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psnet.ahrq.gov/issue/review-current-and-emerging-approaches-address-failure-rescue
March 20, 2024 - Review
A review of current and emerging approaches to address failure-to-rescue.
Citation Text:
Taenzer AH, Pyke JB, McGrath SP. A review of current and emerging approaches to address failure-to-rescue. Anesthesiology. 2011;115(2):421-31. doi:10.1097/ALN.0b013e318219d633.
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psnet.ahrq.gov/node/46097/psn-pdf
August 09, 2017 - Administering and monitoring high-alert medications in
acute care.
August 9, 2017
Cajanding JMR. Administering and monitoring high-alert medications in acute care. Nurs Stand.
2017;31(47):42-52. doi:10.7748/ns.2017.e10849.
https://psnet.ahrq.gov/issue/administering-and-monitoring-high-alert-medications-acute-care
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psnet.ahrq.gov/node/34706/psn-pdf
December 23, 2012 - Analysing potential harm in Australian general practice:
an incident-monitoring study.
December 23, 2012
Bhasale AL, Miller GC, Reid SE, et al. Analysing potential harm in Australian general practice: an incident-
monitoring study. Med J Aust. 1998;169(2):73-6.
https://psnet.ahrq.gov/issue/analysing-potential-harm…
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psnet.ahrq.gov/issue/24-hour-inpatient-pulse-oximetry-monitoring-reduces-rescue-events-and-intensive-care-unit
July 02, 2014 - Government Resource
24-Hour inpatient pulse oximetry monitoring reduces rescue events and intensive care unit transfers.
Citation Text:
Agency for Healthcare Research and Quality; AHRQ.
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psnet.ahrq.gov/node/47099/psn-pdf
May 16, 2018 - Defense Health Agency Should Improve Tracking of
Serious Adverse Medical Events and Monitoring of
Required Follow-up.
May 16, 2018
Washington, DC: United States Government Accountability Office; April 2018. Publication GAO-18-378.
https://psnet.ahrq.gov/issue/defense-health-agency-should-improve-tracking-serious-a…
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psnet.ahrq.gov/node/47249/psn-pdf
July 25, 2018 - Survey results: smart pump data analytics pump metrics
that should be monitored to improve safety.
July 25, 2018
ISMP Medication Safety Alert! Acute care edition. July 12, 2018;23:1-4.
https://psnet.ahrq.gov/issue/survey-results-smart-pump-data-analytics-pump-metrics-should-be-monitored-
improve-safety
Smart pump…
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psnet.ahrq.gov/node/45438/psn-pdf
September 07, 2016 - Delayed recognition of deterioration of patients in general
wards is mostly caused by human related monitoring
failures: a root cause analysis of unplanned ICU
admissions.
September 7, 2016
van Galen LS, Struik PW, Driesen BEJM, et al. Delayed Recognition of Deterioration of Patients in General
Wards Is Mostly Ca…
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psnet.ahrq.gov/node/866216/psn-pdf
July 10, 2024 - Health Plan Patient Safety Initiatives
July 10, 2024
Helwig A, Sousane Z, Mossburg S. Health Plan Patient Safety Initiatives. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/health-plan-patient-safety-initiatives
When we think of improving patient safety, we often think of strategies that can be implemen…
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psnet.ahrq.gov/issue/assessing-and-monitoring-override-medications-automated-dispensing-devices
May 06, 2009 - Study
Assessing and monitoring override medications in automated dispensing devices.
Citation Text:
Kowiatek JG, Weber RJ, Skledar S, et al. Assessing and monitoring override medications in automated dispensing devices. Jt Comm J Qual Patient Saf. 2006;32(6):309-17.
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psnet.ahrq.gov/issue/administering-and-monitoring-high-alert-medications-acute-care
February 01, 2017 - Commentary
Administering and monitoring high-alert medications in acute care.
Citation Text:
Cajanding JMR. Administering and monitoring high-alert medications in acute care. Nurs Stand. 2017;31(47):42-52. doi:10.7748/ns.2017.e10849.
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psnet.ahrq.gov/node/45262/psn-pdf
April 01, 2021 - Each Baby Counts.
April 1, 2021
Royal College of Obstetricians and Gynaecologists.
https://psnet.ahrq.gov/issue/each-baby-counts-key-messages-2015
This organization highlights the importance of in-depth reporting and investigation of adverse events in
labor and delivery, involving parents in the analysis, engaging…
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psnet.ahrq.gov/sites/default/files/2023-06/under_pressure.pdf
January 01, 2023 - site was evaluated by the clinical team and instructions
were given to further inflate the cuff and monitor
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psnet.ahrq.gov/issue/drawn-curtains-muted-alarms-and-diverted-attention-lead-tragedy-postanesthesia-care-unit
June 10, 2018 - Newspaper/Magazine Article
Drawn curtains, muted alarms, and diverted attention lead to tragedy in the postanesthesia care unit.
Citation Text:
Drawn curtains, muted alarms, and diverted attention lead to tragedy in the postanesthesia care unit. ISMP Medication Safety Alert! Acute Care E…
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psnet.ahrq.gov/node/47693/psn-pdf
January 23, 2019 - Solving alarm fatigue with smartphone technology.
January 23, 2019
Short K, Chung YJ. Solving alarm fatigue with smartphone technology. Nursing (Brux). 2019;49(1):52-57.
doi:10.1097/01.NURSE.0000549728.37810.d9.
https://psnet.ahrq.gov/issue/solving-alarm-fatigue-smartphone-technology
Alarm fatigue contributes to d…
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psnet.ahrq.gov/node/60752/psn-pdf
August 05, 2020 - Association of state-level opioid-reduction policies with
pediatric opioid poisoning.
August 5, 2020
Toce MS, Michelson K, Hudgins J, et al. Association of state-level opioid-reduction policies with pediatric
opioid poisoning. JAMA Pediatr. 2020;74(10):961-968. doi:10.1001/jamapediatrics.2020.1980.
https://psnet.a…
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psnet.ahrq.gov/node/72677/psn-pdf
January 27, 2021 - An implementation science approach to promote optimal
implementation, adoption, use, and spread of continuous
clinical monitoring system technology.
January 27, 2021
Dykes PC, Lowenthal G, Faris A, et al. An Implementation Science Approach to Promote Optimal
Implementation, Adoption, Use, and Spread of Continuous …
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psnet.ahrq.gov/issue/managing-alarm-systems-quality-and-safety-hospital-setting
August 13, 2014 - Review
Managing alarm systems for quality and safety in the hospital setting.
Citation Text:
Bach TA, Berglund L-M, Turk E. Managing alarm systems for quality and safety in the hospital setting. BMJ Open Qual. 2018;7(3):e000202. doi:10.1136/bmjoq-2017-000202.
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psnet.ahrq.gov/node/45626/psn-pdf
October 29, 2017 - The impacts of a pharmacist-managed outpatient clinic
and chemotherapy-directed electronic order sets for
monitoring oral chemotherapy.
October 29, 2017
Battis B, Clifford L, Huq M, et al. The impacts of a pharmacist-managed outpatient clinic and
chemotherapy-directed electronic order sets for monitoring oral chem…
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psnet.ahrq.gov/node/45457/psn-pdf
September 01, 2016 - Patient safety implications of electronic alerts and alarms
of maternal–fetal status during labor.
September 1, 2016
Simpson KR, Lyndon A, Davidson LA. Patient Safety Implications of Electronic Alerts and Alarms of
Maternal - Fetal Status During Labor. Nurs Womens Health. 2016;20(4):358-66.
doi:10.1016/j.nwh.2016.…
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psnet.ahrq.gov/node/49407/psn-pdf
July 01, 2003 - Bleeding Risk
July 1, 2003
Crowther MA. Bleeding Risk. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/bleeding-risk
The Case
A frail 78-year-old woman fell at home and fractured her left hip. Her past medical history included atrial
fibrillation, hypertension, coronary artery disease, and stroke. The surgi…