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psnet.ahrq.gov/node/46444/psn-pdf
December 19, 2017 - Nil per os orders for imaging: a teachable moment.
December 19, 2017
Wickerham AL, Schultz EJ, Lewine EB. Nil per Os Orders for Imaging: A Teachable Moment. JAMA Intern
Med. 2017;177(11):1670-1671. doi:10.1001/jamainternmed.2017.3943.
https://psnet.ahrq.gov/issue/nil-os-orders-imaging-teachable-moment
Patients are…
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psnet.ahrq.gov/node/43888/psn-pdf
August 02, 2015 - Diagnostic performance by medical students working
individually or in teams.
August 2, 2015
Hautz WE, Kämmer JE, Schauber SK, et al. Diagnostic performance by medical students working
individually or in teams. JAMA. 2015;313(3):303-4. doi:10.1001/jama.2014.15770.
https://psnet.ahrq.gov/issue/diagnostic-performance…
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psnet.ahrq.gov/node/74118/psn-pdf
January 01, 2022 - From HRO to HERO: making health equity a core system
capability.
November 24, 2021
Moy E, Hausmann LRM, Clancy CM. From HRO to HERO: making health equity a core system capability.
Am J Med Qual. 2022;37(1):81-83. doi:10.1097/jmq.0000000000000020.
https://psnet.ahrq.gov/issue/hro-hero-making-health-equity-core-syst…
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psnet.ahrq.gov/node/42961/psn-pdf
February 19, 2014 - Healthcare-associated infections: a national patient safety
problem and the coordinated response.
February 19, 2014
Jeeva RR, Wright D. Healthcare-associated infections: a national patient safety problem and the
coordinated response. Med Care. 2014;52(2 Suppl 1):S4-8. doi:10.1097/MLR.0b013e3182a54581.
https://psne…
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psnet.ahrq.gov/node/39218/psn-pdf
January 13, 2010 - Prolonged hospital stay and the resident duty hour rules
of 2003.
January 13, 2010
Silber JH, Rosenbaum PR, Rosen AK, et al. Prolonged Hospital Stay and the Resident Duty Hour Rules of
2003. Med Care. 2009;47(12). doi:10.1097/mlr.0b013e3181adcbff.
https://psnet.ahrq.gov/issue/prolonged-hospital-stay-and-resident-d…
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psnet.ahrq.gov/node/44048/psn-pdf
November 20, 2015 - Clinical handover of the critically ill postoperative patient:
an integrative review.
November 20, 2015
Gardiner TM, Marshall AP, Gillespie BM. Clinical handover of the critically ill postoperative patient: an
integrative review. Aust Crit Care. 2015;28(4):226-34. doi:10.1016/j.aucc.2015.02.001.
https://psnet.ahrq…
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psnet.ahrq.gov/node/34100/psn-pdf
February 09, 2011 - Safety of patients isolated for infection control.
February 9, 2011
Stelfox HT, Bates DW, Redelmeier DA. Safety of patients isolated for infection control. JAMA.
2003;290(14):1899-1905.
https://psnet.ahrq.gov/issue/safety-patients-isolated-infection-control
This study discovered that patients isolated for coloniza…
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psnet.ahrq.gov/node/46519/psn-pdf
December 22, 2018 - Delirium in hospitalized older adults.
December 22, 2018
Marcantonio ER. Delirium in Hospitalized Older Adults. N Engl J Med. 2017;377(15):1456-1466.
doi:10.1056/NEJMcp1605501.
https://psnet.ahrq.gov/issue/delirium-hospitalized-older-adults
Delirium is considered a patient safety problem that can be prevented with…
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psnet.ahrq.gov/node/46253/psn-pdf
August 28, 2017 - Diagnostic stewardship—leveraging the laboratory to
improve antimicrobial use.
August 28, 2017
Morgan DJ, Malani P, Diekema DJ. Diagnostic Stewardship-Leveraging the Laboratory to Improve
Antimicrobial Use. JAMA. 2017;318(7):607-608. doi:10.1001/jama.2017.8531.
https://psnet.ahrq.gov/issue/diagnostic-stewardship-l…
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psnet.ahrq.gov/node/46742/psn-pdf
March 14, 2018 - Evidence-based guidelines for fatigue risk management in
emergency medical services.
March 14, 2018
Patterson D, Higgins S, Van Dongen HPA, et al. Evidence-Based Guidelines for Fatigue Risk Management
in Emergency Medical Services. Prehosp Emerg Care. 2018;22(sup1):89-101.
doi:10.1080/10903127.2017.1376137.
https…
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psnet.ahrq.gov/node/47089/psn-pdf
May 09, 2018 - Leadership Survey: Immunization Against Burnout:
Insights Report.
May 9, 2018
Swensen S, Strongwater S, Mohta NS. NEJM Catalyst: Insights Report. April 12, 2018.
https://psnet.ahrq.gov/issue/leadership-survey-immunization-against-burnout-insights-report
Clinician burnout presents challenges to organizational and p…
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psnet.ahrq.gov/node/39789/psn-pdf
August 25, 2010 - Using evidence, rigorous measurement, and collaboration
to eliminate central catheter-associated bloodstream
infections.
August 25, 2010
Sawyer M, Weeks K, Goeschel CA, et al. Using evidence, rigorous measurement, and collaboration to
eliminate central catheter-associated bloodstream infections. Crit Care Med. 201…
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psnet.ahrq.gov/node/44299/psn-pdf
November 06, 2015 - Nurse practitioner–led medication reconciliation in critical
access hospitals.
November 6, 2015
Young L, Barnason S, Hays K, et al. Nurse Practitioner–led Medication Reconciliation in Critical Access
Hospitals. The Journal for Nurse Practitioners. 2015;11(5). doi:10.1016/j.nurpra.2015.03.005.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/73249/psn-pdf
May 12, 2021 - I-PASS handover system: a decade of evidence demands
action.
May 12, 2021
Shahian DM. I-PASS handover system: a decade of evidence demands action. BMJ Qual Saf.
2021;30(10):769-774. doi:10.1136/bmjqs-2021-013314.
https://psnet.ahrq.gov/issue/i-pass-handover-system-decade-evidence-demands-action
The I-PASS structu…
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psnet.ahrq.gov/node/50666/psn-pdf
November 13, 2019 - Over-the-top risky: overuse of ADC overrides, removal of
drugs without an order, and use of non-profiled cabinets.
November 13, 2019
ISMP Medication Safety Alert! Acute Care Edition. October 24, 2019.
https://psnet.ahrq.gov/issue/over-top-risky-overuse-adc-overrides-removal-drugs-without-order-and-use-
non-profile…
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psnet.ahrq.gov/node/862151/psn-pdf
February 07, 2024 - Taking up the challenge to improve name and role
recognition in the operating room.
February 7, 2024
Thota B, Rabinowitz A, Guttman OT. Taking up the challenge to improve name and role recognition in the
operating room. J Patient Saf. 2024;20(1):45-47. doi:10.1097/pts.0000000000001177.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/43321/psn-pdf
August 02, 2015 - Costs associated with surgical site infections in Veterans
Affairs hospitals.
August 2, 2015
Schweizer ML, Cullen JJ, Perencevich E, et al. Costs Associated With Surgical Site Infections in Veterans
Affairs Hospitals. JAMA Surg. 2014;149(6):575-81. doi:10.1001/jamasurg.2013.4663.
https://psnet.ahrq.gov/issue/costs…
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psnet.ahrq.gov/node/764411/psn-pdf
March 02, 2022 - Nowhere is safe: record number of patients contracted
Covid in the hospital in January.
March 2, 2022
Levy R, Vestal AJ. Politico. February 19, 2022.
https://psnet.ahrq.gov/issue/nowhere-safe-record-number-patients-contracted-covid-hospital-january
Transmission of COVID-19 in the health care setting continues to b…
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psnet.ahrq.gov/node/47462/psn-pdf
October 31, 2018 - Emergency department checklist: an innovation to
improve safety in emergency care.
October 31, 2018
Redfern E, Hoskins R, Gray J, et al. Emergency department checklist: an innovation to improve safety in
emergency care. BMJ Open Qual. 2018;7(3):e000325. doi:10.1136/bmjoq-2018-000325.
https://psnet.ahrq.gov/issue/e…
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psnet.ahrq.gov/node/33927/psn-pdf
June 23, 2015 - Errors, incidents and accidents in anaesthetic practice.
June 23, 2015
Runciman WB, Sellen A, Webb RK, et al. The Australian Incident Monitoring Study. Errors, incidents and
accidents in anaesthetic practice. Anaesth Intensive Care. 1993;21(5):506-19.
https://psnet.ahrq.gov/issue/errors-incidents-and-accidents-anae…