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psnet.ahrq.gov/issue/use-maternal-early-warning-trigger-tool-reduces-maternal-morbidity
September 27, 2017 - Study
Use of maternal early warning trigger tool reduces maternal morbidity.
Citation Text:
Shields LE, Wiesner S, Klein C, et al. Use of Maternal Early Warning Trigger tool reduces maternal morbidity. Am J Obstet Gynecol. 2016;214(4):527.e1-527.e6. doi:10.1016/j.ajog.2016.01.154.
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psnet.ahrq.gov/issue/anticoagulant-medication-errors-nursing-homes-characteristics-causes-outcomes-and-association
December 15, 2011 - Study
Anticoagulant medication errors in nursing homes: characteristics, causes, outcomes, and association with patient harm.
Citation Text:
Desai RJ, Williams CE, Greene SB, et al. Anticoagulant medication errors in nursing homes: characteristics, causes, outcomes, and association with…
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psnet.ahrq.gov/issue/intervention-reduce-transmission-resistant-bacteria-intensive-care
February 29, 2012 - Study
Classic
Intervention to reduce transmission of resistant bacteria in intensive care.
Citation Text:
Huskins C, Huckabee CM, O'Grady NP, et al. Intervention to reduce transmission of resistant bacteria in intensive care. N Engl J Med. 2011;364(15):1407-18…
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psnet.ahrq.gov/issue/changes-medical-errors-after-implementation-handoff-program
April 24, 2018 - Study
Classic
Changes in medical errors after implementation of a handoff program.
Citation Text:
Starmer AJ, Spector ND, Srivastava R, et al. Changes in medical errors after implementation of a handoff program. New Engl J Med. 2014;371(19):1803-1812. doi:10.105…
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psnet.ahrq.gov/issue/assessment-incorrect-surgical-procedures-within-and-outside-operating-room-follow-study-us
October 24, 2018 - Study
Assessment of incorrect surgical procedures within and outside the operating room. A follow-up study from US Veterans Health Administration medical centers.
Citation Text:
Neily J, Soncrant C, Mills PD, et al. Assessment of Incorrect Surgical Procedures Within and Outside the Opera…
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psnet.ahrq.gov/issue/structured-override-reasons-drug-drug-interaction-alerts-electronic-health-records
April 29, 2018 - Study
Structured override reasons for drug–drug interaction alerts in electronic health records.
Citation Text:
Wright A, McEvoy D, Aaron S, et al. Structured override reasons for drug-drug interaction alerts in electronic health records. J Am Med Info Asso. 2019;26(10):934-942. doi:10.1…
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psnet.ahrq.gov/issue/root-cause-analysis-reports-help-identify-common-factors-delayed-diagnosis-and-treatment
October 24, 2018 - Study
Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients.
Citation Text:
Giardina TD, King BJ, Ignaczak AP, et al. Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients. Health A…
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psnet.ahrq.gov/issue/wrong-side-thoracentesis-lessons-learned-root-cause-analysis
July 16, 2015 - Study
Wrong-side thoracentesis: lessons learned from root cause analysis.
Citation Text:
Miller K, Mims M, Paull DE, et al. Wrong-side thoracentesis: lessons learned from root cause analysis. JAMA Surg. 2014;149(8):774-9. doi:10.1001/jamasurg.2014.146.
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psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers
August 30, 2023 - Annual Perspective
Impact of System Failures on Healthcare Workers
George Zangaro, PhD, RN, FAAN, Cindy Manaoat Van, MHSA, Sarah Mossburg, RN, PhD
| March 21, 2023
View more articles from the same authors.
Citation Text:
Zangaro G, Van CM, Mossburg S. Imp…
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psnet.ahrq.gov/perspective/beyond-hospital-new-frontier-patient-safety
August 01, 2014 - a month or more without having the continuity clinic, and that presents a significant challenge to maintaining
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psnet.ahrq.gov/perspective/measuring-patient-safety
December 14, 2022 - or utilize measures developed by other “ measure stewards ” who own measures and are responsible for maintaining
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psnet.ahrq.gov/perspective/conversation-dr-michelle-schreiber-measuring-patient-safety
December 14, 2022 - or utilize measures developed by other “ measure stewards ” who own measures and are responsible for maintaining
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psnet.ahrq.gov/node/837659/psn-pdf
July 08, 2022 - Medication Safety Events Related to Diagnostic Imaging
July 8, 2022
Sanchez L, Porras H, Lammers C. Medication Safety Events Related to Diagnostic Imaging. PSNet
[internet]. 2022.
https://psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
The Cases
Case #1: A 42-year-old woman admitted with…
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psnet.ahrq.gov/web-mm/when-taking-sglt2-inhibitor-remember-sstop-stop-sglt2-inhibitor-three-days-bef-o-re
February 01, 2023 - When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!
Citation Text:
Bagley B, Tan CL, Plante D. When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!. PSNet [internet]. Rockville (MD): Agency for Healthcar…
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psnet.ahrq.gov/issue/efficiency-and-thoroughness-trade-offs-high-volume-organisational-routines-ethnographic-study
June 14, 2017 - Study
Efficiency and thoroughness trade-offs in high-volume organisational routines: an ethnographic study of prescribing safety in primary care.
Citation Text:
Grant S, Guthrie B. Efficiency and thoroughness trade-offs in high-volume organisational routines: an ethnographic study of pre…
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psnet.ahrq.gov/node/33567/psn-pdf
June 15, 2024 - Handoffs
June 15, 2024
Handoffs and Signouts. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/handoffs
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. Last reviewed in 2024.
Backgroun…
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psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
January 26, 2022 - Medication Safety Events Related to Diagnostic Imaging
Citation Text:
Sanchez L, Porras H, Lammers C. Medication Safety Events Related to Diagnostic Imaging. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/web-mm/triaging-interhospital-transfers
April 12, 2023 - SPOTLIGHT CASE
Triaging Interhospital Transfers
Citation Text:
Mueller SK. Triaging Interhospital Transfers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/perspective/remote-patient-monitoring
March 15, 2023 - benefits on patient outcomes, there are opportunities to understand the impact that RPM may have on maintaining
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psnet.ahrq.gov/perspective/conversation-dr-neal-sikka-and-dr-colton-hood-about-remote-patient-monitoring
March 15, 2023 - benefits on patient outcomes, there are opportunities to understand the impact that RPM may have on maintaining