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  1. Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees | PSNet

    psnet.ahrq.gov/web-mm/supervision-and-entrustment-clinical-training-protecting-patients-protecting-trainees
    February 22, 2017 - SPOTLIGHT CASE Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees Citation Text: Cate O ten-. Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…

  2. The Case of Mistaken Intubation | PSNet

    psnet.ahrq.gov/web-mm/case-mistaken-intubation
    July 01, 2016 - SPOTLIGHT CASE The Case of Mistaken Intubation Citation Text: Silveira MJ. The Case of Mistaken Intubation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX End…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/842919/psn-pdf
    February 01, 2023 - Hospital-Acquired Diabetic Ketoacidosis. February 1, 2023 Zuidema D, Bagley B, Tan CL. Hospital-Acquired Diabetic Ketoacidosis. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis The Cases Case #1: A 46-year-old Hindi-speaking resident of a skilled nursing facility (SNF) …

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865467/psn-pdf
    March 27, 2024 - I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences March 27, 2024 Steinberg K. I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/i-just-want-go-home-understanding-deliriums-impact-treatment-preferenc…

  5. Patient reported receipt of medication instructions for warfarin is associated with reduced risk of serious bleeding events. | PSNet

    psnet.ahrq.gov/issue/patient-reported-receipt-medication-instructions-warfarin-associated-reduced-risk-serious
    February 03, 2011 - Study Patient reported receipt of medication instructions for warfarin is associated with reduced risk of serious bleeding events. Citation Text: Metlay JP, Hennessy S, Localio R, et al. Patient reported receipt of medication instructions for warfarin is associated with reduced risk of…

  6. Will the COVID-19 pandemic transform infection prevention and control in surgery? Seeking leverage points for organizational learning. | PSNet

    psnet.ahrq.gov/issue/will-covid-19-pandemic-transform-infection-prevention-and-control-surgery-seeking-leverage
    February 09, 2022 - Commentary Will the COVID-19 pandemic transform infection prevention and control in surgery? Seeking leverage points for organizational learning. Citation Text: Will the COVID-19 pandemic transform infection prevention and control in surgery? Seeking leverage points for organizational le…

  7. Differences of reasons for alert overrides on contraindicated co-prescriptions by admitting department. | PSNet

    psnet.ahrq.gov/issue/differences-reasons-alert-overrides-contraindicated-co-prescriptions-admitting-department
    January 23, 2017 - Study Differences of reasons for alert overrides on contraindicated co-prescriptions by admitting department. Citation Text: Ahn EK, Cho S-Y, Shin D, et al. Differences of Reasons for Alert Overrides on Contraindicated Co-prescriptions by Admitting Department. Healthc Inform Res. 2014;20…

  8. Perspectives about racism and patient-clinician communication among black adults with serious illness. | PSNet

    psnet.ahrq.gov/issue/perspectives-about-racism-and-patient-clinician-communication-among-black-adults-serious
    September 13, 2023 - Study Perspectives about racism and patient-clinician communication among black adults with serious illness. Citation Text: Brown CE, Marshall AR, Snyder CR, et al. Perspectives about racism and patient-clinician communication among black adults with serious illness. JAMA Netw Open. 2023…

  9. Team experiences of the root cause analysis process after a sentinel event: a qualitative case study. | PSNet

    psnet.ahrq.gov/issue/team-experiences-root-cause-analysis-process-after-sentinel-event-qualitative-case-study
    October 07, 2020 - Study Team experiences of the root cause analysis process after a sentinel event: a qualitative case study. Citation Text: Liepelt S, Sundal H, Kirchhoff R. Team experiences of the root cause analysis process after a sentinel event: a qualitative case study. BMC Health Serv Res. 2023;23(…

  10. Development of a professionalism committee approach to address unprofessional medical staff behavior at an academic medical center. | PSNet

    psnet.ahrq.gov/issue/development-professionalism-committee-approach-address-unprofessional-medical-staff-behavior
    October 19, 2022 - Commentary Development of a professionalism committee approach to address unprofessional medical staff behavior at an academic medical center. Citation Text: Speck RM, Foster JJ, Mulhern VA, et al. Development of a professionalism committee approach to address unprofessional medical staf…

  11. Systematically improving physician assignment during in-hospital transitions of care by enhancing a preexisting hospital electronic health record. | PSNet

    psnet.ahrq.gov/issue/systematically-improving-physician-assignment-during-hospital-transitions-care-enhancing
    March 14, 2022 - Study Systematically improving physician assignment during in-hospital transitions of care by enhancing a preexisting hospital electronic health record. Citation Text: Zsenits B, Polashenski WA, Sterns RH, et al. Systematically improving physician assignment during in-hospital transiti…

  12. State medical board regulation of compounding in physician offices. | PSNet

    psnet.ahrq.gov/issue/state-medical-board-regulation-compounding-physician-offices
    July 13, 2022 - Study State medical board regulation of compounding in physician offices. Citation Text: Reynolds KA, Hellquist K, Ibrahim SA, et al. State medical board regulation of compounding in physician offices. Arch Dermatol Res. 2022;314(4):363-367. doi:10.1007/s00403-021-02237-8. Copy Citatio…

  13. Vulnerability of the medical product supply chain: the wake-up call of COVID-19. | PSNet

    psnet.ahrq.gov/issue/vulnerability-medical-product-supply-chain-wake-call-covid-19
    December 02, 2020 - Commentary Emerging Classic Vulnerability of the medical product supply chain: the wake-up call of COVID-19. Citation Text: Miller FA, Young SB, Dobrow M, et al. Vulnerability of the medical product supply chain: the wake-up call of COVID-19. BMJ Qual Saf. 2020;…

  14. Society for Maternal-Fetal Medicine Special Statement: curriculum outline on patient safety and quality for maternal-fetal medicine fellows. | PSNet

    psnet.ahrq.gov/issue/society-maternal-fetal-medicine-special-statement-curriculum-outline-patient-safety-and
    September 22, 2021 - Organizational Policy/Guidelines Society for Maternal-Fetal Medicine Special Statement: curriculum outline on patient safety and quality for maternal-fetal medicine fellows. Citation Text: Society for Maternal-Fetal Medicine Special Statement: curriculum outline on patient safety and qua…

  15. Incident learning in pursuit of high reliability: implementing a comprehensive, low-threshold reporting program in a large, multisite radiation oncology department. | PSNet

    psnet.ahrq.gov/issue/incident-learning-pursuit-high-reliability-implementing-comprehensive-low-threshold-reporting
    September 27, 2017 - Study Incident learning in pursuit of high reliability: implementing a comprehensive, low-threshold reporting program in a large, multisite radiation oncology department. Citation Text: Gabriel PE, Volz E, Bergendahl HW, et al. Incident learning in pursuit of high reliability: implementi…

  16. The effectiveness of tele-triage during the COVID-19 pandemic: a systematic review and narrative synthesis. | PSNet

    psnet.ahrq.gov/issue/effectiveness-tele-triage-during-covid-19-pandemic-systematic-review-and-narrative-synthesis
    February 01, 2023 - Review The effectiveness of tele-triage during the COVID-19 pandemic: a systematic review and narrative synthesis. Citation Text: Farzandipour M, Nabovati E, Sharif R. The effectiveness of tele-triage during the COVID-19 pandemic: a systematic review and narrative synthesis. J Telemed Te…

  17. A novel approach to increase residents' involvement in reporting adverse events. | PSNet

    psnet.ahrq.gov/issue/novel-approach-increase-residents-involvement-reporting-adverse-events
    September 23, 2020 - Study A novel approach to increase residents' involvement in reporting adverse events. Citation Text: Scott DR, Weimer M, English C, et al. A novel approach to increase residents' involvement in reporting adverse events. Acad Med. 2011;86(6):742-746. doi:10.1097/ACM.0b013e318217e12a. C…

  18. Evolution of intravenous medication errors and preventive systemic defenses in hospital settings-a narrative review of recent evidence. | PSNet

    psnet.ahrq.gov/issue/evolution-intravenous-medication-errors-and-preventive-systemic-defenses-hospital-settings
    July 01, 2020 - Review Evolution of intravenous medication errors and preventive systemic defenses in hospital settings-a narrative review of recent evidence. Citation Text: Kuitunen S, Airaksinen M, Holmström A-R. Evolution of intravenous medication errors and preventive systemic defenses in hospital s…

  19. Information handoff and outcomes of critically ill patients transferred between hospitals. | PSNet

    psnet.ahrq.gov/issue/information-handoff-and-outcomes-critically-ill-patients-transferred-between-hospitals
    July 18, 2016 - Study Information handoff and outcomes of critically ill patients transferred between hospitals. Citation Text: Usher MG, Fanning C, Wu D, et al. Information handoff and outcomes of critically ill patients transferred between hospitals. J Crit Care. 2016;36:240-245. doi:10.1016/j.jcrc.20…

  20. Impact of nighttime rapid response team activation on outcomes of hospitalized patients with acute deterioration. | PSNet

    psnet.ahrq.gov/issue/impact-nighttime-rapid-response-team-activation-outcomes-hospitalized-patients-acute
    April 06, 2022 - Study Impact of nighttime rapid response team activation on outcomes of hospitalized patients with acute deterioration. Citation Text: Fernando SM, Reardon PM, Bagshaw SM, et al. Impact of nighttime Rapid Response Team activation on outcomes of hospitalized patients with acute deteriorat…
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