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psnet.ahrq.gov/issue/implementing-aorn-recommended-practices-prevention-retained-surgical-items
January 05, 2017 - Commentary
Implementing AORN recommended practices for prevention of retained surgical items.
Citation Text:
Goldberg JL, Feldman DL. Implementing AORN recommended practices for prevention of retained surgical items. AORN J. 2012;95(2):205-16; quiz 217-9. doi:10.1016/j.aorn.2011.11.010…
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psnet.ahrq.gov/issue/medication-safety-officers-handbook
September 01, 2018 - Book/Report
Medication Safety Officer's Handbook.
Citation Text:
Medication Safety Officer's Handbook. Larson CM, Saine D, eds. Bethesda, MD: American Society of Health-System Pharmacists; 2013. ISBN: 9781585282104.
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psnet.ahrq.gov/issue/updated-guidance-needed-longstanding-large-volume-parenteral-lvp-labeling-and-packaging
March 10, 2021 - Newspaper/Magazine Article
Updated guidance needed for longstanding large volume parenteral (LVP) labeling and packaging problems.
Citation Text:
Updated guidance needed for longstanding large volume parenteral (LVP) labeling and packaging problems. ISMP Medication Safety Alert! Acute ca…
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psnet.ahrq.gov/issue/administration-concentrated-potassium-chloride-injection-during-code-still-deadly
May 02, 2018 - Newspaper/Magazine Article
Administration of concentrated potassium chloride for injection during a code: still deadly!
Citation Text:
Administration of concentrated potassium chloride for injection during a code: still deadly! ISMP Medication Safety Alert! Acute care edition. June …
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psnet.ahrq.gov/issue/cognitive-biases-associated-medical-decisions-systematic-review
March 01, 2023 - Review
Cognitive biases associated with medical decisions: a systematic review.
Citation Text:
Saposnik G, Redelmeier DA, Ruff CC, et al. Cognitive biases associated with medical decisions: a systematic review. BMC Med Inform Decis Mak. 2016;16(1):138.
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psnet.ahrq.gov/issue/coronavirus-commission-safety-and-quality-nursing-homes
May 26, 2021 - Book/Report
Coronavirus Commission for Safety and Quality in Nursing Homes.
Citation Text:
Coronavirus Commission for Safety and Quality in Nursing Homes. Centers for Medicare and Medicaid Services. McLean, VA: MITRE Corporation; September 2020.
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psnet.ahrq.gov/primer/covid-19-and-dentistry-challenges-and-opportunities-providing-safe-care
February 24, 2022 - errors (e.g., leaving cement in the sulcus), can all jeopardize patient safety and quality of care. 66 Managing
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psnet.ahrq.gov/web-mm/dangers-missing-epidural-abscess-multiple-visits-and-delayed-diagnosis-severely-negative
April 27, 2022 - SPOTLIGHT CASE
Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome
Citation Text:
Lantz L, Yoon J, Barnes DK. Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome. PSNet [internet…
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psnet.ahrq.gov/node/863650/psn-pdf
February 28, 2024 - ABCDEF Bundle + Data Literacy Training, Performance
Measurement Tracking, and Performance Feedback
February 28, 2024
https://psnet.ahrq.gov/innovation/abcdef-bundle-data-literacy-training-performance-measurement-tracking-
and-performance
Summary
To improve patient care and outcomes in the intensive care unit (ICU…
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psnet.ahrq.gov/web-mm/transfusion-thresholds-gastrointestinal-bleeding
November 26, 2014 - SPOTLIGHT CASE
Transfusion Thresholds in Gastrointestinal Bleeding
Citation Text:
Strate L, Swanson S. Transfusion Thresholds in Gastrointestinal Bleeding. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/more-treatment-better-care
August 11, 2021 - More Treatment—Better Care?
Citation Text:
Redberg R. More Treatment—Better Care?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/node/49663/psn-pdf
September 01, 2012 - Peripheral IV in Too Long
September 1, 2012
Fang C-T. Peripheral IV in Too Long. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/peripheral-iv-too-long
Case Objectives
Appreciate the complications associated with peripheral intravenous (IV) catheters.
Describe the optimal sterile technique that should be us…
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psnet.ahrq.gov/node/49676/psn-pdf
February 01, 2013 - Death by PCA
February 1, 2013
Hicks RW. Death by PCA. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/death-pca
The Case
A healthy 21-year-old pregnant woman delivered a healthy baby via Caesarean section after an
uncomplicated pregnancy. Two hours after delivery, the post-anesthesia care unit (PACU) nurse …
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psnet.ahrq.gov/node/841139/psn-pdf
December 14, 2022 - Open wider: Failure to use an interpreter results in
fractured teeth and hypoxia during a simple elective
operation.
December 14, 2022
Bohringer C, Godoy L. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia
during a simple elective operation. PSNet [internet]. 2022.
https://psnet.ah…
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psnet.ahrq.gov/node/49645/psn-pdf
February 01, 2012 - E-prescribing: E for error?
February 1, 2012
Ashton EW. E-prescribing: E for error? PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/e-prescribing-e-error
Case Objectives
Define e-prescribing.
Describe ways in which e-prescribing can reduce health care costs.
State how commonly prescription errors occur wit…
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psnet.ahrq.gov/perspective/second-victim-phenomenon-harsh-reality-health-care-professions
November 13, 2024 - The Second Victim Phenomenon: A Harsh Reality of Health Care Professions
Susan D. Scott RN, MSN | May 1, 2011
View more articles from the same authors.
Citation Text:
Scott SD. The Second Victim Phenomenon: A Harsh Reality of Health Care Professions. PSNet [intern…
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psnet.ahrq.gov/print/pdf/node/867461
January 31, 2024 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Patient and Family Engagement in Long
Term Care
Curated Library
Foundations
Long-term Care and Patient Safety
Deb Bakerjian PhD, APRN, FAAN, FAANP, FGSA | April, 10 2024
A large and growing number of Americans require care in skilled nursin…
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psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning
January 29, 2021 - SPOTLIGHT CASE
A Missed Bowel Perforation - the Importance of Diagnostic Reasoning
Citation Text:
Timbag L, Sinigayan VR, Molla M. A Missed Bowel Perforation - the Importance of Diagnostic Reasoning. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of He…
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psnet.ahrq.gov/perspective/playing-well-others-translocational-research-patient-safety
September 01, 2005 - Playing Well with Others: "Translocational Research" in Patient Safety
Robert M. Wachter, MD | September 1, 2005
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Wachter R. Playing Well with Others: "Translocational Research" in…
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psnet.ahrq.gov/node/74226/psn-pdf
February 01, 2019 - Veterans Health Administration Stratification Tool for
Opioid Risk Mitigation (STORM) Shows Promise for
Targeting Prevention Interventions to Reduce Mortality in
Patients Who Are Prescribed Opioids
January 7, 2022
https://psnet.ahrq.gov/innovation/veterans-health-administration-stratification-tool-opioid-risk-miti…