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3021. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49511/psn-pdf
      May 01, 2006 - Citrate Mix-Up May 1, 2006 Weber RJ. Citrate Mix-Up. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/citrate-mix The Case A 36-year-old woman with multiple sclerosis, diabetes, and chronic renal failure was transferred from a skilled nursing facility (SNF) to the hospital for treatment of an infection. On a…

3022. Communication Between Clinicians | PSNet
      psnet.ahrq.gov/primer/communication-between-clinicians
      September 15, 2024 - September 21, 2022 Communication disparities between nursing home team members.

3023. Errors, near misses and adverse events in the emergency department: what can patients tell us? | PSNet
      psnet.ahrq.gov/issue/errors-near-misses-and-adverse-events-emergency-department-what-can-patients-tell-us
      April 25, 2018 - Addressing delays in medication administration for patients transferred from the hospital to the nursing … home: a pilot quality improvement project.

3024. LeDeR - Learning from Lives and Deaths. | PSNet
      psnet.ahrq.gov/issue/leder-learning-lives-and-deaths
      October 19, 2022 - July 1, 2020 Nursing home workers warned government about safety violations before COVID

3025. AHRQ-Funded Patient Safety Project Highlights: Improving Healthcare Safety by Engaging Patients and Families. | PSNet
      psnet.ahrq.gov/issue/ahrq-funded-patient-safety-project-highlights-improving-healthcare-safety-engaging-patients
      March 22, 2024 - View More Related Resources Surveys on Patient Safety Culture Nursing … Home Survey: User Database Report.

3026. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60609/psn-pdf
      June 24, 2020 - When the Indications for Drug Administration Blur June 24, 2020 Munsch J, Doroy A. When the Indications for Drug Administration Blur . PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/when-indications-drug-administration-blur Disclosure of Relevant Financial Relationships: As a provider accredited by the Accre…

3027. ECRI Guidelines Trust. | PSNet
      psnet.ahrq.gov/issue/ecri-guidelines-trust
      March 10, 2021 - July 22, 2015 Nursing Home Compare.

3028. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49518/psn-pdf
      August 01, 2006 - It's All in the Syringe August 1, 2006 Weingart SN. It's All in the Syringe. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/its-all-syringe The Case A 33-year-old man with type 2 diabetes presented to his physician's office to discuss his diabetes management. The patient admitted not taking his medications…

3029. The impact of coronavirus disease 2019 (COVID-19) on healthcare-associated infections in 2020: a summary of data reported to the National Healthcare Safety Network. | PSNet
      psnet.ahrq.gov/issue/impact-coronavirus-disease-2019-covid-19-healthcare-associated-infections-2020-summary-data
      February 07, 2022 - September 16, 2020 Is there a link between nursing home reported quality and COVID-19

3030. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49854/psn-pdf
      February 01, 2019 - Diagnostic Failure: The Growing Deficit February 1, 2019 Chang R, Flanders S. Diagnostic Failure: The Growing Deficit. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/diagnostic-failure-growing-deficit The Case A 65-year-old woman with a history of diabetes and hypertension was admitted to a hospital's telem…

3031. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.257_slideshow.ppt
      December 01, 2011 - Multitasking Mishap (1) A 56-year-old man with dementia was admitted to an academic medical center from a nursing … home for replacement of a percutaneous endoscopic gastrostomy (PEG) tube. … The patient recovered from the operation and was discharged to the nursing home after a 3-week hospital

3032. Improvement of medication event interventions through use of an electronic database. | PSNet
      psnet.ahrq.gov/issue/improvement-medication-event-interventions-through-use-electronic-database
      December 19, 2014 - Study Improvement of medication event interventions through use of an electronic database. Citation Text: Merandi J, Morvay S, Lewe D, et al. Improvement of medication event interventions through use of an electronic database. Am J Health Syst Pharm. 2013;70(19):1708-14. doi:10.2146/ajh…

3033. Preoperative multidisciplinary team huddle improves communication and safety for unscheduled cesarean deliveries: a system redesign using improvement science. | PSNet
      psnet.ahrq.gov/issue/preoperative-multidisciplinary-team-huddle-improves-communication-and-safety-unscheduled
      October 19, 2022 - Study Preoperative multidisciplinary team huddle improves communication and safety for unscheduled cesarean deliveries: a system redesign using improvement science. Citation Text: Girnius A, Snyder C, Czarny H, et al. Preoperative multidisciplinary team huddle improves communication and …

3034. Benefactor or burden: exploring the professional identity of safety professionals. | PSNet
      psnet.ahrq.gov/issue/benefactor-or-burden-exploring-professional-identity-safety-professionals
      October 11, 2017 - Study Benefactor or burden: exploring the professional identity of safety professionals. Citation Text: Provan DJ, Dekker SWA, Rae AJ. Benefactor or burden: Exploring the professional identity of safety professionals. J Safety Res. 2018;66:21-32. doi:10.1016/j.jsr.2018.05.005. Copy Cit…

3035. Bad behavior in healthcare: an insidious threat to patients, staff, and organizations. | PSNet
      psnet.ahrq.gov/issue/bad-behavior-healthcare-insidious-threat-patients-staff-and-organizations
      October 16, 2019 - Commentary Bad behavior in healthcare: an insidious threat to patients, staff, and organizations. Citation Text: Crowe L, Riley CM. Bad behavior in healthcare: an insidious threat to patients, staff, and organizations. Curr Opin Cardiol. 2024;39(4):331-337. doi:10.1097/hco.00000000000011…

3036. Resident work hour limits and patient safety. | PSNet
      psnet.ahrq.gov/issue/resident-work-hour-limits-and-patient-safety
      July 03, 2014 - Study Classic Resident work hour limits and patient safety. Citation Text: Poulose BK, Ray WA, Arbogast PG, et al. Resident work hour limits and patient safety. Ann Surg. 2005;241(6):847-56; discussion 856-60. Copy Citation Format: Google Scholar…

3037. Design and trial of a new ambulance-to-emergency department handover protocol: 'IMIST-AMBO.' | PSNet
      psnet.ahrq.gov/issue/design-and-trial-new-ambulance-emergency-department-handover-protocol-imist-ambo
      March 14, 2022 - Study Design and trial of a new ambulance-to-emergency department handover protocol: 'IMIST-AMBO.' Citation Text: Iedema R, Ball C, Daly B, et al. Design and trial of a new ambulance-to-emergency department handover protocol: 'IMIST-AMBO'. BMJ Qual Saf. 2012;21(8):627-33. doi:10.1136/b…

3038. High reliability pediatric heart centers: always working toward getting better. | PSNet
      psnet.ahrq.gov/issue/high-reliability-pediatric-heart-centers-always-working-toward-getting-better
      September 18, 2024 - Commentary High reliability pediatric heart centers: always working toward getting better. Citation Text: Torzone A, Birely A. High reliability pediatric heart centers: always working toward getting better. Curr Opin Cardiol. 2024;39(4):356-363. doi:10.1097/hco.0000000000001143. Copy C…

3039. Evidence summary and recommendations for improved communication during care transitions. | PSNet
      psnet.ahrq.gov/issue/evidence-summary-and-recommendations-improved-communication-during-care-transitions
      October 19, 2022 - Review Evidence summary and recommendations for improved communication during care transitions. Citation Text: Jackson PD, Biggins MS, Cowan L, et al. Evidence Summary and Recommendations for Improved Communication during Care Transitions. Rehabil Nurs. 2016;41(3):135-48. doi:10.1002/rnj…

3040. In-hospital sequelae of injurious falls in 24 medical/surgical units in four hospitals in the United States. | PSNet
      psnet.ahrq.gov/issue/hospital-sequelae-injurious-falls-24-medicalsurgical-units-four-hospitals-united-states
      December 12, 2012 - Study In-hospital sequelae of injurious falls in 24 medical/surgical units in four hospitals in the United States. Citation Text: Hill A-M, Jacques A, Chandler M, et al. In-Hospital Sequelae of Injurious Falls in 24 Medical/Surgical Units in Four Hospitals in the United States. Jt Comm J…