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psnet.ahrq.gov/issue/hospital-experiences-using-electronic-health-records-support-medication-reconciliation
August 08, 2014 - August 23, 2006
AHRQ Nursing Home Survey on Patient Safety Culture: 2016 User Comparative
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psnet.ahrq.gov/issue/patient-safety-organizations-hospital-participation-value-and-challenges
February 11, 2015 - August 9, 2017
Trends in Nursing Home Deficiencies and Complaints.
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psnet.ahrq.gov/issue/cognitive-load-theory-and-its-impact-diagnostic-accuracy
August 07, 2024 - February 7, 2024
Resident Safety Practices in Nursing Home Settings.
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psnet.ahrq.gov/issue/improving-care-using-patient-feedback
April 19, 2017 - View More
Related Resources
Surveys on Patient Safety Culture Nursing … Home Survey: User Database Report.
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psnet.ahrq.gov/issue/ems-crews-brought-patients-hospital-misplaced-breathing-tubes-none-them-survived
November 20, 2019 - July 29, 2020
Nursing home workers warned government about safety violations before COVID
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psnet.ahrq.gov/issue/taking-action-against-clinician-burnout-systems-approach-professional-well-being
September 12, 2018 - November 15, 2023
The National Imperative to Improve Nursing Home Quality: Honoring Our
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psnet.ahrq.gov/node/49679/psn-pdf
March 01, 2013 - The Unfamiliar Catheter
March 1, 2013
Swayze SC, James A. The Unfamiliar Catheter. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/unfamiliar-catheter
The Case
A 28-year-old woman, 20 months post–bilateral lung transplant, presented to the emergency department
with sudden onset of severe shortness of breath…
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psnet.ahrq.gov/issue/governing-surgical-count-through-communication-interactions-implications-patient-safety
November 06, 2015 - Study
Governing the surgical count through communication interactions: implications for patient safety.
Citation Text:
Riley R, Manias E, Polglase A. Governing the surgical count through communication interactions: implications for patient safety. Qual Saf Health Care. 2006;15(5):369-3…
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psnet.ahrq.gov/issue/building-social-capital-healthcare-organizations-thinking-ecologically-safer-care
June 23, 2009 - Commentary
Building social capital in healthcare organizations: thinking ecologically for safer care.
Citation Text:
Hofmeyer A, Marck PB. Building social capital in healthcare organizations: thinking ecologically for safer care. Nurs Outlook. 2008;56(4):145-151.e2. doi:10.1016/j.outlo…
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psnet.ahrq.gov/issue/eliciting-functional-processes-apologizing-errors-health-care-developing-explanatory-model
February 01, 2023 - Commentary
Eliciting the functional processes of apologizing for errors in health care: developing an explanatory model of apology.
Citation Text:
Prothero MM, Morse JM. Eliciting the Functional Processes of Apologizing for Errors in Health Care: Developing an Explanatory Model of Apolog…
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psnet.ahrq.gov/node/61078/psn-pdf
October 28, 2020 - Inpatient Stroke Management in an Adolescent with Type
1 Diabetes and Home Insulin Pump
October 28, 2020
Bagley B, Zuidema D, Crossen S, et al. Inpatient Stroke Management in an Adolescent with Type 1
Diabetes and Home Insulin Pump . PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/inpatient-stroke-management…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.296_slideshow.ppt
April 01, 2013 - Spotlight Case July 2008
Spotlight Case
Total Parenteral Nutrition, Multifarious Errors
*
*
Source and Credits
This presentation is based on the April 2013
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Joseph I. Boullata, PharmD, RPh, BCNSP…
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psnet.ahrq.gov/issue/patient-safety-climate-variation-perceptions-infection-preventionists-and-quality-directors
January 09, 2011 - Study
Patient safety climate: variation in perceptions by infection preventionists and quality directors.
Citation Text:
Nelson S, Stone PW, Jordan S, et al. Patient safety climate: variation in perceptions by infection preventionists and quality directors. Interdiscip Perspect Infect …
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psnet.ahrq.gov/issue/preventing-blood-transfusion-failures-fmea-effective-assessment-method
August 25, 2021 - Study
Preventing blood transfusion failures: FMEA, an effective assessment method.
Citation Text:
Najafpour Z, Hasoumi M, Behzadi F, et al. Preventing blood transfusion failures: FMEA, an effective assessment method. BMC Health Serv Res. 2017;17(1):453. doi:10.1186/s12913-017-2380-3.
C…
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psnet.ahrq.gov/issue/national-trauma-care-system-integrating-military-and-civilian-trauma-systems-achieve-zero
September 12, 2018 - May 11, 2022
The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment
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psnet.ahrq.gov/issue/economics-patient-safety-part-iii-long-term-care-valuing-safety-long-haul
September 28, 2022 - September 28, 2022
The National Imperative to Improve Nursing Home Quality: Honoring
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psnet.ahrq.gov/node/33567/psn-pdf
June 15, 2024 - Handoffs
June 15, 2024
Handoffs and Signouts. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/handoffs
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in 2024.
Backgroun…
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psnet.ahrq.gov/issue/lingering-safety-menace-10-year-review-enteral-misconnection-adverse-events-and-narrative
January 06, 2017 - Review
The lingering safety menace: a 10-year review of enteral misconnection adverse events and narrative review.
Citation Text:
Ethington S, Volpe A, Guenter P, et al. The lingering safety menace: A 10‐year review of enteral misconnection adverse events and narrative review. Nutr Clin …
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psnet.ahrq.gov/node/50907/psn-pdf
February 19, 2020 - Oral chemotherapy: a home safety educational framework
for healthcare providers, patients, and caregivers.
February 19, 2020
Huff C. Oral chemotherapy: A home safety educational framework for healthcare providers, patients, and
caregivers. Clin J Oncol Nurs. 2020;24(1):22-30. doi:10.1188/20.cjon.22-30.
https://psn…
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psnet.ahrq.gov/issue/adverse-events-intensive-care-and-continuing-care-units-during-bed-bath-procedures
March 05, 2025 - Study
Adverse events in intensive care and continuing care units during bed-bath procedures: the prospective observational NURSIng during critical carE (NURSIE) study.
Citation Text:
Decormeille G, Maurer-Maouchi V, Mercier G, et al. Adverse events in intensive care and continuing care u…