-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.362_slideshow.ppt
December 01, 2015 - PowerPoint Presentation
Spotlight
Harm From Alarm Fatigue
This presentation is based on the December 2015
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Michele M. Pelter, RN, PhD, and Barbara J. Drew, RN, PhD, University of California, San …
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.164_slideshow.ppt
December 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case December 2007
Elopement
Source and Credits
This presentation is based on the December 2007 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Debra Gerardi, RN, MPH, JD
Creighton University School of Law
Ed…
-
psnet.ahrq.gov/primer/missed-nursing-care
September 15, 2024 - Missed Nursing Care
Citation Text:
Missed Nursing Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
-
psnet.ahrq.gov/perspective/measuring-and-responding-deaths-medical-errors
April 01, 2008 - Annual Perspective
Measuring and Responding to Deaths From Medical Errors
Sumant Ranji, MD | March 22, 2016
View more articles from the same authors.
Citation Text:
Ranji SR. Measuring and Responding to Deaths From Medical Errors. PSNet [internet]. Rockville…
-
psnet.ahrq.gov/perspective/burnout-among-health-professionals-and-its-effect-patient-safety
December 22, 2018 - Annual Perspective
Burnout Among Health Professionals and Its Effect on Patient Safety
Audrey Lyndon, PhD | January 1, 2015
View more articles from the same authors.
Citation Text:
Lyndon A. Burnout Among Health Professionals and Its Effect on Patient Safety…
-
psnet.ahrq.gov/node/50697/psn-pdf
November 27, 2019 - Cardiac Arrest in a Woman with UTI: A Case of QT
Prolongation
November 27, 2019
Kulig CE, Ebong IA. Cardiac Arrest in a Woman with UTI: A Case of QT Prolongation. PSNet [internet].
2019.
https://psnet.ahrq.gov/web-mm/cardiac-arrest-woman-uti-case-qt-prolongation
The Case
A 36-year-old woman with a history of dep…
-
psnet.ahrq.gov/node/73146/psn-pdf
April 28, 2021 - Patient Safety in Home Dialysis
April 28, 2021
Morfín JA, Fitall E, Hall KK, et al. Patient Safety in Home Dialysis. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/patient-safety-home-dialysis
Dialysis Care and Patient Safety Concerns
In patients with chronic kidney disease, kidney function declines ov…
-
psnet.ahrq.gov/node/33778/psn-pdf
March 01, 2015 - Diagnostic Errors
January 1, 2014
Sarkar U, Shojania KG. Diagnostic Errors. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/diagnostic-errors
Annual Perspective 2014
Until very recently, diagnostic errors received relatively little attention in the field of patient safety,
particularly when compared wi…
-
psnet.ahrq.gov/node/33601/psn-pdf
December 15, 2024 - Electronic Health Records
December 15, 2024
Electronic Health Records. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/electronic-health-records
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safet…
-
psnet.ahrq.gov/node/845074/psn-pdf
March 02, 2011 - Preventable hospital admissions related to medication
(HARM): cost analysis of the HARM study.
March 2, 2011
Leendertse AJ, van den Bemt PMLA, Poolman JB, et al. Preventable hospital admissions related to
medication (HARM): cost analysis of the HARM study. Value Health. 2011;14(1):34-40.
doi:10.1016/j.jval.2010.10…
-
psnet.ahrq.gov/node/42439/psn-pdf
November 23, 2016 - Guide to Patient and Family Engagement in Hospital
Quality and Safety.
November 23, 2016
Rockville, MD: Agency for Healthcare Research and Quality; June 2013.
https://psnet.ahrq.gov/issue/guide-patient-and-family-engagement-hospital-quality-and-safety
Studies have shown that a surprisingly large proportion of hosp…
-
psnet.ahrq.gov/node/867445/psn-pdf
January 08, 2025 - Using human factors methods to mitigate bias in artificial
intelligence-based clinical decision support.
January 8, 2025
Militello LG, Diiulio J, Wilson DL, et al. Using human factors methods to mitigate bias in artificial
intelligence-based clinical decision support. J Am Med Inform Assoc. 2025;32(2):398-403.
doi…
-
psnet.ahrq.gov/node/37856/psn-pdf
June 16, 2011 - Improving patient safety in intensive care units in
Michigan.
June 16, 2011
Pronovost P, Berenholtz SM, Goeschel CA, et al. Improving patient safety in intensive care units in
Michigan. J Crit Care. 2008;23(2):207-212. doi:10.1016/j.jcrc.2007.09.002.
https://psnet.ahrq.gov/issue/improving-patient-safety-intensive-…
-
psnet.ahrq.gov/node/38485/psn-pdf
June 23, 2017 - Impact of a comprehensive patient safety strategy on
obstetric adverse events.
June 23, 2017
Pettker CM, Thung SF, Norwitz ER, et al. Impact of a comprehensive patient safety strategy on obstetric
adverse events. Am J Obstet Gynecol. 2009;200(5):492.e1-8. doi:10.1016/j.ajog.2009.01.022.
https://psnet.ahrq.gov/issu…
-
psnet.ahrq.gov/node/867523/psn-pdf
January 15, 2025 - How do we know when we have done enough? Ensuring
sufficient patient notification efforts after a large-scale
adverse event.
January 15, 2025
Alfandre D, Foglia MB, Holodniy M, et al. How do we know when we have done enough? Ensuring
sufficient patient notification efforts after a large-scale adverse event. Jt Com…
-
psnet.ahrq.gov/node/73513/psn-pdf
July 21, 2021 - Analysis of suicides reported as adverse events in
psychiatry resulted in nine quality improvement
initiatives.
July 21, 2021
Mackenhauer J, Winsløv J-H, Holmskov J, et al. Analysis of suicides reported as adverse events in
psychiatry resulted in nine quality improvement initiatives. Crisis. 2021;43(4):307-314. do…
-
psnet.ahrq.gov/node/836955/psn-pdf
April 20, 2022 - The National Imperative to Improve Nursing Home
Quality: Honoring Our Commitment to Residents,
Families, and Staff.
April 20, 2022
National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies
Press; 2022. ISBN: 9780309686259
https://psnet.ahrq.gov/issue/national-imperative-imp…
-
psnet.ahrq.gov/node/867437/psn-pdf
January 08, 2025 - Handoff mnemonics used in perioperative handoff
intervention studies: a systematic review.
January 8, 2025
Patel SM, Fuller S, Michael MM, et al. Handoff mnemonics used in perioperative handoff intervention
studies: a systematic review. Anesth Analg. 2024;Epub Nov 26. doi:10.1213/ane.0000000000007261.
https://psne…
-
psnet.ahrq.gov/node/60224/psn-pdf
April 15, 2020 - Information transfer at hospital discharge: a systematic
review.
April 15, 2020
Kattel S, Manning DM, Erwin PJ, et al. Information transfer at hospital discharge: a systematic review. J
Patient Saf. 2020;16(1):e25-e33. doi:10.1097/pts.0000000000000248.
https://psnet.ahrq.gov/issue/information-transfer-hospital-dis…
-
psnet.ahrq.gov/node/60866/psn-pdf
January 01, 2022 - Association of implementation and social network factors
with patient safety culture in medical homes: a
coincidence analysis.
September 2, 2020
Dy SM, Acton RM, Yuan CT, et al. Association of implementation and social network factors with patient
safety culture in medical homes: a coincidence analysis. J Patient …