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psnet.ahrq.gov/node/846164/psn-pdf
March 15, 2023 - Crowding in the Emergency Department: Challenges for
the Care of Children.
March 15, 2023
Gross TK, Lane NE, Timm NL, et al. Crowding in the Emergency Department: Challenges for the Care of
Children. Pediatrics. 2023;151(3):e2022060971-e2022060972. doi:10.1542/peds.2022-060971.
https://psnet.ahrq.gov/issue/crowdin…
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psnet.ahrq.gov/node/60992/psn-pdf
October 14, 2020 - Another medical malpractice crisis?: Try something
different.
October 14, 2020
Sage WM, Boothman RC, Gallagher TH. Another medical malpractice crisis?: Try something different.
JAMA. 2020;324(14):1395-1396. doi:10.1001/jama.2020.16557.
https://psnet.ahrq.gov/issue/another-medical-malpractice-crisis-try-something-d…
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psnet.ahrq.gov/node/863757/psn-pdf
March 06, 2024 - Debriefing to improve interprofessional teamwork in the
operating room: a systematic review.
March 6, 2024
Skegg E, McElroy C, Mudgway M, et al. Debriefing to improve interprofessional teamwork in the operating
room: a systematic review. J Nurs Scholarsh. 2023;55(6):1179-1188. doi:10.1111/jnu.12924.
https://psnet.…
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digital.ahrq.gov/ahrq-funded-projects/enabling-shared-decision-making-reduce-harm-drug-interactions-end-end/citation/shared
January 01, 2023 - A shared decision-making tool for drug interactions between warfarin and nonsteroidal anti-inflammatory drugs: Design and usability study.
Citation
Reese TJ, Del Fiol G, Morgan K, Hurwitz JT, Kawamoto K, Gomez-Lumbreras A, Brown ML, Thiess H, Vazquez SR, Nelson SD, Boyce R, Malone D. A shared decisio…
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psnet.ahrq.gov/node/72828/psn-pdf
March 10, 2021 - A recurring call to action: every healthcare organization
needs a medication safety officer!
March 10, 2021
ISMP Medication Safety Alert! Acute care edition. February 25, 2021;26(4);1-4.
https://psnet.ahrq.gov/issue/recurring-call-action-every-healthcare-organization-needs-medication-safety-
officer
Leadership ro…
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psnet.ahrq.gov/node/857459/psn-pdf
December 06, 2023 - Five strategies for a safer EHR modernization journey.
December 6, 2023
Sittig DF, Yackel EE, Singh H. Five strategies for a safer EHR modernization journey. J Gen Intern Med.
2023;38(S4):940-942. doi:10.1007/s11606-023-08331-z.
https://psnet.ahrq.gov/issue/five-strategies-safer-ehr-modernization-journey
Large-sca…
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digital.ahrq.gov/location/usa-ca-san-diego
January 01, 2023 - USA, CA, San Diego
Quantifying Electronic Medical Record Usability to Improve Clinical Workflow
Description
This project studied electronic health record use, workflow, physician-patient communication, cognitive load, and user satisfaction and found multiple factors that influ…
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psnet.ahrq.gov/node/60032/psn-pdf
March 11, 2020 - Medical teamwork and the evolution of safety science: a
critical review.
March 11, 2020
Neuhaus C, Lutnæs DE, Bergström J. Medical teamwork and the evolution of safety science: a critical
review. Cogn Technol Work. 2020;22(1):13-27. doi:10.1007/s10111-019-00545-8.
https://psnet.ahrq.gov/issue/medical-teamwork-and-…
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psnet.ahrq.gov/node/47738/psn-pdf
February 06, 2019 - ISMP Guidelines for Safe Electronic Communication of
Medication Information.
February 6, 2019
Horsham, PA: Institute for Safe Medication Practices; January 2019.
https://psnet.ahrq.gov/issue/ismp-guidelines-safe-electronic-communication-medication-information
Inaccurate or incomplete data in electronic health reco…
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psnet.ahrq.gov/node/72499/psn-pdf
November 25, 2020 - Transformational improvement in quality care and health
systems: the next decade.
November 25, 2020
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/s12916-020-01739-y.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/837075/psn-pdf
May 11, 2022 - Lessons Learned from the COVID-19 Pandemic to
Improve Diagnosis. Proceedings of a Workshop–in Brief.
May 11, 2022
National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies
Press; 2022.
https://psnet.ahrq.gov/issue/lessons-learned-covid-19-pandemic-improve-diagnosis-proceedin…
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psnet.ahrq.gov/node/837760/psn-pdf
January 01, 2024 - Criminal liability for nursing and medical harm.
August 3, 2022
Maher V, Cwiek M. Criminal liability for nursing and medical harm. Hosp Top. 2024;102(2):117-124.
doi:10.1080/00185868.2022.2101571.
https://psnet.ahrq.gov/issue/criminal-liability-nursing-and-medical-harm
Fear of criminal liability may inhibit clinic…
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psnet.ahrq.gov/node/838623/psn-pdf
October 19, 2022 - Resident and nurse perspectives on the use of secure
text messaging systems.
October 19, 2022
Aziz S, Barber J, Singh A, et al. Resident and nurse perspectives on the use of secure text messaging
systems. J Hosp Med. 2022;17(11):880-887. doi:10.1002/jhm.12953.
https://psnet.ahrq.gov/issue/resident-and-nurse-perspe…
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psnet.ahrq.gov/node/34643/psn-pdf
December 23, 2008 - The health care cost of drug-related morbidity and
mortality in nursing facilities.
December 23, 2008
Bootman JL, Harrison DL, Cox E. The health care cost of drug-related morbidity and mortality in nursing
facilities. Arch Intern Med. 1997;157(18):2089-96.
https://psnet.ahrq.gov/issue/health-care-cost-drug-related…
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psnet.ahrq.gov/node/43478/psn-pdf
August 27, 2014 - Is it time to move beyond errors in clinical reasoning and
discuss accuracy?
August 27, 2014
Wood TJ. Is it time to move beyond errors in clinical reasoning and discuss accuracy? Adv Health Sci Educ
Theory Pract. 2014;19(3):403-407. doi:10.1007/s10459-014-9498-4.
https://psnet.ahrq.gov/issue/it-time-move-beyond-er…
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psnet.ahrq.gov/node/46968/psn-pdf
April 18, 2018 - Attitudes and practices related to clinical alarms: a follow-
up survey.
April 18, 2018
Ruppel H, Funk M, Clark T, et al. Attitudes and Practices Related to Clinical Alarms: A Follow-up Survey.
Am J Crit Care. 2018;27(2):114-123. doi:10.4037/ajcc2018185.
https://psnet.ahrq.gov/issue/attitudes-and-practices-related…
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psnet.ahrq.gov/node/45082/psn-pdf
April 27, 2016 - Surgeons must tell patients of double-booked surgeries,
new guidelines say.
April 27, 2016
Abelson J, Staltzman J. Boston Globe. April 13, 2016.
https://psnet.ahrq.gov/issue/surgeons-must-tell-patients-double-booked-surgeries-new-guidelines-say
Although scheduling overlapping surgeries may improve operating room e…
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psnet.ahrq.gov/node/45332/psn-pdf
August 27, 2018 - Guideline implementation: prevention of retained surgical
items.
August 27, 2018
Fencl JL. Guideline Implementation: Prevention of Retained Surgical Items. AORN J. 2016;104(1):37-48.
doi:10.1016/j.aorn.2016.05.005.
https://psnet.ahrq.gov/issue/guideline-implementation-prevention-retained-surgical-items
Although i…
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psnet.ahrq.gov/node/43333/psn-pdf
January 15, 2017 - A multidisciplinary, multifaceted improvement initiative to
eliminate mislabelled laboratory specimens at a large
tertiary care hospital.
January 15, 2017
Seferian EG, Jamal S, Clark K, et al. A multidisciplinary, multifaceted improvement initiative to eliminate
mislabelled laboratory specimens at a large tertiary…
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psnet.ahrq.gov/node/37336/psn-pdf
January 05, 2012 - 'My five moments for hand hygiene': a user-centred
design approach to understand, train, monitor and report
hand hygiene.
January 5, 2012
Sax H, Allegranzi B, Uçkay I, et al. 'My five moments for hand hygiene': a user-centred design approach to
understand, train, monitor and report hand hygiene. J Hosp Infect. 200…