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psnet.ahrq.gov/node/852455/psn-pdf
August 16, 2023 - A quality improvement initiative to improve pediatric
discharge medication safety and efficiency.
August 16, 2023
Ring LM, Cinotti J, Hom LA, et al. A quality improvement initiative to improve pediatric discharge
medication safety and efficiency. Pediatr Qual Saf. 2023;8(4):e671. doi:10.1097/pq9.0000000000000671.
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psnet.ahrq.gov/node/72660/psn-pdf
January 20, 2021 - An in situ simulation program: a quantitative and
qualitative prospective study identifying latent safety
threats and examining participant experiences.
January 20, 2021
Kjaergaard-Andersen G, Ibsgaard P, Paltved C, et al. An in situ simulation program: a quantitative and
qualitative prospective study identifying …
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psnet.ahrq.gov/node/44811/psn-pdf
March 15, 2016 - Prevalence and patterns of potentially avoidable
hospitalizations in the US long-term care setting.
March 15, 2016
Mcandrew RM, Grabowski DC, Dangi A, et al. Prevalence and patterns of potentially avoidable
hospitalizations in the US long-term care setting. Int J Qual Health Care. 2016;28(1):104-9.
doi:10.1093/int…
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psnet.ahrq.gov/node/73418/psn-pdf
June 23, 2021 - Evaluation of older persons' medications: a critical
incident technique study exploring healthcare
professionals' experiences and actions.
June 23, 2021
Holmqvist M, Thor J, Ros A, et al. Evaluation of older persons’ medications: a critical incident technique
study exploring healthcare professionals’ experiences a…
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psnet.ahrq.gov/node/46844/psn-pdf
March 07, 2018 - Learning collaboratives: insights and a new taxonomy
from AHRQ's two decades of experience.
March 7, 2018
Nix M, McNamara P, Genevro J, et al. Learning Collaboratives: Insights And A New Taxonomy From
AHRQ's Two Decades Of Experience. Health Aff (Millwood). 2018;37(2):205-212.
doi:10.1377/hlthaff.2017.1144.
https…
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psnet.ahrq.gov/node/47604/psn-pdf
December 21, 2018 - Principles for Patient and Family Partnership in Care: An
American College of Physicians Position Paper.
December 21, 2018
Nickel WK, Weinberger SE, Guze PA, et al. Principles for Patient and Family Partnership in Care: An
American College of Physicians Position Paper. Ann Intern Med. 2018;169(11):796-799. doi:10.7…
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psnet.ahrq.gov/node/47651/psn-pdf
December 12, 2018 - Are national efforts to reduce drug name confusion
paying off?
December 12, 2018
ISMP Medication Safety Alert! Acute Care Edition. November 29, 2018;23:1-6.
https://psnet.ahrq.gov/issue/are-national-efforts-reduce-drug-name-confusion-paying
Look-alike and sound-alike medications present a recurring threat to patie…
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psnet.ahrq.gov/node/838310/psn-pdf
October 12, 2022 - Intravenous smart pumps at the point of care: a
descriptive, observational study.
October 12, 2022
Giuliano KK, Blake JWC, Bittner NP, et al. Intravenous smart pumps at the point of care: a descriptive,
observational study. J Patient Saf. 2022;18(6):553-558. doi:10.1097/pts.0000000000001057.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/44874/psn-pdf
July 11, 2017 - Establishing an ambulatory medicine quality and safety
oversight structure: leveraging the fractal model.
July 11, 2017
Kravet SJ, Bailey J, Demski R, et al. Establishing an Ambulatory Medicine Quality and Safety Oversight
Structure: Leveraging the Fractal Model. Acad Med. 2016;91(7):962-6.
doi:10.1097/ACM.0000000…
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psnet.ahrq.gov/node/60334/psn-pdf
May 13, 2020 - Crisis Standards of Care: Ten Years of Successes and
Challenges–Proceedings of a Workshop.
May 13, 2020
National Academies of Sciences, Engineering, and Medicine. Washington, DC; The National Academies
Press: 2020. ISBN 9780309676250.
https://psnet.ahrq.gov/issue/crisis-standards-care-ten-years-successes-and-…
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psnet.ahrq.gov/node/47793/psn-pdf
June 12, 2019 - Can mindfulness in health care professionals improve
patient care? An integrative review and proposed model.
June 12, 2019
Braun SE, Kinser PA, Rybarczyk B. Can mindfulness in health care professionals improve patient care? An
integrative review and proposed model. Transl Behav Med. 2019;9(2):187-201. doi:10.1093/t…
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psnet.ahrq.gov/node/74066/psn-pdf
November 10, 2021 - Lessons Learned? Building a Culture of Patient Safety
Within the Veterans Health Administration.
November 10, 2021
US House of Representatives Committee on Veterans' Affairs Subcommittee on Health. 117th
Cong. 1st Sess (2021).
https://psnet.ahrq.gov/issue/lessons-learned-building-culture-patient-safety-withi…
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psnet.ahrq.gov/node/853237/psn-pdf
September 06, 2023 - Clinical pathway adherence and missed diagnostic
opportunities among children with musculoskeletal
infections.
September 6, 2023
Grubenhoff JA, Bakel LA, Dominguez F, et al. Clinical pathway adherence and missed diagnostic
opportunities among children with musculoskeletal infections. Jt Comm J Qual Patient Saf.
2…
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psnet.ahrq.gov/node/43702/psn-pdf
May 07, 2018 - Strengthen your resolve: no unlabeled containers
anywhere, ever!
May 7, 2018
ISMP Medication Safety Alert! Acute Care Edition. November 6, 2014;19:1-4.
https://psnet.ahrq.gov/issue/strengthen-your-resolve-no-unlabeled-containers-anywhere-ever
Despite the designation of proper labeling as a National Patient Safety …
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psnet.ahrq.gov/node/45123/psn-pdf
May 07, 2018 - Hardwiring safety into the computer system: one
hospital's actions to provide technology support for U-
500 insulin.
May 7, 2018
ISMP Medication Safety Alert! Acute Care Edition. May 5, 2016;21:1-4.
https://psnet.ahrq.gov/issue/hardwiring-safety-computer-system-one-hospitals-actions-provide-technology-
support-u-…
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psnet.ahrq.gov/web-mm/bloody-bp-cuff
June 21, 2016 - Bloody BP Cuff
Citation Text:
Madan AK. Bloody BP Cuff. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/perspective/video-improve-patient-safety-clinical-and-educational-uses
March 01, 2004 - Video to Improve Patient Safety: Clinical and Educational Uses
Yan Xiao, PhD; Colin F. Mackenzie, MB, ChB; and F. Jacob Seagull, PhD | May 1, 2015
View more articles from the same authors.
Citation Text:
Xiao Y, Mackenzie CF, Seagull JF. Video to Improve Patient S…
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psnet.ahrq.gov/web-mm/chest-tube-complications
September 27, 2023 - Chest Tube Complications
Citation Text:
Santhosh L, Broaddus C. Chest Tube Complications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/delayed-diagnosis-kidney-transplant-complications
January 29, 2020 - Delayed Diagnosis of Kidney Transplant Complications
Citation Text:
Kapa N, Morfín JA. Delayed Diagnosis of Kidney Transplant Complications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/perspective/conversation-kathleen-sutcliffe-mn-phd
April 26, 2023 - In Conversation With… Kathleen Sutcliffe, MN, PhD
April 1, 2017
Citation Text:
In Conversation With… Kathleen Sutcliffe, MN, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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