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psnet.ahrq.gov/issue/providing-feedback-following-leadership-walkrounds-associated-better-patient-safety-culture
February 01, 2023 - Study
Classic
Providing feedback following Leadership WalkRounds is associated with better patient safety culture, higher employee engagement and lower burnout.
Citation Text:
Sexton B, Adair KC, Leonard MW, et al. Providing feedback following Leadership WalkRou…
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psnet.ahrq.gov/issue/situ-simulation-tool-longitudinally-identify-and-track-latent-safety-threats-structured
June 08, 2022 - Study
In situ simulation as a tool to longitudinally identify and track latent safety threats in a structured quality improvement initiative for SARS-CoV-2 airway management: a single-center study.
Citation Text:
Jafri FN, Yang CJ, Kumar A, et al. In situ simulation as a tool to longitud…
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psnet.ahrq.gov/issue/healthcare-failure-mode-and-effect-analysis-hfmea-effective-mechanism-preventing-infection
April 05, 2023 - Study
Healthcare failure mode and effect analysis (HFMEA) as an effective mechanism in preventing infection caused by accompanying caregivers during COVID-19-experience of a city medical center in Taiwan.
Citation Text:
Tiao C-H, Tsai L-C, Chen L-C, et al. Healthcare Failure Mode and Eff…
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psnet.ahrq.gov/issue/investigating-impact-pharmacist-intervention-inappropriate-prescribing-practices-hospital
November 30, 2022 - Study
Investigating the impact of a pharmacist intervention on inappropriate prescribing practices at hospital admission and discharge in older patients: a secondary outcome analysis from a randomized controlled trial.
Citation Text:
Garcia BH, Omma KK, Småbrekke L, et al. Investigating …
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psnet.ahrq.gov/issue/toward-zero-harm-mackenzie-healths-journey-toward-becoming-high-reliability-organization-and
September 14, 2022 - Study
Toward zero harm: Mackenzie Health's journey toward becoming a high reliability organization and eliminating avoidable harm.
Citation Text:
Wilson M-A, Sinno M, Hacker Teper M, et al. Toward zero harm: Mackenzie Health's journey toward becoming a high reliability organization and e…
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psnet.ahrq.gov/issue/national-cluster-randomized-trial-duty-hour-flexibility-surgical-training
September 09, 2015 - Study
Classic
National cluster-randomized trial of duty-hour flexibility in surgical training.
Citation Text:
Bilimoria KY, Chung JW, Hedges L, et al. National Cluster-Randomized Trial of Duty-Hour Flexibility in Surgical Training. New Engl J Med. 2016;374(8):71…
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psnet.ahrq.gov/issue/quality-hospital-work-environments-and-missed-nursing-care-linked-heart-failure-readmissions
September 09, 2020 - Study
The quality of hospital work environments and missed nursing care is linked to heart failure readmissions: a cross-sectional study of US hospitals.
Citation Text:
Carthon MB, Lasater KB, Sloane DM, et al. The quality of hospital work environments and missed nursing care is linked t…
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psnet.ahrq.gov/issue/weekend-effect-hospital-mortality-ischemic-and-hemorrhagic-stroke-us-rural-and-urban
January 19, 2022 - Study
Weekend effect on in-hospital mortality for ischemic and hemorrhagic stroke in US rural and urban hospitals.
Citation Text:
Mekonnen B, Wang G, Rajbhandari-Thapa J, et al. Weekend effect on in-hospital mortality for ischemic and hemorrhagic stroke in US rural and urban hospitals. J…
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psnet.ahrq.gov/node/72835/psn-pdf
March 10, 2021 - When they're overwhelmed with measurement and with the day-to-day operations of a health
system, patient
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psnet.ahrq.gov/node/49721/psn-pdf
December 01, 2014 - assessment using simulated patient scenarios is the best means to ensure that skills are
adequate and operations
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psnet.ahrq.gov/web-mm/fatal-twist-pseudohyperkalemia
February 10, 2021 - Cases
Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations
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psnet.ahrq.gov/web-mm/outbreak
January 29, 2015 - Outbreak
Citation Text:
Rothman R, Stapleton S. Outbreak. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/node/72564/psn-pdf
November 14, 2018 - Antibiotic and Opioid Stewardship in Dentistry
December 7, 2020
Suda KJ, Fitall E, Hall KK, et al. Antibiotic and Opioid Stewardship in Dentistry. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/antibiotic-and-opioid-stewardship-dentistry
Introduction
Medication stewardship refers to efforts by frontlin…
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psnet.ahrq.gov/node/49397/psn-pdf
May 01, 2003 - The Dropped Lung
May 1, 2003
Heffner JR. The Dropped Lung. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/dropped-lung
The Case
A 79-year-old woman was admitted for hypoxia and shortness of breath. Two weeks prior she had been
hospitalized for dyspnea and was found to have multiple bilateral pulmonary nodu…
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psnet.ahrq.gov/node/33823/psn-pdf
January 01, 2017 - Workplace Safety in Health Care
January 1, 2017
Simon RW, Canacari EG. Workplace Safety in Health Care. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/workplace-safety-health-care
Perspective
The patient safety movement has highlighted the risks that patients face when receiving health care. But,
impo…
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psnet.ahrq.gov/node/33673/psn-pdf
September 01, 2008 - The Role of Bar Coding and Smart Pumps in Safety
September 1, 2008
Rothschild JM, Keohane C. The Role of Bar Coding and Smart Pumps in Safety. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/role-bar-coding-and-smart-pumps-safety
Perspective
Medication safety in hospitals depends on the successful execu…
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psnet.ahrq.gov/node/33632/psn-pdf
April 01, 2006 - In Conversation with… Michael Cohen, RPh, MS, ScD
(hon)
April 1, 2006
In Conversation with… Michael Cohen, RPh, MS, ScD (hon). PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon
Robert Wachter, Editor, AHRQ WebM&M: Tell us a little bit about your background and how…
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psnet.ahrq.gov/node/33881/psn-pdf
August 01, 2019 - In Conversation With… Erik Hollnagel, PhD
June 1, 2019
In Conversation With… Erik Hollnagel, PhD. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-erik-hollnagel-phd
Editor's note: Dr. Hollnagel is Senior Professor of Patient Safety at the University of Jönköping (Sweden)
as well as Visiting…
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psnet.ahrq.gov/node/33639/psn-pdf
September 01, 2006 - In Conversation with...James P. Bagian, MD
September 1, 2006
In Conversation with..James P. Bagian, MD. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-withjames-p-bagian-md
Dr. Robert Wachter, Editor, AHRQ WebM&M: Where did your interest in safety come from?
Dr. James Bagian: I don't know …
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psnet.ahrq.gov/node/49691/psn-pdf
September 01, 2013 - DRESSed for Failure
September 1, 2013
Abramson EL, Kaushal R. DRESSed for Failure. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/dressed-failure
The Case
A 60-year-old woman who uses a wheelchair presented to the emergency department (ED) with right hand
cellulitis and an uncomplicated urinary tract infec…