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psnet.ahrq.gov/issue/predictors-nursing-home-nurses-willingness-report-medication-near-misses
July 31, 2024 - Study
Predictors of nursing home nurses' willingness to report medication near-misses.
Citation Text:
Farag A, Vogelsmeier A, Knox K, et al. Predictors of nursing home nurses' willingness to report medication near-misses. J Gerontol Nurs. 2020;46(4):21-30. doi:10.3928/00989134-20200303-0…
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digital.ahrq.gov/principal-investigator/ornstein-steven
January 01, 2023 - Ornstein, Steven
Learning From Primary Care EHR Exemplars About Health IT Safety - Final Report
Citation
Ornstein S. Learning From Primary Care EHR Exemplars About Health IT Safety - Final Report. (Prepared by Medical University of South Carolina under Grant No. R21 HS024327).…
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psnet.ahrq.gov/issue/we-are-not-there-yet-qualitative-system-probing-study-hospital-rapid-response-system
March 15, 2023 - Study
We are not there yet: a qualitative system probing study of a hospital rapid response system.
Citation Text:
Olsen SL, Søreide E, Hansen BS. We are not there yet: a qualitative system probing study of a hospital rapid response system. J Patient Saf. 2022;18(7):717-721. doi:10.1097/…
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psnet.ahrq.gov/issue/perceptions-and-attitudes-pediatricians-and-families-regard-pediatric-medication-errors-home
August 11, 2021 - Study
Perceptions and attitudes of pediatricians and families with regard to pediatric medication errors at home.
Citation Text:
de Dios JG, Lopez-Pineda A, Juan GM-P, et al. Perceptions and attitudes of pediatricians and families with regard to pediatric medication errors at home. BMC P…
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psnet.ahrq.gov/issue/barriers-and-facilitators-implementing-interventions-reducing-avoidable-hospital-readmission
April 25, 2018 - Review
Barriers and facilitators to implementing interventions for reducing avoidable hospital readmission: systematic review of qualitative studies.
Citation Text:
Fu BQ, Zhong CCW, Wong CHL, et al. Barriers and facilitators to implementing interventions for reducing avoidable hospital …
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digital.ahrq.gov/principal-investigator/rangachari-pavani
January 01, 2023 - Rangachari, Pavani
A health system's pilot experience with using mobile Social Knowledge Networking (SKN) technology to enable meaningful use of EHR medication reconciliation technology.
Citation
Rangachari P, Dellsperger KC, Rethemeyer RK. A health system's pilot experience w…
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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/use-audit-feedback-implementation-strategy-promote-medication-error-reporting-nurses
March 24, 2021 - Study
Use of an audit with feedback implementation strategy to promote medication error reporting by nurses.
Citation Text:
Hutchinson A, Brotto V, Chapman A, et al. Use of an audit with feedback implementation strategy to promote medication error reporting by nurses. J Clin Nurs. 2020;2…
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psnet.ahrq.gov/issue/errors-adult-trauma-resuscitation-systematic-review
December 01, 2021 - Review
Errors in adult trauma resuscitation: a systematic review.
Citation Text:
Nikouline A, Quirion A, Jung JJ, et al. Errors in adult trauma resuscitation: a systematic review. CJEM. 2021;23:537–546. doi:10.1007/s43678-021-00118-7.
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DOI Google Schola…
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digital.ahrq.gov/2018-year-review/research-dissemination/conference-proceedings/ahrq-funded-research-2018-amia-annual-symposium
January 01, 2018 - AHRQ-Funded Research at the 2018 AMIA Annual Symposium
Investigator Name
AHRQ Research Profile
AMIA Title
Type
Abraham, Joanna
An Etiology for Medication Ordering Errors in Computerized Provider Order Entry Systems
Clinician Perspectives on Duplicate Medication Ordering…
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psnet.ahrq.gov/issue/identification-latent-safety-threats-using-high-fidelity-simulation-based-training
June 26, 2019 - Study
Identification of latent safety threats using high-fidelity simulation-based training with multidisciplinary neonatology teams.
Citation Text:
Wetzel EA, Lang TR, Pendergrass TL, et al. Identification of Latent Safety Threats Using High-Fidelity Simulation-Based Training with Mult…
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psnet.ahrq.gov/issue/wisdom-and-justice-not-paying-preventable-complications
January 22, 2014 - Commentary
Classic
The wisdom and justice of not paying for "preventable complications."
Citation Text:
Pronovost P, Goeschel CA, Wachter R. The wisdom and justice of not paying for "preventable complications". JAMA. 2008;299(18):2197-9. doi:10.1001/jama.299.1…
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psnet.ahrq.gov/issue/seniors-managing-multiple-medications-using-mixed-methods-view-home-care-safety-lens
June 23, 2021 - Study
Seniors managing multiple medications: using mixed methods to view the home care safety lens.
Citation Text:
Lang A, Macdonald M, Marck P, et al. Seniors managing multiple medications: using mixed methods to view the home care safety lens. BMC Health Serv Res. 2015;15:548. doi:10.1…
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psnet.ahrq.gov/issue/does-lean-management-improve-patient-safety-culture-extensive-evaluation-safety-culture
December 05, 2018 - Study
Does lean management improve patient safety culture? An extensive evaluation of safety culture in a radiotherapy institute.
Citation Text:
Simons P, Houben R, Vlayen A, et al. Does lean management improve patient safety culture? An extensive evaluation of safety culture in a radiot…
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psnet.ahrq.gov/issue/learning-lawsuits-using-malpractice-claims-data-develop-care-transitions-planning-tools
January 21, 2019 - Study
Learning from lawsuits: using malpractice claims data to develop care transitions planning tools.
Citation Text:
Arbaje AI, Werner NE, Kasda EM, et al. Learning From Lawsuits: Using Malpractice Claims Data to Develop Care Transitions Planning Tools. J Patient Saf. 2020;16(1):52-57.…
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psnet.ahrq.gov/issue/im-concerned-multi-site-assessment-emergency-medicine-resident-speaking-behaviors
December 02, 2020 - Study
“I’m concerned”: a multi-site assessment of emergency medicine resident speaking up behaviors.
Citation Text:
Feldman N, Volz N, Snow T, et al. “I’m concerned”: A multi-site assessment of emergency medicine resident speaking up behaviors. J Patient Saf Risk Manag. 2022;27(5):229-23…
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digital.ahrq.gov/sites/default/files/docs/citation/r21hs023960-rudin-final-report-2018.pdf
January 01, 2018 - Using mHealth and Patient-Reported Outcomes to Deliver Evidence-Based Asthma Care - Final Report
Using mHealth and Patient-Reported Outcomes to Deliver Evidence-Based Asthma Care
Final Report
Principal Investigator and Team Members: Robert S. Rudin, PI; Maria O. Edelen, Co-I; David W.
Bates, Co…
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psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
November 30, 2023 - A Sweet Case of Hidden Hydrogen Ions
Citation Text:
Plante D, Falero A. A Sweet Case of Hidden Hydrogen Ions. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/web-mm/spotlight-overdiagnosis-and-delay-challenges-sepsis-diagnosis
October 28, 2020 - SPOTLIGHT CASE
Spotlight: Overdiagnosis and Delay: Challenges in Sepsis Diagnosis
Citation Text:
Kuye I, Rhee C. Spotlight: Overdiagnosis and Delay: Challenges in Sepsis Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…
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psnet.ahrq.gov/sites/default/files/2020-05/final_may-spotlight-fatal_pca_slides_05.01.2020_cme_review-revised.pdf
January 01, 2020 - Spotlight
Spotlight
Fatal PCA Opioid-Induced
Respiratory Depression
Source and Credits
• This presentation is based on the May 2020 AHRQ
WebM&M Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
• Commentary by: Sarina Fazio, PhD, RN and Rachelle
Firestone, PharmD, BCCCP
o Editors in Chie…