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psnet.ahrq.gov/node/49535/psn-pdf
May 01, 2007 - A second anesthesiologist in the group spends the day in the operating room (OR)
supervising three nurse
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psnet.ahrq.gov/node/840175/psn-pdf
November 16, 2022 - The patient was taken to the Operating Room (OR) to extirpate the arterial
thrombus, but the surgeon
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psnet.ahrq.gov/sites/default/files/2022-01/final_spotlight_stacked_opioid_administration_01.03.2022.pdf
January 01, 2022 - Spotlight
Spotlight
Patient Safety Events Involving Opioid
Dose Stacking
Source and Credits
• This presentation is based on the January 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Hollie Porras, PharmD, BCPS and Cathy Lammers…
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psnet.ahrq.gov/perspective/annual-perspective-psychological-safety-healthcare-staff
November 16, 2022 - Annual Perspective
Annual Perspective: Psychological Safety of Healthcare Staff
March 31, 2022
View more articles from the same authors.
Citation Text:
Kingston MB, Dowell P, Mossburg SE, et al. Annual Perspective: Psychological Safety of Healthcare Staff. P…
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psnet.ahrq.gov/web-mm/diagnostic-delay-emergency-department
September 18, 2024 - He was taken to the operating room for repair of his dissection.
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psnet.ahrq.gov/issue/virtual-breakthrough-series-collaborative-missed-test-results-stepped-wedge-cluster
May 12, 2021 - Study
A virtual breakthrough series collaborative for missed test results: a stepped-wedge cluster-randomized clinical trial.
Citation Text:
Zubkoff L, Zimolzak AJ, Meyer AND, et al. A virtual breakthrough series collaborative for missed test results: a stepped-wedge cluster-randomized c…
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psnet.ahrq.gov/issue/application-human-factors-methods-understand-missed-follow-abnormal-test-results
December 16, 2020 - Study
Application of human factors methods to understand missed follow-up of abnormal test results.
Citation Text:
Rogith D, Satterly T, Singh H, et al. Application of human factors methods to understand missed follow-up of abnormal test results. Appl Clin Inform. 2020;11(05):692-698. do…
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psnet.ahrq.gov/issue/patterns-potential-opioid-misuse-and-subsequent-adverse-outcomes-medicare-2008-2012
June 30, 2021 - Study
Patterns of potential opioid misuse and subsequent adverse outcomes in Medicare, 2008 to 2012.
Citation Text:
Carey CM, Jena AB, Barnett ML. Patterns of Potential Opioid Misuse and Subsequent Adverse Outcomes in Medicare, 2008 to 2012. Ann Intern Med. 2018;168(12):837-845. doi:10.7…
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psnet.ahrq.gov/issue/personality-traits-and-traumatic-outcome-symptoms-registered-nurses-aftermath-patient-safety
October 06, 2021 - Study
Personality traits and traumatic outcome symptoms in registered nurses in the aftermath of a patient safety incident.
Citation Text:
Stovall MC, Firkins J, Hansen L, et al. Personality traits and traumatic outcome symptoms in registered nurses in the aftermath of a patient safety i…
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psnet.ahrq.gov/issue/patient-perceptions-mistakes-ambulatory-care
July 29, 2015 - Study
Patient perceptions of mistakes in ambulatory care.
Citation Text:
Kistler CE, Walter LC, Mitchell M, et al. Patient perceptions of mistakes in ambulatory care. Arch Intern Med. 2010;170(16):1480-7. doi:10.1001/archinternmed.2010.288.
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Format:
DOI Google …
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psnet.ahrq.gov/issue/anticoagulation-associated-adverse-drug-events-hospitalized-patients-across-two-time-periods
December 14, 2011 - Study
Anticoagulation-associated adverse drug events in hospitalized patients across two time periods.
Citation Text:
Fanikos J, Tawfik Y, Almheiri D, et al. Anticoagulation-associated adverse drug events in hospitalized patients across two time periods. Am J Med. 2023;136(9):927-936. do…
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psnet.ahrq.gov/issue/comprehensive-departmental-care-review-model-requirements-structure-and-flow
July 06, 2022 - Commentary
A comprehensive departmental care review model: requirements, structure, and flow.
Citation Text:
Nestler DM, Laack TA, Scanlan-Hanson L, et al. A comprehensive departmental care review model: requirements, structure, and flow. Jt Comm J Qual Patient Saf. 2021;47(8):503-509. d…
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psnet.ahrq.gov/issue/assessing-clinical-economic-and-health-resource-utilization-impacts-prefilled-syringes-versus
August 15, 2018 - Review
Assessing the clinical, economic, and health resource utilization impacts of prefilled syringes versus conventional medication administration methods: results from a systematic literature review.
Citation Text:
Benhamou D, Weiss M, Borms M, et al. Assessing the clinical, economic,…
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psnet.ahrq.gov/issue/study-error-reporting-nurses-significant-impact-nursing-team-dynamics
April 12, 2014 - Study
A study of error reporting by nurses: the significant impact of nursing team dynamics.
Citation Text:
Munn LT, Lynn MR, Knafl GJ, et al. A study of error reporting by nurses: the significant impact of nursing team dynamics. J Res Nurs. 2023;28(5):354-364. doi:10.1177/17449871231194…
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psnet.ahrq.gov/issue/multidisciplinary-multifaceted-improvement-initiative-eliminate-mislabelled-laboratory
December 24, 2008 - Study
A multidisciplinary, multifaceted improvement initiative to eliminate mislabelled laboratory specimens at a large tertiary care hospital.
Citation Text:
Seferian EG, Jamal S, Clark K, et al. A multidisciplinary, multifaceted improvement initiative to eliminate mislabelled laborator…
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psnet.ahrq.gov/issue/assessing-effectiveness-engaging-patients-and-their-families-three-step-fall-prevention
February 19, 2020 - Study
Assessing the effectiveness of engaging patients and their families in the three-step fall prevention process across modalities of an evidence-based fall prevention toolkit: an implementation science study.
Citation Text:
Duckworth M, Adelman JS, Belategui K, et al. Assessing the E…
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psnet.ahrq.gov/issue/lost-translation-silent-reporting-and-electronic-patient-records-nursing-handovers
October 20, 2021 - Study
Lost in translation--silent reporting and electronic patient records in nursing handovers: an ethnographic study.
Citation Text:
Ihlebæk HM. Lost in translation--silent reporting and electronic patient records in nursing handovers: an ethnographic study. Int J Nurs Stud. 2020;109:1…
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psnet.ahrq.gov/issue/impact-unacceptable-behaviour-between-healthcare-workers-clinical-performance-and-patient
April 27, 2022 - Review
Impact of unacceptable behaviour between healthcare workers on clinical performance and patient outcomes: a systematic review.
Citation Text:
Guo L, Ryan B, Leditschke IA, et al. Impact of unacceptable behaviour between healthcare workers on clinical performance and patient outcom…
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psnet.ahrq.gov/issue/primer-pdsa-executing-plan-do-study-act-cycles-practice-not-just-name
December 04, 2016 - Review
A primer on PDSA: executing plan–do–study–act cycles in practice, not just in name.
Citation Text:
Leis JA, Shojania KG. A primer on PDSA: executing plan-do-study-act cycles in practice, not just in name. BMJ Qual Saf. 2017;26(7):572-577. doi:10.1136/bmjqs-2016-006245.
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psnet.ahrq.gov/issue/combined-assessment-tool-teamwork-communication-and-workload-hospital-procedural-units
August 04, 2021 - Study
A combined assessment tool of teamwork, communication, and workload in hospital procedural units.
Citation Text:
Weaver BW, Murphy DJ. A combined assessment tool of teamwork, communication, and workload in hospital procedural units. Jt Comm J Qual Patient Saf. 2024;50(3):219-227. d…