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psnet.ahrq.gov/print/pdf/node/867461
January 31, 2024 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Patient and Family Engagement in Long
Term Care
Curated Library
Foundations
Long-term Care and Patient Safety
Deb Bakerjian PhD, APRN, FAAN, FAANP, FGSA | April, 10 2024
A large and growing number of Americans require care in skilled nursin…
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psnet.ahrq.gov/innovation/patient-and-family-centered-i-pass-family-centered-communication-program-reduce-medical
February 26, 2025 - Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes)
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psnet.ahrq.gov/primer/burnout
November 20, 2024 - Burnout
Citation Text:
Yellowlees P, Rea M. Burnout. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Do…
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psnet.ahrq.gov/web-mm/endotracheal-tube-fallout-patient-severe-obesity-during-eye-surgery
January 29, 2021 - Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery.
Citation Text:
Bohringer C. Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services.…
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psnet.ahrq.gov/web-mm/inside-time-out
March 01, 2004 - The Inside of a Time Out
Citation Text:
Feldman DL. The Inside of a Time Out. 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/node/49573/psn-pdf
January 01, 2009 - Dangerous Shift
November 1, 2008
Patterson ES. Dangerous Shift. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/dangerous-shift
Case Objectives
Review the evidence base on erroneous actions related to shift changes.
Understand the limits of standardizing handoffs in preventing errors at shift change.
Expla…
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psnet.ahrq.gov/node/846768/psn-pdf
March 29, 2023 - Endotracheal Tube Fallout in a Patient with Severe
Obesity During Eye Surgery.
March 29, 2023
Bohringer C. Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/web-mm/endotracheal-tube-fallout-patient-severe-obesity-during-eye-surgery
The Ca…
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psnet.ahrq.gov/print/pdf/node/74277
January 01, 2021 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Medication/Drug Errors
Curated Library
Primers
Medication Administration Errors
Paul MacDowell, PharmD, BCPS, Ann Cabri, PharmD, and Michaela Davis, MSN, RN, CNS | March,
12 2021
Medication administration errors are a persistent patient saf…
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psnet.ahrq.gov/web-mm/failure-reevaluate
February 01, 2014 - Failure to Reevaluate
Citation Text:
Wong-Beringer A. Failure to Reevaluate. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/node/49731/psn-pdf
April 01, 2015 - Fire in the Hole!—An OR Fire
April 1, 2015
Mehta SP, Domino KM. Fire in the Hole!—An OR Fire. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/fire-hole-or-fire
The Case
A patient was taken to the operating room (OR) to undergo a planned laparoscopic subtotal colon resection
for a biopsy-proven adenocarcinom…
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psnet.ahrq.gov/node/49492/psn-pdf
November 01, 2005 - Reconciling Doses
November 1, 2005
Federico F. Reconciling Doses. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/reconciling-doses
Case Objectives
List the steps involved in medication reconciliation.
Describe the role of each of the stakeholders in medication reconciliation.
Discuss how medication reconc…
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psnet.ahrq.gov/node/49797/psn-pdf
June 01, 2017 - Diagnostic Overshadowing Dangers
June 1, 2017
Raven MC. Diagnostic Overshadowing Dangers. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/diagnostic-overshadowing-dangers
The Case
A 72-year-old woman with history of opioid abuse was sent to the emergency department (ED) from a
methadone clinic because she a…
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psnet.ahrq.gov/node/49637/psn-pdf
October 01, 2011 - The Dropped "No"
October 1, 2011
Johnson AJ. The Dropped "No". PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/dropped-no
The Case
A 62-year-old man with a history of cirrhosis was admitted with increasing abdominal girth and swelling in
his legs. Because the leg swelling was somewhat more pronounced in his…
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psnet.ahrq.gov/node/37087/psn-pdf
October 03, 2011 - Improving patient safety in the ED waiting room.
October 3, 2011
Blank FSJ, Santoro J, Maynard AM, et al. Improving patient safety in the ED waiting room. Journal of
emergency nursing: JEN : official publication of the Emergency Department Nurses Association.
2007;33(4):331-5.
https://psnet.ahrq.gov/issue/improvin…
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psnet.ahrq.gov/node/45663/psn-pdf
November 09, 2016 - Nursing Home Antimicrobial Stewardship Guide.
November 9, 2016
Rockville, MD: Agency for Healthcare Research and Quality; October 2016.
https://psnet.ahrq.gov/issue/nursing-home-antimicrobial-stewardship-guide
Antimicrobial stewardship is one strategy to reduce health care–associated infections in a variety of
set…
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psnet.ahrq.gov/node/42584/psn-pdf
September 11, 2013 - Cardiac surgical ICU care: eliminating "preventable"
complications.
September 11, 2013
Shake JG, Pronovost P, Whitman GJR. Cardiac surgical ICU care: eliminating "preventable" complications.
J Card Surg. 2013;28(4):406-13. doi:10.1111/jocs.12124.
https://psnet.ahrq.gov/issue/cardiac-surgical-icu-care-eliminating-p…
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psnet.ahrq.gov/node/42613/psn-pdf
September 25, 2013 - Approaches to decreasing medication and other care
errors in the ICU.
September 25, 2013
Valentin A. Approaches to decreasing medication and other care errors in the ICU. Curr Opin Crit Care.
2013;19(5):474-9. doi:10.1097/MCC.0b013e328364d4f9.
https://psnet.ahrq.gov/issue/approaches-decreasing-medication-and-other…
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psnet.ahrq.gov/node/42664/psn-pdf
August 11, 2014 - Positive deviance: a new tool for infection prevention and
patient safety.
August 11, 2014
Marra AR, Santos OFPD, Neto MC, et al. Positive Deviance: A New Tool for Infection Prevention and
Patient Safety. Curr Infect Dis Rep. 2013.
https://psnet.ahrq.gov/issue/positive-deviance-new-tool-infection-prevention-and-pa…
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psnet.ahrq.gov/node/42185/psn-pdf
April 10, 2013 - Improving patient safety in medicine: is the model of
anaesthesia care enough?
April 10, 2013
Haller G. Improving patient safety in medicine: is the model of anaesthesia care enough? Swiss Med Wkly.
2013;143:w13770. doi:10.4414/smw.2013.13770.
https://psnet.ahrq.gov/issue/improving-patient-safety-medicine-model-an…
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psnet.ahrq.gov/node/36914/psn-pdf
March 21, 2017 - Reasons for after-hours calls by hospital floor nurses to
on-call physicians.
March 21, 2017
Bernstam E, Pancheri KK, Johnson CM, et al. Reasons for after-hours calls by hospital floor nurses to on-
call physicians. Jt Comm J Qual Patient Saf. 2007;33(6):342-9.
https://psnet.ahrq.gov/issue/reasons-after-hours-call…