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psnet.ahrq.gov/node/73374/psn-pdf
June 09, 2021 - Effects of pharmacist-conducted medication
reconciliation at discharge on 30-day readmission rates of
patients with chronic obstructive pulmonary disease.
June 9, 2021
Singh D, Fahim G, Ghin HL, et al. Effects of pharmacist-conducted medication reconciliation at discharge
on 30-day readmission rates of patients wi…
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psnet.ahrq.gov/node/44960/psn-pdf
February 14, 2017 - Readmissions, observation, and the Hospital
Readmissions Reduction Program.
February 14, 2017
Zuckerman RB, Sheingold SH, Orav J, et al. Readmissions, Observation, and the Hospital Readmissions
Reduction Program. N Engl J Med. 2016;374(16):1543-51. doi:10.1056/NEJMsa1513024.
https://psnet.ahrq.gov/issue/readmissio…
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psnet.ahrq.gov/node/44904/psn-pdf
June 01, 2016 - Does time pressure have a negative effect on diagnostic
accuracy?
June 1, 2016
ALQahtani DA, Rotgans JI, Mamede S, et al. Does Time Pressure Have a Negative Effect on Diagnostic
Accuracy? Acad Med. 2016;91(5):710-716. doi:10.1097/ACM.0000000000001098.
https://psnet.ahrq.gov/issue/does-time-pressure-have-negative-e…
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psnet.ahrq.gov/node/46119/psn-pdf
August 15, 2018 - Incidence and predictors of opioid prescription at
discharge after traumatic injury.
August 15, 2018
Chaudhary MA, Schoenfeld AJ, Harlow AF, et al. Incidence and Predictors of Opioid Prescription at
Discharge After Traumatic Injury. JAMA Surg. 2017;152(10):930-936. doi:10.1001/jamasurg.2017.1685.
https://psnet.ahr…
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psnet.ahrq.gov/node/38163/psn-pdf
April 11, 2011 - Retrospective evaluation of a computerized physician
order entry adaptation to prevent prescribing errors in a
pediatric emergency department.
April 11, 2011
Sard BE, Walsh KE, Doros G, et al. Retrospective evaluation of a computerized physician order entry
adaptation to prevent prescribing errors in a pediatric e…
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psnet.ahrq.gov/node/840484/psn-pdf
November 30, 2022 - Interdisciplinary collaboration across secondary and
primary care to improve medication safety in the elderly
(The IMMENSE study) - a randomized controlled trial.
November 30, 2022
Johansen JS, Halvorsen KH, Svendsen K, et al. Interdisciplinary collaboration across secondary and
primary care to improve medication …
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psnet.ahrq.gov/node/45802/psn-pdf
December 12, 2018 - Intravenous smart pump drug library compliance: a
descriptive study of 44 hospitals.
December 12, 2018
Giuliano KK, Su W-T, Degnan DD, et al. Intravenous Smart Pump Drug Library Compliance: A Descriptive
Study of 44 Hospitals. J Patient Saf. 2018;14(4):e76-e82. doi:10.1097/PTS.0000000000000383.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/60987/psn-pdf
October 07, 2020 - Process failures that increase the risk of infection
through respiratory droplets: a study of patient safety
events reported by hospitals across Pennsylvania.
October 7, 2020
Harper A, Kukielka E, Jones RM. Process failures that increase the risk of infection through respiratory
droplets: a study of patient safety…
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psnet.ahrq.gov/node/40122/psn-pdf
February 01, 2011 - Attitudes and barriers to a medical emergency team
system at a tertiary paediatric hospital.
February 1, 2011
Azzopardi P, Kinney S, Moulden A, et al. Attitudes and barriers to a Medical Emergency Team system at a
tertiary paediatric hospital. Resuscitation. 2011;82(2):167-74. doi:10.1016/j.resuscitation.2010.10.01…
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psnet.ahrq.gov/perspective/ensuring-patient-and-workforce-safety-culture-healthcare
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/846564/psn-pdf
March 29, 2023 - Technology as a Tool for Improving Patient Safety
March 29, 2023
Holmgren AJ, McBride S, Gale B, et al. Technology as a Tool for Improving Patient Safety . PSNet
[internet]. 2023.
https://psnet.ahrq.gov/perspective/technology-tool-improving-patient-safety
Introduction
In the past several decades, technological a…
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psnet.ahrq.gov/innovation/e-autopsye-biopsy-systematic-chart-review-increase-safety-and-diagnostic-accuracy
April 01, 2005 - The e-Autopsy/e-Biopsy: A Systematic Chart Review to Increase Safety and Diagnostic Accuracy Innovation
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August 30, 2023
View more articles from the…
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psnet.ahrq.gov/innovation/suicide-prevention-emergency-department-population-ed-safe
July 23, 2024 - Suicide Prevention in an Emergency Department Population: ED-SAFE
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April 24, 2024
View more articles from the same authors.
Innovation
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psnet.ahrq.gov/web-mm/walking-patient-missing-drain
April 01, 2006 - Walking Patient, Missing Drain
Citation Text:
Olkowski BF, Ravenel M, Stiefel MF. Walking Patient, Missing Drain. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/web-mm/point-care-mixup-1-shot-turns-3
February 14, 2024 - Point-of-care Mixup: 1 Shot Turns Into 3
Citation Text:
Berberich RF. Point-of-care Mixup: 1 Shot Turns Into 3. 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/node/49711/psn-pdf
June 01, 2014 - Wandering Off the Floors: Safety and Security Risks of
Patient Wandering
June 1, 2014
Smith TA. Wandering Off the Floors: Safety and Security Risks of Patient Wandering. PSNet [internet].
2014.
https://psnet.ahrq.gov/web-mm/wandering-floors-safety-and-security-risks-patient-wandering
Case Objectives
Define patie…
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psnet.ahrq.gov/web-mm/delayed-clozapine-prescription-elderly-man-dementia
August 06, 2014 - Delayed Clozapine Prescription in an Elderly Man With Dementia
Citation Text:
Tsourounis C, Ghomeshi KK. Delayed Clozapine Prescription in an Elderly Man With Dementia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/33607/psn-pdf
September 27, 2022 - Burnout
September 27, 2022
Yellowlees P, Rea M. Burnout. PSNet [internet]. 2022.
https://psnet.ahrq.gov/primer/burnout
Originally published in December 2011 by researchers at the University of California, San Francisco.
Updated in September 2022 by Peter Yellowlees, MD and Margaret Rea, PhD. PSNet primers are regu…
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psnet.ahrq.gov/issue/assessing-clinical-economic-and-health-resource-utilization-impacts-prefilled-syringes-versus
August 15, 2018 - Review
Assessing the clinical, economic, and health resource utilization impacts of prefilled syringes versus conventional medication administration methods: results from a systematic literature review.
Citation Text:
Benhamou D, Weiss M, Borms M, et al. Assessing the clinical, economic,…
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psnet.ahrq.gov/issue/outcomes-medication-misadventure-among-people-cognitive-impairment-or-dementia-systematic
March 08, 2023 - Review
Outcomes of medication misadventure among people with cognitive impairment or dementia: a systematic review and meta-analysis.
Citation Text:
Zaidi AS, Peterson GM, Bereznicki LRE, et al. Outcomes of medication misadventure among people with cognitive impairment or dementia: a sys…