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2821. Application of human factors methods to ensure appropriate infant identification and abduction prevention within the hospital setting. | PSNet
      psnet.ahrq.gov/issue/application-human-factors-methods-ensure-appropriate-infant-identification-and-abduction
      April 27, 2022 - Commentary Application of human factors methods to ensure appropriate infant identification and abduction prevention within the hospital setting. Citation Text: Webster KLW, Stikes R, Bunnell L, et al. Application of human factors methods to ensure appropriate infant identification and a…

2822. How nurses and physicians judge their own quality of care for deteriorating patients on medical wards: self-assessment of quality of care is suboptimal. | PSNet
      psnet.ahrq.gov/issue/how-nurses-and-physicians-judge-their-own-quality-care-deteriorating-patients-medical-wards
      November 20, 2015 - Study How nurses and physicians judge their own quality of care for deteriorating patients on medical wards: self-assessment of quality of care is suboptimal. Citation Text: Ludikhuize J, Dongelmans DA, Smorenburg SM, et al. How nurses and physicians judge their own quality of care for…

2823. Understanding nurses' and physicians' fear of repercussions for reporting errors: clinician characteristics, organization demographics, or leadership factors? | PSNet
      psnet.ahrq.gov/issue/understanding-nurses-and-physicians-fear-repercussions-reporting-errors-clinician
      October 13, 2021 - Study Understanding nurses' and physicians' fear of repercussions for reporting errors: clinician characteristics, organization demographics, or leadership factors? Citation Text: Castel ES, Ginsburg LR, Zaheer S, et al. Understanding nurses' and physicians' fear of repercussions for rep…

2824. Barriers and facilitators to reporting medical device-related pressure ulcers: a qualitative exploration of international practice. | PSNet
      psnet.ahrq.gov/issue/barriers-and-facilitators-reporting-medical-device-related-pressure-ulcers-qualitative
      April 07, 2019 - Study Barriers and facilitators to reporting medical device-related pressure ulcers: a qualitative exploration of international practice. Citation Text: Crunden EA, Worsley PR, Coleman SB, et al. Barriers and facilitators to reporting medical device-related pressure ulcers: a qualitative…

2825. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33559/psn-pdf
      December 15, 2024 - implementation-medication-reconciliation-outpatient-cancer-care https://psnet.ahrq.gov/issue/drug-related-problems-and-polypharmacy-nursing-home-residents-cross-sectional-study

2826. What Happened on Telemetry? | PSNet
      psnet.ahrq.gov/web-mm/what-happened-telemetry
      January 18, 2012 - SPOTLIGHT CASE What Happened on Telemetry? Citation Text: Sandau KE, Funk M. What Happened on Telemetry?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNo…

2827. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49513/psn-pdf
      July 01, 2006 - Moving Pains July 1, 2006 Schell H, Wachter R. Moving Pains. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/moving-pains Case Objectives Appreciate the risk posed by intrahospital transport Identify key features of current transport practice and policies Propose interventions that might improve safety of …

2828. Spotlight
      psnet.ahrq.gov/sites/default/files/2024-06/spotlight_case_hemorrhagic_shock_slides_final.pptx
      January 01, 2024 - Spotlight Spotlight Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns 1 Source and Credits This presentation is based on the July 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary …

2829. Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan. | PSNet
      psnet.ahrq.gov/web-mm/be-picky-about-your-piccs-fragmented-care-and-poor-communication-discharge-leads-picc
      July 19, 2023 - Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan. Citation Text: Marti CS, Reese SK, Brown-McManus M. Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan.. PSNet [internet]. Rockville (MD): A…

2830. Code Blue—Where To? | PSNet
      psnet.ahrq.gov/web-mm/code-blue-where
      March 30, 2020 - Code Blue—Where To? Citation Text: Adams BD. Code Blue—Where To?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS…

2831. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73145/psn-pdf
      April 28, 2021 - In Conversation With... José A, Morfín, MD, FASN April 28, 2021 In Conversation With.. José A, Morfín, MD, FASN. PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/conversation-jose-morfin-md-fasn Editor’s Note: José A, Morfín, MD, FASN, is a health sciences clinical professor at the University of Californ…

2832. COVID-19: Team and Human Factors to Improve Safety | PSNet
      psnet.ahrq.gov/primer/covid-19-team-and-human-factors-improve-safety
      September 15, 2024 - Primers Coronavirus Disease 2019 (COVID-19) and Safety of Older Adults Residing in Nursing … Homes February 24, 2022 Burnout and its relationship to self-reported quality

2833. Barcode technology flaws put some patients at risk. | PSNet
      psnet.ahrq.gov/issue/barcode-technology-flaws-put-some-patients-risk
      July 23, 2008 - Newspaper/Magazine Article Barcode technology flaws put some patients at risk. Citation Text: Barcode technology flaws put some patients at risk. Preidt R. ABC News. July 4, 2008. Copy Citation Save Save to your library Print Download PDF …

2834. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/845630/psn-pdf
      March 08, 2023 - The effect of transitions intervention to ensure patient safety and satisfaction when transferred from hospital to home health care-a systematic review. March 8, 2023 Oksholm T, Gissum KR, Hunskår I, et al. The effect of transitions intervention to ensure patient safety and satisfaction when transferred from hospi…

2835. Medication Administration Errors | PSNet
      psnet.ahrq.gov/primer/medication-administration-errors
      December 15, 2024 - Medication Administration Errors Citation Text: MacDowell P, Cabri A, Davis M. Medication Administration Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format: Google Scholar BibTeX EndNote X…

2836. Impact of pharmacist interventions on medication errors in hospitalized pediatric patients: a systematic review and meta-analysis. | PSNet
      psnet.ahrq.gov/issue/impact-pharmacist-interventions-medication-errors-hospitalized-pediatric-patients-systematic
      August 04, 2021 - July 22, 2020 Impact of a pharmacist-administered deprescribing intervention on nursing … home residents: a randomized controlled trial.

2837. Hospital-acquired conditions reduction program, racial and ethnic diversity, and Magnet designation in the United States. | PSNet
      psnet.ahrq.gov/issue/hospital-acquired-conditions-reduction-program-racial-and-ethnic-diversity-and-magnet
      June 08, 2022 - March 23, 2022 Nursing home workers warned government about safety violations before

2838. Adverse events present on arrival to the emergency department: the ED as a dual safety net. | PSNet
      psnet.ahrq.gov/issue/adverse-events-present-arrival-emergency-department-ed-dual-safety-net
      September 30, 2020 - Organizational readiness to change as a leverage point for improving safety: a national nursing … home survey.

2839. Using a human factors framework to assess clinician perceptions of and barriers to high reliability in hand hygiene. | PSNet
      psnet.ahrq.gov/issue/using-human-factors-framework-assess-clinician-perceptions-and-barriers-high-reliability-hand
      December 02, 2020 - April 20, 2022 Drug-related problems and polypharmacy in nursing home residents: a cross-sectional

2840. Are evidence-based practices associated with effective prevention of hospital-acquired pressure ulcers in US academic medical centers? | PSNet
      psnet.ahrq.gov/issue/are-evidence-based-practices-associated-effective-prevention-hospital-acquired-pressure
      September 23, 2020 - Organizational readiness to change as a leverage point for improving safety: a national nursing … home survey.