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6601. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865698/psn-pdf
      April 24, 2024 - Patient Safety Amid Nursing Workforce Challenges April 24, 2024 Leary KB, Lee M, Mossburg S. Patient Safety Amid Nursing Workforce Challenges . PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/patient-safety-amid-nursing-workforce-challenges Introduction Nurses are essential to patient care, and having a…

6602. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73549/psn-pdf
      July 28, 2021 - Local Anesthesia-Induced Coma During Total Knee Arthroplasty. July 28, 2021 Aldwinckle R. Local Anesthesia-Induced Coma During Total Knee Arthroplasty. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/local-anesthesia-induced-coma-during-total-knee-arthroplasty The Case A 61-year-old male patient weighing 57…

6603. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49589/psn-pdf
      August 01, 2009 - Hiding in Plain Sight August 1, 2009 Weinberg JM. Hiding in Plain Sight. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/hiding-plain-sight The Case A 65-year-old woman presented to an emergency department (ED) with 48 hours of nontraumatic left lower back pain and general malaise. She was diagnosed with a …

6604. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33818/psn-pdf
      November 01, 2016 - been a model for how research has been translated into practice and has made a difference in terms of reducing

6605. Hard to Swallow | PSNet
      psnet.ahrq.gov/web-mm/hard-swallow
      April 26, 2023 - Hard to Swallow Citation Text: Driver J. Hard to Swallow. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

6606. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39544/psn-pdf
      May 19, 2010 - Preventing infections: how Portland hospitals compare. May 19, 2010 Rojas-Burke J. The Oregonian. May 8, 2010. https://psnet.ahrq.gov/issue/preventing-infections-how-portland-hospitals-compare This newspaper article describes how lessons from the Keystone ICU Project have reduced central line infections in Oregon …

6607. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37009/psn-pdf
      March 18, 2010 - Doing the "right" things to correct wrong-site surgery. March 18, 2010 Patient Safety Advisory https://psnet.ahrq.gov/issue/doing-right-things-correct-wrong-site-surgery This article discusses reports of wrong-site surgery submitted to the PA-PSRS, compares them with results of other studies, and provides suggesti…

6608. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36824/psn-pdf
      October 03, 2017 - Department of Defense (DoD) Patient Safety Program. October 3, 2017 US Department of Defense; DOD https://psnet.ahrq.gov/issue/department-defense-dod-patient-safety-program This Web site includes information on several initiatives within the US Military Health System to support its culture of safety and reduce med…

6609. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36423/psn-pdf
      December 22, 2010 - Care transitions: a threat and an opportunity for patient safety. December 22, 2010 Clancy CM. Care Transitions: A Threat and an Opportunity for Patient Safety. American Journal of Medical Quality. 2006;21(6). doi:10.1177/1062860606293537. https://psnet.ahrq.gov/issue/care-transitions-threat-and-opportunity-patien…

6610. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40298/psn-pdf
      May 13, 2019 - Improving patient safety in radiation oncology. May 13, 2019 Hendee WR, Herman MG. Improving patient safety in radiation oncology. https://psnet.ahrq.gov/issue/improving-patient-safety-radiation-oncology This commentary discusses radiation safety issues and describes recommendations developed at a conference to re…

6611. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40491/psn-pdf
      June 08, 2011 - Medical error reduction: the effect of employee satisfaction with organizational support. June 8, 2011 Lee D; Lee SM; Schniederjans MJ. https://psnet.ahrq.gov/issue/medical-error-reduction-effect-employee-satisfaction-organizational-support This survey conducted at four South Korean hospitals found that employees'…

6612. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37935/psn-pdf
      February 17, 2011 - The (slowly) vanishing prescription pad. February 17, 2011 Steinbrook R. The (slowly) vanishing prescription pad. N Engl J Med. 2008;359(2):115-7. doi:10.1056/NEJMp0802864. https://psnet.ahrq.gov/issue/slowly-vanishing-prescription-pad This perspective discusses the proliferation of electronic vs. paper-based pres…

6613. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35161/psn-pdf
      March 13, 2016 - The forgotten tourniquet—an update. March 13, 2016 PA Patient Saf Advis. 2016;13(1):4. http://patientsafety.pa.gov/ADVISORIES/Pages/201603_32.aspx. https://psnet.ahrq.gov/issue/forgotten-tourniquet-update This advisory from the Pennsylvania Patient Safety Reporting System discusses 1079 reports of tourniquets bein…

6614. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39776/psn-pdf
      January 25, 2017 - First, protect the patient from harm: applying adult learning principles to patient safety. January 25, 2017 Duffy B. https://psnet.ahrq.gov/issue/first-protect-patient-harm-applying-adult-learning-principles-patient-safety This piece describes how education can reduce patient harm by promoting attitude and behavi…

6615. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40616/psn-pdf
      July 13, 2011 - Clinical decision support and malpractice risk. July 13, 2011 Greenberg MD, Ridgely MS. Clinical Decision Support and Malpractice Risk. JAMA. 2011;306(1). doi:10.1001/jama.2011.929. https://psnet.ahrq.gov/issue/clinical-decision-support-and-malpractice-risk This commentary discusses liabilities associated with cli…

6616. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39871/psn-pdf
      September 22, 2010 - Kaiser Permanente's innovation on the front lines. September 22, 2010 McCreary L. Kaiser Permanente's innovation on the front lines. Harv Bus Rev. 2010;88(9):92, 94-7, 126. https://psnet.ahrq.gov/issue/kaiser-permanentes-innovation-front-lines This article describes how innovation has reduced medication errors and …

6617. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40552/psn-pdf
      June 22, 2011 - Don't come back, hospitals say. June 22, 2011 Landro L. https://psnet.ahrq.gov/issue/dont-come-back-hospitals-say This newspaper article describes government-funded and hospital-based efforts to improve discharge and reduce preventable readmissions. https://psnet.ahrq.gov/issue/dont-come-back-hospitals-say https:…

6618. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35137/psn-pdf
      May 27, 2011 - Drug errors show need for tech aid. May 27, 2011 Landro L. https://psnet.ahrq.gov/issue/drug-errors-show-need-tech-aid The article discusses the importance of using computerized physician order entry systems that provide more sophisticated alerts, such as drug dosages and strategies for monitoring patients, to red…

6619. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36259/psn-pdf
      October 21, 2010 - How we cut drug errors. October 21, 2010 Nicol N, Huminski L. How we cut drug errors. At one hospital, IT and changed culture saves lives. Modern healthcare. 2006;36(34):38. https://psnet.ahrq.gov/issue/how-we-cut-drug-errors This article discusses technology-based tools and culture change strategies employed by o…

6620. Communication During Transitions of Care | PSNet
      psnet.ahrq.gov/perspective/communication-during-transitions-care
      July 10, 2024 - Annual Perspective Communication During Transitions of Care Ayse P. Gurses; Sarah Mossburg; Zoe Sousane | March 27, 2024  View more articles from the same authors. Citation Text: Gurses AP, Sousane Z, Mossburg S. Communication During Transitions of Care. PS…