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psnet.ahrq.gov/issue/swarming-improve-patient-care-novel-approach-root-cause-analysis
September 23, 2020 - Study
"SWARMing" to improve patient care: a novel approach to root cause analysis.
Citation Text:
Li J, Boulanger B, Norton J, et al. "SWARMing" to Improve Patient Care: A Novel Approach to Root Cause Analysis. Jt Comm J Qual Patient Saf. 2015;41(11):494-501.
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psnet.ahrq.gov/issue/patient-outcomes-dose-reduction-or-discontinuation-long-term-opioid-therapy-systematic-review
April 08, 2019 - Review
Classic
Patient outcomes in dose reduction or discontinuation of long-term opioid therapy: a systematic review.
Citation Text:
Frank JW, Lovejoy TI, Becker WC, et al. Patient Outcomes in Dose Reduction or Discontinuation of Long-Term Opioid Therapy: A Sys…
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psnet.ahrq.gov/issue/medication-errors-associated-code-situations-us-hospitals-direct-and-collateral-damage
June 29, 2011 - Study
Medication errors associated with code situations in U.S. hospitals: direct and collateral damage.
Citation Text:
Lipshutz AKM, Morlock LL, Shore AD, et al. Medication Errors Associated with Code Situations in U.S. Hospitals: Direct and Collateral Damage. Jt Comm J Qual Patient Saf…
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psnet.ahrq.gov/issue/viewing-prevention-catheter-associated-urinary-tract-infection-system-using-systems
July 12, 2023 - Study
Viewing prevention of catheter-associated urinary tract infection as a system: using systems engineering and human factors engineering in a quality improvement project in an academic medical center.
Citation Text:
Rhee C, Phelps E, Meyer B, et al. Viewing Prevention of Catheter-Ass…
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psnet.ahrq.gov/issue/clinical-decision-support-systems-could-be-modified-reduce-alert-fatigue-while-still
December 21, 2022 - Commentary
Clinical decision support systems could be modified to reduce 'alert fatigue' while still minimizing the risk of litigation.
Citation Text:
Kesselheim AS, Cresswell K, Phansalkar S, et al. Clinical decision support systems could be modified to reduce 'alert fatigue' while stil…
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psnet.ahrq.gov/issue/factors-associated-mental-health-outcomes-among-health-care-workers-exposed-coronavirus
March 24, 2019 - Study
Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019.
Citation Text:
Lai J, Ma S, Wang Y, et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open. 20…
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psnet.ahrq.gov/issue/clinical-reasoning-education-us-medical-schools-results-national-survey-internal-medicine
October 12, 2022 - Study
Clinical reasoning education at US medical schools: results from a national survey of internal medicine clerkship directors.
Citation Text:
Rencic J, Trowbridge RL, Fagan M, et al. Clinical Reasoning Education at US Medical Schools: Results from a National Survey of Internal Medici…
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psnet.ahrq.gov/issue/preventing-adverse-events-caused-emergency-electrical-power-system-failures
July 31, 2023 - Sentinel Event Alerts
Preventing adverse events caused by emergency electrical power system failures.
Citation Text:
Preventing adverse events caused by emergency electrical power system failures. Sentinel Event Alert. 2006;37(37):1-3.
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psnet.ahrq.gov/node/42245/psn-pdf
July 22, 2013 - 25-Year summary of US malpractice claims for diagnostic
errors 1986–2010: an analysis from the National
Practitioner Data Bank.
July 22, 2013
Tehrani ASS, Lee HW, Mathews SC, et al. 25-Year summary of US malpractice claims for diagnostic errors
1986-2010: an analysis from the National Practitioner Data Bank. BMJ Q…
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psnet.ahrq.gov/node/47272/psn-pdf
August 15, 2018 - Centers for Medicare and Medicaid Services hospital-
acquired conditions policy for central line–associated
bloodstream infection (CLABSI) and catheter-associated
urinary tract infection (CAUTI) shows minimal impact on
hospital reimbursement.
August 15, 2018
Calderwood MS, Kawai AT, Jin R, et al. Centers for medi…
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psnet.ahrq.gov/node/45897/psn-pdf
August 20, 2018 - Clinical reasoning education at US medical schools:
results from a national survey of internal medicine
clerkship directors.
August 20, 2018
Rencic J, Trowbridge RL, Fagan M, et al. Clinical Reasoning Education at US Medical Schools: Results
from a National Survey of Internal Medicine Clerkship Directors. J Gen In…
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psnet.ahrq.gov/issue/model-patient-how-simulators-are-changing-way-doctors-are-trained
August 24, 2016 - Newspaper/Magazine Article
A model patient: how simulators are changing the way doctors are trained.
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February 8, 2011
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psnet.ahrq.gov/node/45887/psn-pdf
August 15, 2018 - Association of changing hospital readmission rates with
mortality rates after hospital discharge.
August 15, 2018
Dharmarajan K, Wang Y, Lin Z, et al. Association of Changing Hospital Readmission Rates With Mortality
Rates After Hospital Discharge. JAMA. 2017;318(3):270-278. doi:10.1001/jama.2017.8444.
https://psn…
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psnet.ahrq.gov/node/44342/psn-pdf
November 03, 2015 - How effective are patient safety initiatives? A
retrospective patient record review study of changes to
patient safety over time.
November 3, 2015
Baines RJ, Langelaan M, de Bruijne M, et al. How effective are patient safety initiatives? A retrospective
patient record review study of changes to patient safety over…
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psnet.ahrq.gov/issue/toolkit-mrsa-prevention-icu-non-icu-settings
November 08, 2023 - Toolkit
Toolkit for MRSA Prevention in ICU & Non-ICU Settings.
Citation Text:
Agency for Healthcare Research and Quality. Toolkit for MRSA Prevention in ICU & Non-ICU Settings. October 2024.
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psnet.ahrq.gov/web-mm/antibiotics-urisinusitis-simple-decision-gone-bad
January 01, 2014 - SPOTLIGHT CASE
Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad
Citation Text:
Ranji SR. Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens
April 18, 2018 - Pre-analytical pitfalls: Missing and mislabeled specimens
Citation Text:
Tran NK, Liu Y. Pre-analytical pitfalls: Missing and mislabeled specimens . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/node/866343/psn-pdf
December 31, 2024 - Mismanagement of Acute Decompensated Heart Failure
with Hypertensive Emergency
December 31, 2024
Lee J, Fernilius J, Frick W. Mismanagement of Acute Decompensated Heart Failure with Hypertensive
Emergency. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/mismanagement-acute-decompensated-heart-failure-hyperte…
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psnet.ahrq.gov/node/49730/psn-pdf
April 01, 2015 - Transition to Nowhere
April 1, 2015
Farrell TW. Transition to Nowhere. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/transition-nowhere
The Case
A 75-year-old man with a history of prostate cancer, poorly controlled myotonic dystrophy, hypertension,
and chronic kidney disease was admitted to the hospital …
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psnet.ahrq.gov/node/49578/psn-pdf
January 01, 2009 - Hospital Admission Due to High-Dose Methotrexate Drug
Interaction
January 1, 2009
Siegel LC, Gandhi TK. Hospital Admission Due to High-Dose Methotrexate Drug Interaction. PSNet
[internet]. 2009.
https://psnet.ahrq.gov/web-mm/hospital-admission-due-high-dose-methotrexate-drug-interaction
The Case
A 40-year-old wo…