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psnet.ahrq.gov/web-mm/case-mistaken-capacity-why-thorough-psychosocial-history-can-improve-care
July 08, 2022 - SPOTLIGHT CASE
A Case of Mistaken Capacity: Why A Thorough Psychosocial History Can Improve Care.
Citation Text:
Pasao K, Kashkouli P. A Case of Mistaken Capacity: Why A Thorough Psychosocial History Can Improve Care.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, …
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psnet.ahrq.gov/issue/increased-patient-safety-related-incidents-following-transition-daylight-savings-time
May 19, 2021 - Study
Increased patient safety-related incidents following the transition into Daylight Savings Time.
Citation Text:
Kolla BP, Coombes BJ, Morgenthaler TI, et al. Increased patient safety-related incidents following the transition into Daylight Savings Time. J Gen Intern Med. 2020;36(1):…
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psnet.ahrq.gov/issue/review-medical-error-reporting-system-design-considerations-and-proposed-cross-level-systems
May 16, 2012 - Review
A review of medical error reporting system design considerations and a proposed cross-level systems research framework.
Citation Text:
Holden RJ, Karsh B-T. A review of medical error reporting system design considerations and a proposed cross-level systems research framework. Hu…
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psnet.ahrq.gov/issue/well-being-playbook-20-covid-19-resource-hospital-and-health-system-leaders
July 21, 2021 - Tools/Toolkit
Well-Being Playbook 2.0. A COVID-19 Resource for Hospital and Health System Leaders.
Citation Text:
Well-Being Playbook 2.0. A COVID-19 Resource for Hospital and Health System Leaders. AHA Physician Alliance. Chicago, IL: American Hospital Association. February 2021.
…
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psnet.ahrq.gov/issue/missing-clinical-and-behavioral-health-data-large-electronic-health-record-ehr-system
July 19, 2023 - Study
Missing clinical and behavioral health data in a large electronic health record (EHR) system.
Citation Text:
Madden JM, Lakoma MD, Rusinak D, et al. Missing clinical and behavioral health data in a large electronic health record (EHR) system. J Am Med Info Asso. 2016;23(6):1143-114…
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psnet.ahrq.gov/issue/characteristics-disease-specific-and-generic-diagnostic-pitfalls-qualitative-study
December 02, 2020 - Study
Characteristics of disease-specific and generic diagnostic pitfalls: a qualitative study.
Citation Text:
Schiff GD, Volodarskaya M, Ruan E, et al. Characteristics of disease-specific and generic diagnostic pitfalls: a qualitative study. JAMA Netw Open. 2022;5(1):e2144531. doi:10.10…
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psnet.ahrq.gov/issue/state-medical-board-regulation-compounding-physician-offices
July 13, 2022 - Study
State medical board regulation of compounding in physician offices.
Citation Text:
Reynolds KA, Hellquist K, Ibrahim SA, et al. State medical board regulation of compounding in physician offices. Arch Dermatol Res. 2022;314(4):363-367. doi:10.1007/s00403-021-02237-8.
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psnet.ahrq.gov/node/841493/psn-pdf
December 14, 2022 - Telehealth and Patient Safety.
December 14, 2022
O'Malley G, Shaikh U, Marcin JP. Telehealth and Patient Safety. PSNet [internet]. 2022.
https://psnet.ahrq.gov/primer/telehealth-and-patient-safety
Background
In recent years, telehealth, or the delivery of healthcare over a distance using telecommunications
techno…
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psnet.ahrq.gov/issue/clinician-well-being-assessment-and-interventions-joint-commission-accredited-hospitals-and
June 07, 2023 - Study
Clinician well-being assessment and interventions in Joint Commission-accredited hospitals and federally qualified health centers.
Citation Text:
Longo BA, Schmaltz SP, Williams SC, et al. Clinician well-being assessment and interventions in Joint Commission-accredited hospitals an…
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psnet.ahrq.gov/issue/identifying-and-characterizing-preventable-adverse-drug-events-prioritizing-pharmacist
July 15, 2010 - Study
Identifying and characterizing preventable adverse drug events for prioritizing pharmacist intervention in hospitals.
Citation Text:
Jeon N, Staley B, Johns T, et al. Identifying and characterizing preventable adverse drug events for prioritizing pharmacist intervention in hospital…
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psnet.ahrq.gov/node/863641/psn-pdf
February 28, 2024 - Revising TeamSTEPPS: The Evolution of Patient Safety
Teamwork Training
February 28, 2024
Haugstetter M, Hines S, Sousane Z, et al. Revising TeamSTEPPS: The Evolution of Patient Safety
Teamwork Training. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/revising-teamstepps-evolution-patient-safety-teamwork…
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psnet.ahrq.gov/issue/understanding-preventable-deaths-geriatric-trauma-population-analysis-3452339-patients-center
February 16, 2022 - Study
Understanding preventable deaths in the geriatric trauma population: analysis of 3,452,339 patients from the Center of Medicare and Medicaid Services Database.
Citation Text:
Ang D, Nieto K, Sutherland M, et al. Understanding preventable deaths in the geriatric trauma population: a…
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psnet.ahrq.gov/node/49785/psn-pdf
February 01, 2017 - Refused Medication Error
February 1, 2017
Foley M. Refused Medication Error. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/refused-medication-error
The Case
A 59-year-old man was admitted to the hospital with acute renal failure and mental status changes. He was
alert to self and place only. The patient h…
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psnet.ahrq.gov/issue/workarounds-electronic-health-record-systems-and-revised-sociotechnical-electronic-health
October 05, 2022 - Review
Workarounds in electronic health record systems and the revised Sociotechnical Electronic Health Record Workaround Analysis Framework: scoping review.
Citation Text:
Blijleven V, Hoxha F, Jaspers MWM. Workarounds in electronic health record systems and the revised sociotechnical E…
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psnet.ahrq.gov/issue/patient-safety-committing-learn-and-acting-improve
June 09, 2009 - Special or Theme Issue
Patient Safety: Committing to Learn and Acting to Improve.
Citation Text:
Patient Safety: Committing to Learn and Acting to Improve. Twigg D, Attree M, eds. Nurse Educ Today. 2014;34(2):159-284.
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psnet.ahrq.gov/node/836794/psn-pdf
March 31, 2022 - A Case of Mistaken Capacity: Why A Thorough
Psychosocial History Can Improve Care.
March 31, 2022
Pasao K, Kashkouli P. A Case of Mistaken Capacity: Why A Thorough Psychosocial History Can Improve
Care. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/case-mistaken-capacity-why-thorough-psychosocial-history-c…
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psnet.ahrq.gov/issue/what-would-you-ideally-do-if-there-were-no-targets-ethnographic-study-unintended-consequences
July 27, 2011 - Study
What would you ideally do if there were no targets? An ethnographic study of the unintended consequences of top-down governance in two clinical settings.
Citation Text:
Allard J, Bleakley A. What would you ideally do if there were no targets? An ethnographic study of the unintended…
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psnet.ahrq.gov/issue/outsourcing-health-care-services-private-sector-and-treatable-mortality-rates-england-2013-20
October 21, 2020 - Study
Outsourcing health-care services to the private sector and treatable mortality rates in England, 2013-20: an observational study of NHS privatisation.
Citation Text:
Goodair B, Reeves A. Outsourcing health-care services to the private sector and treatable mortality rates in England…
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psnet.ahrq.gov/issue/mixed-method-study-practitioners-perspectives-issues-related-ehr-medication-reconciliation
September 23, 2020 - Study
A mixed-method study of practitioners' perspectives on issues related to EHR medication reconciliation at a health system.
Citation Text:
Rangachari P, Dellsperger KC, Fallaw D, et al. A Mixed-Method Study of Practitioners' Perspectives on Issues Related to EHR Medication Reconcili…
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psnet.ahrq.gov/issue/operationalizing-occupational-fatigue-pharmacists-exploratory-factor-analysis
March 23, 2022 - Study
Operationalizing occupational fatigue in pharmacists: an exploratory factor analysis.
Citation Text:
Watterson TL, Look KA, Steege LM, et al. Operationalizing occupational fatigue in pharmacists: an exploratory factor analysis. Res Social Adm Pharm. 2021;17(7):1282-1287. doi:10.101…