clinician
October 12, 2022 - Study
Medical record review of deaths, unexpected intensive care unit admissions and clinician referrals: detection of adverse events and insight into the system.
Citation Text:
Dunn KL, Reddy P, Moulden A, et al. Medical record review of deaths, unexpected intensive care unit admissio…
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psnet.ahrq.gov/issue/better-health-mothers-and-babies
April 15, 2021 - Multi-use Website
Better Health for Mothers and Babies.
Citation Text:
Better Health for Mothers and Babies. American Hospital Association.
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psnet.ahrq.gov/node/33608/psn-pdf
February 01, 2024 - Maternal Safety
January 31, 2024
Shauer M, Nichols A, Lyndon A. Maternal Safety. PSNet [internet]. 2024.
https://psnet.ahrq.gov/primer/maternal-safety
Originally published in 2018 by researchers at the University of California, San Francisco. Updated in
February 2024 by Marla Shauer, PhD(c), MSN, CNM, Amy Nichols,…
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psnet.ahrq.gov/issue/excess-dosing-antiplatelet-and-antithrombin-agents-treatment-non-st-segment-elevation-acute
November 10, 2015 - Study
Excess dosing of antiplatelet and antithrombin agents in the treatment of non–ST-segment elevation acute coronary syndromes.
Citation Text:
Alexander KP, Chen AY, Roe MT, et al. Excess dosing of antiplatelet and antithrombin agents in the treatment of non-ST-segment elevation acu…
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psnet.ahrq.gov/issue/health-professionals-experiences-whistleblowing-maternal-and-newborn-healthcare-settings
November 02, 2010 - Review
Health professionals' experiences of whistleblowing in maternal and newborn healthcare settings: a scoping review and thematic analysis.
Citation Text:
Capper T, Ferguson B, Muurlink O. Health professionals' experiences of whistleblowing in maternal and newborn healthcare settings…
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psnet.ahrq.gov/issue/how-can-we-improve-recognition-reporting-and-resolution-medical-device-related-incidents
May 06, 2015 - Study
How can we improve the recognition, reporting and resolution of medical device-related incidents in hospitals? A qualitative study of physicians and registered nurses.
Citation Text:
Polisena J, Gagliardi AR, Clifford T. How can we improve the recognition, reporting and resolution …
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psnet.ahrq.gov/issue/improving-timely-recognition-and-treatment-sepsis-pediatric-icu
December 09, 2020 - Study
Improving timely recognition and treatment of sepsis in the pediatric ICU.
Citation Text:
Vidrine R, Zackoff M, Paff Z, et al. Improving timely recognition and treatment of sepsis in the pediatric ICU. Jt Comm J Qual Patient Saf. 2020;46(5):299-307. doi:10.1016/j.jcjq.2020.02.005. …