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psnet.ahrq.gov/node/837073/psn-pdf
May 11, 2022 - Clinical progress note: situation awareness for clinical
deterioration in hospitalized children.
May 11, 2022
Sosa T, Galligan MM, Brady PW. Clinical progress note: situation awareness for clinical deterioration in
hospitalized children. J Hosp Med. 2022;17(3):199-202. doi:10.1002/jhm.2774.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/40263/psn-pdf
March 02, 2011 - Trauma resuscitation errors and computer-assisted
decision support.
March 2, 2011
FitzGerald M, Cameron P, Mackenzie CF, et al. Trauma resuscitation errors and computer-assisted
decision support. Arch Surg. 2011;146(2):218-25. doi:10.1001/archsurg.2010.333.
https://psnet.ahrq.gov/issue/trauma-resuscitation-errors-…
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psnet.ahrq.gov/node/73530/psn-pdf
July 28, 2021 - The nature, severity and causes of medication incidents
from an Australian community pharmacy incident
reporting system: the QUMwatch study.
July 28, 2021
Adie K, Fois RA, McLachlan AJ, et al. The nature, severity and causes of medication incidents from an
Australian community pharmacy incident reporting system: T…
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psnet.ahrq.gov/node/46088/psn-pdf
May 24, 2017 - Innovative use of the electronic health record to support
harm reduction efforts.
May 24, 2017
Hyman D, Neiman J, Rannie M, et al. Innovative Use of the Electronic Health Record to Support Harm
Reduction Efforts. Pediatrics. 2017;139(5). doi:10.1542/peds.2015-3410.
https://psnet.ahrq.gov/issue/innovative-use-elect…
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psnet.ahrq.gov/node/47495/psn-pdf
October 31, 2018 - Developing and evaluating clinical leadership
interventions for frontline healthcare providers: a review
of the literature.
October 31, 2018
Mianda S, Voce A. Developing and evaluating clinical leadership interventions for frontline healthcare
providers: a review of the literature. BMC Health Serv Res. 2018;18(1):…
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psnet.ahrq.gov/node/36276/psn-pdf
October 21, 2010 - Effects of nursing rounds on patients' call light use,
satisfaction, and safety.
October 21, 2010
Meade CM, Bursell AL, Ketelsen L. Effects of nursing rounds: on patients' call light use, satisfaction, and
safety. Am J Nurs. 2006;106(9):58-71.
https://psnet.ahrq.gov/issue/effects-nursing-rounds-patients-call-light…
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psnet.ahrq.gov/node/47224/psn-pdf
June 27, 2018 - Managing Alarms in Acute Care Across the Life Span:
Electrocardiography and Pulse Oximetry.
June 27, 2018
Managing Alarms in Acute Care Across the Life Span: Electrocardiography and Pulse Oximetry. Crit Care
Nurse. 2018;38(2):e16-e20. doi:10.4037/ccn2018468.
https://psnet.ahrq.gov/issue/managing-alarms-acute-care-…
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psnet.ahrq.gov/node/36698/psn-pdf
February 24, 2011 - The impact of duty hours on resident self reports of
errors.
February 24, 2011
Vidyarthi A, Auerbach AD, Wachter R, et al. The impact of duty hours on resident self reports of errors. J
Gen Intern Med. 2007;22(2):205-9.
https://psnet.ahrq.gov/issue/impact-duty-hours-resident-self-reports-errors
Residency programs…
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psnet.ahrq.gov/node/47541/psn-pdf
March 04, 2019 - Health outcomes of deprescribing interventions among
older residents in nursing homes: a systematic review
and meta-analysis.
March 4, 2019
Kua C-H, Mak VSL, Lee SWH. Health Outcomes of Deprescribing Interventions Among Older Residents in
Nursing Homes: A Systematic Review and Meta-analysis. J Amer Med Direct Asso…
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psnet.ahrq.gov/node/74084/psn-pdf
November 17, 2021 - Healthcare failure mode and effect analysis in the
chemotherapy preparation process.
November 17, 2021
Pueyo-López C, Sánchez-Cuervo M, Vélez-Díaz-Pallarés M, et al. Healthcare failure mode and effect
analysis in the chemotherapy preparation process. J Oncol Pharm Pract. 2021;27(7):1588-1595.
doi:10.1177/107815522…
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psnet.ahrq.gov/node/866270/psn-pdf
July 10, 2024 - Identifying and measuring administrative harms
experienced by hospitalists and administrative leaders.
July 10, 2024
Burden M, Astik GJ, Auerbach AD, et al. Identifying and measuring administrative harms experienced by
hospitalists and administrative leaders. JAMA Intern Med. 2024;184(9):1014-1023.
doi:10.1001/jam…
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psnet.ahrq.gov/node/45898/psn-pdf
August 16, 2017 - Estimating hospital-related deaths due to medical error: a
perspective from patient advocates.
August 16, 2017
Kavanagh KT, Saman DM, Bartel R, et al. Estimating Hospital-Related Deaths Due to Medical Error: A
Perspective From Patient Advocates. J Patient Saf. 2017;13(1):1-5. doi:10.1097/PTS.0000000000000364.
http…
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psnet.ahrq.gov/node/865454/psn-pdf
March 27, 2024 - create an inclusive and trusting work
environment that facilitates psychological safety and ultimately reduces
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psnet.ahrq.gov/node/866848/psn-pdf
September 25, 2024 - In Conversation with Eric Thomas about Zero Harm:
Striving to Reduce Preventable Harms – Point,
Counterpoint, and Areas of Agreement
September 25, 2024
Thomas E, Mossburg S, Lee M. In Conversation with Eric Thomas about Zero Harm: Striving to Reduce
Preventable Harms – Point, Counterpoint, and Areas of Agreement. …
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psnet.ahrq.gov/node/49640/psn-pdf
November 01, 2011 - The Case for Patient Flow Management
November 1, 2011
Litvak E, Bernheim SA. The Case for Patient Flow Management. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/case-patient-flow-management
The Case
A 52-year-old woman with a history of major depression, posttraumatic stress disorder, and alcohol abuse
wa…
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psnet.ahrq.gov/web-mm/2-week-itch
June 16, 2019 - The 2-Week Itch
Citation Text:
Cohen MR. The 2-Week Itch. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
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October 01, 2018 - Diffusion of Responsibility Leads to Danger
October 1, 2018
Balcezak TJ, Deshpande O. Diffusion of Responsibility Leads to Danger. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/diffusion-responsibility-leads-danger
The Case
A 70-year-old man was sent to the emergency department (ED) from a nursing facility…
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psnet.ahrq.gov/node/49396/psn-pdf
April 01, 2003 - The 2-Week Itch
April 1, 2003
Cohen MR. The 2-Week Itch. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/2-week-itch
The Case
A 40-year-old woman with bipolar disorder (on trazodone) came to her primary care physician with new
urticaria. She received a handwritten prescription for Zyrtec and Atarax.
The ha…
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psnet.ahrq.gov/innovation/system-approaches-social-determinants-health-screening-and-intervention-innovation
July 23, 2024 - System Approaches to Social Determinants of Health Screening and Intervention Innovation Summary
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January 01, 2024 - Impact of hospital-acquired pneumonia on the Medicare
program.
November 8, 2023
Baker DL, Giuliano KK, Desmarais M, et al. Impact of hospital-acquired pneumonia on the Medicare
program. Infect Control Hosp Epidemiol. 2024;45(3):316-321. doi:10.1017/ice.2023.221.
https://psnet.ahrq.gov/issue/impact-hospital-acquire…