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psnet.ahrq.gov/node/846756/psn-pdf
March 29, 2023 - Frequency of medication administration timing error in
hospitals: a systematic review.
March 29, 2023
Pullam T, Russell CL, White-Lewis S. Frequency of medication administration timing error in hospitals: a
systematic review. J Nurs Care Qual. 2023;38(2):126-133. doi:10.1097/ncq.0000000000000668.
https://psnet.ahr…
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psnet.ahrq.gov/node/41594/psn-pdf
January 18, 2013 - Do micropauses prevent surgeon's fatigue and loss of
accuracy associated with prolonged surgery? An
experimental prospective study.
January 18, 2013
Dorion D, Darveau S. Do micropauses prevent surgeon's fatigue and loss of accuracy associated with
prolonged surgery? An experimental prospective study. Ann Surg. 201…
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psnet.ahrq.gov/node/42560/psn-pdf
September 18, 2013 - Intra-operative monitoring—many alarms with minor
impact.
September 18, 2013
de Man FR, Greuters S, Boer C, et al. Intra-operative monitoring--many alarms with minor impact.
Anaesthesia. 2013;68(8):804-10. doi:10.1111/anae.12289.
https://psnet.ahrq.gov/issue/intra-operative-monitoring-many-alarms-minor-impact
The…
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psnet.ahrq.gov/node/50697/psn-pdf
November 27, 2019 - of polymorphic ventricular tachycardia in which the ventricular rate is faster
than 100 beats per minute
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psnet.ahrq.gov/node/74697/psn-pdf
January 26, 2022 - The effect of medication reconciliation via a patient portal
on medication discrepancies: a randomized noninferiority
study.
January 26, 2022
Ebbens MM, Gombert-Handoko KB, Wesselink EJ, et al. The effect of medication reconciliation via a
patient portal on medication discrepancies: a randomized noninferiority stu…
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psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-initial-treatment
May 31, 2023 - Algorithm-Based Decision Support System Guides Trauma Staff During Initial Treatment, Leading to Fewer Medical Errors
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March 3, 2021
Innovation…
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psnet.ahrq.gov/node/43541/psn-pdf
August 28, 2017 - A step toward high reliability: implementation of a daily
safety brief in a children's hospital.
August 28, 2017
Saysana M, McCaskey M, Cox E, et al. A Step Toward High Reliability: Implementation of a Daily Safety
Brief in a Children's Hospital. J Patient Saf. 2017;13(3):149-152. doi:10.1097/PTS.0000000000000131.
…
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psnet.ahrq.gov/perspective/conversation-jane-brice-md-mph
May 01, 2019 - In general, if it's a stroke or a STEMI and the person is sick but not acutely dying and it's a 45-minute
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psnet.ahrq.gov/perspective/safety-prehospital-emergency-medical-services-setting
May 01, 2019 - In general, if it's a stroke or a STEMI and the person is sick but not acutely dying and it's a 45-minute
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psnet.ahrq.gov/node/837199/psn-pdf
May 25, 2022 - Development and usability testing of the Agency for
Healthcare Research and Quality Common Formats to
capture diagnostic safety events.
May 25, 2022
Bradford A, Shahid U, Schiff GD, et al. Development and usability testing of the Agency for Healthcare
Research and Quality Common Formats to capture diagnostic safet…
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psnet.ahrq.gov/node/864373/psn-pdf
March 13, 2024 - Harnessing in situ simulation to identify human errors
and latent safety threats in adult tracheostomy care.
March 13, 2024
Hassan B, Tawfik M-M, Schiff E, et al. Harnessing in situ simulation to identify human errors and latent
safety threats in adult tracheostomy care. Jt Comm J Qual Patient Saf. 2024;50(4):279-2…
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psnet.ahrq.gov/web-mm/hypoxemia-after-emergency-intubation
March 24, 2019 - There is a direct correlation between ETCO2 and cardiac output when the minute ventilation remains constant … When the minute ventilation is not changed, a reduction in cardiac output can be easily diagnosed by
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psnet.ahrq.gov/perspective/conversation-leah-binder-ma-mga
February 26, 2025 - Because we are dependent on CMS data, we are also dependent on the fact that CMS data is not up to the minute … were looking at objects left in after surgery, and my mother just stared at me and she said, "Wait a minute
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psnet.ahrq.gov/sites/default/files/2021-09/Battle%20Buddy%20Pocket%20Card%20-%20final%20(1).pdf
January 01, 2021 - COVID 19 Battle Buddy Support Program
Background: COVID-19 is a pandemic that threatens not only our patients but
ourselves and our sense of safety and control. Like soldiers on a battlefield, our
front line staff are coping with ongoing uncertainty about the scope of the
threat, concerns about adequate PPE, …
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psnet.ahrq.gov/node/33627/psn-pdf
February 01, 2006 - We have produced a 25-minute educational video that features the vignettes mentioned above and
describes
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.29_slideshow.ppt
September 01, 2003 - confirming that the order was understood and seeking clarification of intent) as you watch the two 3-minute
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psnet.ahrq.gov/node/46050/psn-pdf
August 03, 2017 - Video analysis of factors associated with response time
to physiologic monitor alarms in a children's hospital.
August 3, 2017
Bonafide CP, Localio R, Holmes JH, et al. Video Analysis of Factors Associated With Response Time to
Physiologic Monitor Alarms in a Children's Hospital. JAMA Pediatr. 2017;171(6):524-531.
…
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psnet.ahrq.gov/node/41889/psn-pdf
December 19, 2012 - The effects of a mid-day nap on the neurocognitive
performance of first-year medical residents: a controlled
interventional pilot study.
December 19, 2012
Amin MM, Graber ML, Ahmad K, et al. The effects of a mid-day nap on the neurocognitive performance of
first-year medical residents: a controlled interventional …
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psnet.ahrq.gov/web-mm/miscommunication-during-interhospital-transport-critically-ill-child
March 27, 2024 - The following morning, her breathing was labored and rapid at 50-60 breaths a minute. … After 7 hours in the community hospital, the patient was tachypneic at 60-80 breaths per minute, hypoxic
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psnet.ahrq.gov/node/37770/psn-pdf
March 10, 2011 - Identifying and quantifying medication errors: evaluation
of rapidly discontinued medication orders submitted to a
computerized physician order entry system.
March 10, 2011
Koppel R, Leonard CE, Localio R, et al. Identifying and quantifying medication errors: evaluation of rapidly
discontinued medication orders su…