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psnet.ahrq.gov/issue/critical-care-transition-programs-and-risk-readmission-or-death-after-discharge-icu
October 13, 2018 - Review
Critical care transition programs and the risk of readmission or death after discharge from an ICU: a systematic review and meta-analysis.
Citation Text:
Niven DJ, Bastos JF, Stelfox HT. Critical care transition programs and the risk of readmission or death after discharge from …
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psnet.ahrq.gov/issue/there-weekend-effect-major-trauma
September 23, 2020 - Study
Is there a 'weekend effect' in major trauma?
Citation Text:
Metcalfe D, Perry DC, Bouamra O, et al. Is there a 'weekend effect' in major trauma? Emerg Med J. 2016;33(12):836-842. doi:10.1136/emermed-2016-206049.
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psnet.ahrq.gov/issue/state-art-usage-simulation-anesthesia-skills-and-teamwork
June 18, 2014 - Review
State-of-the-art usage of simulation in anesthesia: skills and teamwork.
Citation Text:
Krage R, Erwteman M. State-of-the-art usage of simulation in anesthesia: skills and teamwork. Curr Opin Anaesthesiol. 2015;28(6):727-34. doi:10.1097/ACO.0000000000000257.
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psnet.ahrq.gov/issue/systematic-review-unintended-consequences-clinical-interventions-reduce-adverse-outcomes
November 15, 2023 - Review
A systematic review of the unintended consequences of clinical interventions to reduce adverse outcomes.
Citation Text:
Manojlovich M, Lee S, Lauseng D. A Systematic Review of the Unintended Consequences of Clinical Interventions to Reduce Adverse Outcomes. J Patient Saf. 2016;12(…
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psnet.ahrq.gov/issue/teaching-medication-reconciliation-through-simulation-patient-safety-initiative-second-year
May 04, 2010 - Commentary
Teaching medication reconciliation through simulation: a patient safety initiative for second year medical students.
Citation Text:
Lindquist LA, Gleason KM, McDaniel MR, et al. Teaching medication reconciliation through simulation: a patient safety initiative for second yea…
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psnet.ahrq.gov/issue/evidence-bias-and-variation-diagnostic-accuracy-studies
February 15, 2023 - Review
Evidence of bias and variation in diagnostic accuracy studies.
Citation Text:
Rutjes AWS, Reitsma JB, Di Nisio M, et al. Evidence of bias and variation in diagnostic accuracy studies. CMAJ. 2006;174(4):469-476. doi:10.1503/cmaj.050090.
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psnet.ahrq.gov/issue/continuous-monitoring-adverse-events-influence-quality-care-and-incidence-errors-general
March 09, 2022 - Study
Continuous monitoring of adverse events: influence on the quality of care and the incidence of errors in general surgery.
Citation Text:
Rebasa P, Mora L, Luna A, et al. Continuous monitoring of adverse events: influence on the quality of care and the incidence of errors in gener…
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psnet.ahrq.gov/issue/lacerations-and-embedded-needles-caused-epinephrine-autoinjector-use-children
September 23, 2020 - Study
Lacerations and embedded needles caused by epinephrine autoinjector use in children.
Citation Text:
Brown JC, Tuuri RE, Akhter S, et al. Lacerations and Embedded Needles Caused by Epinephrine Autoinjector Use in Children. Ann Emerg Med. 2016;67(3):307-315.e8. doi:10.1016/j.annemerg…
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psnet.ahrq.gov/issue/user-satisfaction-computerized-order-entry-system-and-its-effect-workplace-level-stress
August 27, 2017 - Study
User satisfaction with computerized order entry system and its effect on workplace level of stress.
Citation Text:
Ghahramani N, Lendel I, Haque R, et al. User satisfaction with computerized order entry system and its effect on workplace level of stress. J Med Syst. 2009;33(3):19…
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psnet.ahrq.gov/issue/scoping-review-clinical-handover-mnemonic-devices
July 24, 2019 - Review
A scoping review of clinical handover mnemonic devices.
Citation Text:
Yung AHW, Pak CS, Watson B. A scoping review of clinical handover mnemonic devices. Int J Qual Health Care. 2023;35(3):mzad065. doi:10.1093/intqhc/mzad065.
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psnet.ahrq.gov/issue/long-term-sustainability-and-adaptation-i-pass-handovers
September 09, 2020 - Study
Long-term sustainability and adaptation of I-PASS handovers.
Citation Text:
Ryan SL, Logan M, Liu X, et al. Long-term sustainability and adaptation of I-PASS handovers. Jt Comm J Qual Patient Saf. 2023;19(12):689-697. doi:10.1016/j.jcjq.2023.07.007.
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…
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psnet.ahrq.gov/node/836794/psn-pdf
March 31, 2022 - A Case of Mistaken Capacity: Why A Thorough
Psychosocial History Can Improve Care.
March 31, 2022
Pasao K, Kashkouli P. A Case of Mistaken Capacity: Why A Thorough Psychosocial History Can Improve
Care. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/case-mistaken-capacity-why-thorough-psychosocial-history-c…
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psnet.ahrq.gov/node/33803/psn-pdf
January 01, 2015 - So we're working on accelerating patient safety improvement in nursing homes and in
ambulatory care—particularly
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psnet.ahrq.gov/issue/fda-urged-move-faster-fix-pulse-oximeters-darker-skinned-patients
September 21, 2016 - Newspaper/Magazine Article
FDA urged to move faster to fix pulse oximeters for darker-skinned patients.
Citation Text:
FDA urged to move faster to fix pulse oximeters for darker-skinned patients. McFarling UL. STAT. February 2, 2024.
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psnet.ahrq.gov/node/49422/psn-pdf
November 01, 2003 - 40 of K
November 1, 2003
Lesar TS. 40 of K. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/40-k
The Case
An 81-year-old female maintained on warfarin for a history of chronic atrial fibrillation and mitral valve
replacement developed asymptomatic runs of ventricular tachycardia while hospitalized. The unit…
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psnet.ahrq.gov/node/60363/psn-pdf
March 01, 2021 - Transition Coaches® Reduce Readmissions for Medicare
Patients With Complex Postdischarge Needs
Originally published on June 12, 2020
Last updated on January 11, 2021
https://psnet.ahrq.gov/innovation/transition-coachesr-reduce-readmissions-medicare-patients-complex-
postdischarge-needs
Summary
Under a program kn…
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psnet.ahrq.gov/node/846126/psn-pdf
March 09, 2023 - Medication Handling and Compounding Errors in the
Operating Room.
March 15, 2023
Chaudhry J, Manning C, Dakwa D, et al. Medication Handling and Compounding Errors in the Operating
Room. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/medication-handling-and-compounding-errors-operating-room
The Case
A 62-y…
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psnet.ahrq.gov/web-mm/right-electrocardiogram-wrong-patient
April 24, 2024 - Right Electrocardiogram, Wrong Patient
Citation Text:
Chen C, Venugopal S. Right Electrocardiogram, Wrong Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/node/49773/psn-pdf
July 01, 2016 - Near Miss With Neonate
October 1, 2016
Malana J, Lyndon A. Near Miss With Neonate. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/near-miss-neonate
The Case
A 37-year-old pregnant woman was admitted to the hospital for scheduled induction of labor for postterm
dates. Early the next morning, intravenous oxy…
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psnet.ahrq.gov/issue/evaluation-design-and-structure-electronic-medication-labels-improve-patient-health-knowledge
October 16, 2024 - Review
Evaluation of the design and structure of electronic medication labels to improve patient health knowledge and safety: a systematic review.
Citation Text:
Saif S, Bui TTT, Srivastava G, et al. Evaluation of the design and structure of electronic medication labels to improve patien…