-
psnet.ahrq.gov/issue/development-medical-checklists-improved-quality-patient-care
March 23, 2011 - Review
Development of medical checklists for improved quality of patient care.
Citation Text:
Hales B, Terblanche M, Fowler R, et al. Development of medical checklists for improved quality of patient care. International Journal for Quality in Health Care. 2007;20(1). doi:10.1093/intqhc…
-
psnet.ahrq.gov/issue/effects-intervention-increase-bed-alarm-use-prevent-falls-hospitalized-patients-cluster
January 03, 2017 - Study
Effects of an intervention to increase bed alarm use to prevent falls in hospitalized patients: a cluster randomized trial.
Citation Text:
Shorr RI, Chandler M, Mion LC, et al. Effects of an intervention to increase bed alarm use to prevent falls in hospitalized patients: a clust…
-
psnet.ahrq.gov/issue/correlation-between-hospital-rating-agencies-data-analysis-and-recommendation
April 05, 2023 - Study
Correlation between hospital rating agencies' data: an analysis and recommendation.
Citation Text:
Sondheim SE, Mattie A, Vigil J, et al. Correlation between hospital rating agencies’ data: An analysis and recommendation. J Healthc Risk Manag. 2020;40(3):18-24. doi:10.1002/jhrm.214…
-
psnet.ahrq.gov/issue/description-and-factors-associated-missed-nursing-care-acute-care-community-hospital
August 15, 2012 - Study
Emerging Classic
Description and factors associated with missed nursing care in an acute care community hospital.
Citation Text:
Duffy JR, Culp S, Padrutt T. Description and factors associated with missed nursing care in an acute care community hospital. J…
-
psnet.ahrq.gov/issue/ashp-national-survey-pharmacy-practice-hospital-settings-dispensing-and-administration-2017
September 30, 2020 - Study
ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2017.
Citation Text:
Schneider PJ, Pedersen CA, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: Dispensing and administration-2017. Am J Health Syst Pharm.…
-
psnet.ahrq.gov/issue/interventions-reduction-prescribed-opioid-use-chronic-non-cancer-pain
April 04, 2011 - Review
Interventions for the reduction of prescribed opioid use in chronic non-cancer pain.
Citation Text:
Eccleston C, Fisher E, Thomas KH, et al. Interventions for the reduction of prescribed opioid use in chronic non-cancer pain. Cochrane Database Syst Rev. 2017;11:CD010323. doi:10.10…
-
psnet.ahrq.gov/issue/evidence-base-us-joint-commission-hospital-accreditation-standards-cross-sectional-study
June 09, 2021 - Study
The evidence base for US Joint Commission hospital accreditation standards: cross sectional study.
Citation Text:
Ibrahim SA, Reynolds KA, Poon E, et al. The evidence base for US joint commission hospital accreditation standards: cross sectional study. BMJ. 2022;377:e063064. doi:10…
-
psnet.ahrq.gov/node/49871/psn-pdf
August 10, 2019 - Renal Failure Due to Benign Prostatic Hyperplasia
August 10, 2019
Barry MJ, Garnick MB. Renal Failure Due to Benign Prostatic Hyperplasia. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/renal-failure-due-benign-prostatic-hyperplasia
The Case
A 65-year-old man was referred to urology for a 5-year history of …
-
psnet.ahrq.gov/node/857260/psn-pdf
November 30, 2023 - When Taking an SGLT2 inhibitor, Remember To SSTOP
(Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!
November 30, 2023
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]. 2023.
https://psnet.ahrq.gov/web-mm/when…
-
psnet.ahrq.gov/node/49544/psn-pdf
September 01, 2007 - Discharging Our Responsibility
September 1, 2007
Fonarow GC. Discharging Our Responsibility. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/discharging-our-responsibility
The Case
A 75-year-old man with a history of hypertension, coronary artery disease, and congestive heart failure
(CHF) presented to the …
-
psnet.ahrq.gov/web-mm/one-got-away-elopement-suicidal-patient-emergency-department
September 27, 2023 - The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department.
Citation Text:
Bourgeois JA, Xiong G, Barnes DK, et al. The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depa…
-
psnet.ahrq.gov/node/49415/psn-pdf
September 01, 2003 - Intubation Mishap
September 1, 2003
Weinger MB, Blike G. Intubation Mishap. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/intubation-mishap
Case Objectives
To understand and apply a structured method of human factors case analysis
To describe the key components of effective teamwork
To understand the imp…
-
psnet.ahrq.gov/node/72520/psn-pdf
January 01, 2021 - Guidelines for opioid prescribing in children and
adolescents after surgery: an expert panel opinion.
December 2, 2020
Kelley-Quon LI, Kirkpatrick MG, Ricca RL, et al. Guidelines for opioid prescribing in children and
adolescents after surgery: an expert panel opinion. JAMA Surg. 2021;156(1):76.
doi:10.1001/jamasu…
-
psnet.ahrq.gov/node/38260/psn-pdf
April 22, 2011 - Information exchange among physicians caring for the
same patient in the community.
April 22, 2011
van Walraven C, Taljaard M, Bell CM, et al. Information exchange among physicians caring for the same
patient in the community. CMAJ. 2008;179(10):1013-8. doi:10.1503/cmaj.080430.
https://psnet.ahrq.gov/issue/informa…
-
psnet.ahrq.gov/node/34669/psn-pdf
June 26, 2015 - Learning from mistakes is easier said than done: group
and organizational influences on the detection and
correction of human error.
June 26, 2015
Edmondson AC. Learning from Mistakes is Easier Said Than Done: Group and Organizational Influences
on the Detection and Correction of Human Error. J Appl Behav Sci. 200…
-
psnet.ahrq.gov/node/47529/psn-pdf
January 21, 2019 - Community-acquired and hospital-acquired medication
harm among older inpatients and impact of a state-wide
medication management intervention.
January 21, 2019
Pellegrin K, Lozano A, Miyamura J, et al. Community-acquired and hospital-acquired medication harm
among older inpatients and impact of a state-wide medica…
-
psnet.ahrq.gov/node/39655/psn-pdf
July 07, 2010 - Errors of diagnosis in pediatric practice: a multisite
survey.
July 7, 2010
Singh H, Thomas EJ, Wilson L, et al. Errors of diagnosis in pediatric practice: a multisite survey. Pediatrics.
2010;126(1):70-9. doi:10.1542/peds.2009-3218.
https://psnet.ahrq.gov/issue/errors-diagnosis-pediatric-practice-multisite-survey…
-
psnet.ahrq.gov/node/60635/psn-pdf
January 01, 2021 - Systemic defenses to prevent intravenous medication
errors in hospitals: a systematic review.
July 1, 2020
Kuitunen SK, Niittynen I, Airaksinen M, et al. Systemic Defenses to Prevent Intravenous Medication Errors
in Hospitals. J Patient Saf. 2021;17(8):e1669-e1680. doi:10.1097/pts.0000000000000688.
https://psnet.a…
-
psnet.ahrq.gov/node/42515/psn-pdf
October 24, 2013 - Using four-phased unit-based patient safety walkrounds
to uncover correctable system flaws.
October 24, 2013
Taylor AM, Chuo J, Figueroa-Altmann A, et al. Using four-phased unit-based patient safety walkrounds to
uncover correctable system flaws. Jt Comm J Qual Patient Saf. 2013;39(9):396-403.
https://psnet.ahrq.g…
-
psnet.ahrq.gov/node/36150/psn-pdf
September 29, 2010 - Nurse-physician communication during labor and birth:
implications for patient safety.
September 29, 2010
Simpson KR, James DC, Knox E. Nurse-physician communication during labor and birth: implications for
patient safety. J Obstet Gynecol Neonatal Nurs. 2006;35(4):547-56.
https://psnet.ahrq.gov/issue/nurse-physic…