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psnet.ahrq.gov/issue/barriers-and-facilitators-implementing-interventions-reducing-avoidable-hospital-readmission
April 25, 2018 - Review
Barriers and facilitators to implementing interventions for reducing avoidable hospital readmission: systematic review of qualitative studies.
Citation Text:
Fu BQ, Zhong CCW, Wong CHL, et al. Barriers and facilitators to implementing interventions for reducing avoidable hospital …
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psnet.ahrq.gov/issue/trends-central-line-associated-bloodstream-infections-trauma-surgical-intensive-care-unit
September 13, 2023 - Study
Trends in central line–associated bloodstream infections in a trauma-surgical intensive care unit.
Citation Text:
Ong A, Dysert K, Herbert C, et al. Trends in central line-associated bloodstream infections in a trauma-surgical intensive care unit. Arch Surg. 2011;146(3):302-7. doi:…
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psnet.ahrq.gov/issue/activation-medical-emergency-team-using-electronic-medical-recording-based-screening-system
September 06, 2017 - Study
Activation of a medical emergency team using an electronic medical recording–based screening system.
Citation Text:
Huh JW, Lim C-M, Koh Y, et al. Activation of a medical emergency team using an electronic medical recording-based screening system*. Crit Care Med. 2014;42(4):801-8. …
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psnet.ahrq.gov/issue/crew-resource-management-intensive-care-unit-prospective-3-year-cohort-study
August 10, 2022 - Study
Crew resource management in the intensive care unit: a prospective 3-year cohort study.
Citation Text:
Haerkens MHTM, Kox M, Lemson J, et al. Crew Resource Management in the Intensive Care Unit: a prospective 3-year cohort study. Acta Anaesthesiol Scand. 2015;59(10):1319-29. doi:10…
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psnet.ahrq.gov/issue/what-happens-medication-regimens-older-adults-during-and-after-acute-hospitalization
May 19, 2021 - Study
What happens to the medication regimens of older adults during and after an acute hospitalization?
Citation Text:
Harris CM, Sridharan A, Landis R, et al. What happens to the medication regimens of older adults during and after an acute hospitalization? J Patient Saf. 2013;9(3):15…
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psnet.ahrq.gov/issue/differential-perceptions-what-constitutes-medical-error-associated-electronic-medical-records
August 09, 2023 - Commentary
Differential perceptions of what constitutes a medical error associated with electronic medical records.
Citation Text:
Koppel R, Kuziemsky C, Elkin PL, et al. Differential perceptions of what constitutes a medical error associated with electronic medical records. Stud Health …
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psnet.ahrq.gov/issue/ergonomic-and-human-factors-affecting-anesthetic-vigilance-and-monitoring-performance
May 31, 2011 - Review
Classic
Ergonomic and human factors affecting anesthetic vigilance and monitoring performance in the operating room environment.
Citation Text:
Biebuyck J F, Weinger M B, Englund C E. Ergonomic and Human Factors Affecting Anesthetic Vigilance and Monitori…
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psnet.ahrq.gov/issue/adverse-drug-events-after-hospital-discharge-older-adults-types-severity-and-involvement
August 11, 2010 - Study
Adverse drug events after hospital discharge in older adults: types, severity, and involvement of Beers criteria medications.
Citation Text:
Kanaan AO, Donovan JL, Duchin NP, et al. Adverse drug events after hospital discharge in older adults: types, severity, and involvement of …
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psnet.ahrq.gov/issue/promises-project
January 30, 2019 - Multi-use Website
The PROMISES Project.
Citation Text:
The PROMISES Project. Brigham and Women's Hospital; Institute for Healthcare Improvement; Massachusetts Coalition for the Prevention of Medical Errors; Coverys; CRICO; Harvard School of Public Health; Harvard Medical School; Health…
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psnet.ahrq.gov/issue/use-audit-feedback-implementation-strategy-promote-medication-error-reporting-nurses
March 24, 2021 - Study
Use of an audit with feedback implementation strategy to promote medication error reporting by nurses.
Citation Text:
Hutchinson A, Brotto V, Chapman A, et al. Use of an audit with feedback implementation strategy to promote medication error reporting by nurses. J Clin Nurs. 2020;2…
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psnet.ahrq.gov/issue/shift-change-handovers-and-subsequent-interruptions-potential-impacts-quality-care
February 04, 2009 - Study
Shift change handovers and subsequent interruptions: potential impacts on quality of care.
Citation Text:
Estryn-Behar MR, Milanini-Magny G, Chaumon E, et al. Shift change handovers and subsequent interruptions: potential impacts on quality of care. J Patient Saf. 2014;10(1):29-44.…
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psnet.ahrq.gov/issue/does-lean-management-improve-patient-safety-culture-extensive-evaluation-safety-culture
December 05, 2018 - Study
Does lean management improve patient safety culture? An extensive evaluation of safety culture in a radiotherapy institute.
Citation Text:
Simons P, Houben R, Vlayen A, et al. Does lean management improve patient safety culture? An extensive evaluation of safety culture in a radiot…
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psnet.ahrq.gov/issue/deviation-preoperative-surgical-and-anaesthetic-care-plan-associated-increased-risk-adverse
August 20, 2018 - Study
Deviation from a preoperative surgical and anaesthetic care plan is associated with increased risk of adverse intraoperative events in major abdominal surgery.
Citation Text:
Gauss T, Merckx P, Brasher C, et al. Deviation from a preoperative surgical and anaesthetic care plan is …
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psnet.ahrq.gov/issue/design-and-implementation-application-and-associated-services-support-interdisciplinary
February 15, 2011 - Study
Design and implementation of an application and associated services to support interdisciplinary medication reconciliation efforts at an integrated healthcare delivery network.
Citation Text:
Poon EG, Blumenfeld B, Hamann C, et al. Design and Implementation of an Application and …
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psnet.ahrq.gov/issue/time-essence-relationship-between-hospital-staff-perceptions-time-safety-attitudes-and-staff
September 01, 2021 - Study
"Time is of the essence": relationship between hospital staff perceptions of time, safety attitudes and staff wellbeing.
Citation Text:
Ellis LA, Tran Y, Pomare C, et al. “Time is of the essence”: relationship between hospital staff perceptions of time, safety attitudes and staff …
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psnet.ahrq.gov/issue/primary-care-providers-opening-time-sensitive-alerts-sent-commercial-electronic-health-record
March 17, 2021 - Study
Primary care providers' opening of time-sensitive alerts sent to commercial electronic health record InBaskets.
Citation Text:
Cutrona SL, Fouayzi H, Burns L, et al. Primary Care Providers' Opening of Time-Sensitive Alerts Sent to Commercial Electronic Health Record InBaskets. J Ge…
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psnet.ahrq.gov/issue/transformational-improvement-quality-care-and-health-systems-next-decade
October 14, 2020 - Commentary
Transformational improvement in quality care and health systems: the next decade.
Citation Text:
Braithwaite J, Vincent CA, Garcia-Elorrio E, et al. Transformational improvement in quality care and health systems: the next decade. BMC Med. 2020;18(1):340. doi:10.1186/s12916-02…
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psnet.ahrq.gov/node/850362/psn-pdf
June 14, 2023 - Home Medications Contribute to a Unique Opportunity for
Error on Discharge from the Hospital
June 14, 2023
Agrawal G, Nguyen DM. Home Medications Contribute to a Unique Opportunity for Error on Discharge from
the Hospital. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/home-medications-contribute-unique-opp…
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psnet.ahrq.gov/node/49748/psn-pdf
December 01, 2015 - Managing Ascites: Hazards of Fluid Removal
December 1, 2015
Moore K. Managing Ascites: Hazards of Fluid Removal. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/managing-ascites-hazards-fluid-removal
The Case
A 50-year-old man with longstanding alcoholic cirrhosis presented to the emergency department (ED) w…
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psnet.ahrq.gov/web-mm/forgotten-med
July 01, 2006 - More
See More About The Topic
Long-Term Care
Physicians
Nurses
Ordering/Prescribing