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psnet.ahrq.gov/node/44571/psn-pdf
June 21, 2016 - One size fits all? Mixed methods evaluation of the impact
of 100% single-room accommodation on staff and patient
experience, safety and costs.
June 21, 2016
Maben J, Griffiths P, Penfold C, et al. One size fits all? Mixed methods evaluation of the impact of 100%
single-room accommodation on staff and patient exper…
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psnet.ahrq.gov/node/60222/psn-pdf
April 15, 2020 - Interventions to improve team effectiveness within health
care: a systematic review of the past decade.
April 15, 2020
Buljac-Samardzic M, Doekhie KD, van Wijngaarden JDH. Interventions to improve team effectiveness
within health care: a systematic review of the past decade. Hum Resourc Health. 2020;18(1).
doi:10.…
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psnet.ahrq.gov/node/38871/psn-pdf
August 19, 2009 - Effect of medication reconciliation with and without
patient counseling on the number of pharmaceutical
interventions among patients discharged from the
hospital.
August 19, 2009
Karapinar-Carkit F, Borgsteede SD, Zoer J, et al. Effect of medication reconciliation with and without
patient counseling on the number…
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psnet.ahrq.gov/node/43590/psn-pdf
October 08, 2014 - Disentangling quality and safety indicator data: a
longitudinal, comparative study of hand hygiene
compliance and accreditation outcomes in 96 Australian
hospitals.
October 8, 2014
Mumford V, Greenfield D, Hogden A, et al. Disentangling quality and safety indicator data: a longitudinal,
comparative study of hand …
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psnet.ahrq.gov/node/39212/psn-pdf
March 04, 2011 - The impact of computerized provider order entry on
medication errors in a multispecialty group practice.
March 4, 2011
Devine EB, Hansen RN, Wilson-Norton JL, et al. The impact of computerized provider order entry on
medication errors in a multispecialty group practice. J Am Med Inform Assoc. 2010;17(1):78-84.
doi…
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psnet.ahrq.gov/node/45491/psn-pdf
May 09, 2017 - A systematic review of the types and causes of
prescribing errors generated from using computerized
provider order entry systems in primary and secondary
care.
May 9, 2017
Brown CL, Mulcaster HL, Triffitt KL, et al. A systematic review of the types and causes of prescribing errors
generated from using computerize…
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psnet.ahrq.gov/node/45893/psn-pdf
August 28, 2017 - Exploring the roots of unintended safety threats
associated with the introduction of hospital ePrescribing
systems and candidate avoidance and/or mitigation
strategies: a qualitative study.
August 28, 2017
Mozaffar H, Cresswell K, Williams R, et al. Exploring the roots of unintended safety threats associated with
…
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psnet.ahrq.gov/node/45863/psn-pdf
August 28, 2017 - Large-scale implementation of the I-PASS handover
system at an academic medical centre.
August 28, 2017
Shahian DM, McEachern K, Rossi L, et al. Large-scale implementation of the I-PASS handover system at
an academic medical centre. BMJ Qual Saf. 2017;26(9):760-770. doi:10.1136/bmjqs-2016-006195.
https://psnet.ahr…
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psnet.ahrq.gov/node/40786/psn-pdf
December 30, 2014 - Exploring situational awareness in diagnostic errors in
primary care.
December 30, 2014
Singh H, Giardina TD, Petersen LA, et al. Exploring situational awareness in diagnostic errors in primary
care. BMJ Qual Saf. 2011;21(1):30-38. doi:10.1136/bmjqs-2011-000310.
https://psnet.ahrq.gov/issue/exploring-situational-a…
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psnet.ahrq.gov/node/48007/psn-pdf
May 21, 2019 - Structured override reasons for drug–drug interaction
alerts in electronic health records.
May 21, 2019
Wright A, McEvoy D, Aaron S, et al. Structured override reasons for drug-drug interaction alerts in
electronic health records. J Am Med Info Asso. 2019;26(10):934-942. doi:10.1093/jamia/ocz033.
https://psnet.ahr…
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psnet.ahrq.gov/web-mm/miscommunication-during-interhospital-transport-critically-ill-child
March 27, 2024 - Effective communication and engagement among providers, patients, and families is imperative to reducing
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psnet.ahrq.gov/node/837913/psn-pdf
August 31, 2022 - Effective communication and engagement among providers, patients, and families is
imperative to reducing
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psnet.ahrq.gov/sites/default/files/2024-03/uterine_artery_injury.pdf
January 01, 2024 - Microsoft PowerPoint - Spotlight Case_Uterine Artery Injury during Cesarean Delivery - FINAL.pptx
Spotlight
Uterine Artery Injury during Cesarean Delivery Leads to
Cardiac Arrests and Emergency Hysterectomy
Source and Credits
• This presentation is based on the March 2024 AHRQ WebM&M
Spotlight Case
o See the ful…
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psnet.ahrq.gov/node/49633/psn-pdf
September 01, 2011 - The Safety and Quality of Long Term Care
September 1, 2011
Vogelsmeier AA. The Safety and Quality of Long Term Care. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/safety-and-quality-long-term-care
Case Objectives
Identify commonly reported adverse events in long-term care.
Identify two to three challenges…
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psnet.ahrq.gov/node/49606/psn-pdf
August 01, 2010 - Weighing In on Surgical Safety
August 1, 2010
Brodsky JB, Margarson M. Weighing In on Surgical Safety. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/weighing-surgical-safety
Case Objectives
Identify the comorbidites associated with obesity that place patients at higher risk for surgical
complications.
Un…
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psnet.ahrq.gov/node/49663/psn-pdf
September 01, 2012 - Peripheral IV in Too Long
September 1, 2012
Fang C-T. Peripheral IV in Too Long. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/peripheral-iv-too-long
Case Objectives
Appreciate the complications associated with peripheral intravenous (IV) catheters.
Describe the optimal sterile technique that should be us…
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psnet.ahrq.gov/innovation/preventing-falls-through-patient-and-family-engagement-create-customized-prevention
July 23, 2024 - Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans
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May 31, 2023
Innovation
Contact
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psnet.ahrq.gov/web-mm/central-line-clot
August 04, 2021 - SPOTLIGHT CASE
Central Line Clot
Citation Text:
Randolph AG. Central Line Clot. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
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psnet.ahrq.gov/web-mm/cvc-placement-speak-now-or-do-not-use-line
November 01, 2003 - CVC Placement: Speak Now or Do Not Use the Line
Citation Text:
Ault M, Rosen B. CVC Placement: Speak Now or Do Not Use the Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/node/33736/psn-pdf
September 01, 2012 - In Conversation With… Jack Needleman, PhD
September 1, 2012
In Conversation With… Jack Needleman, PhD. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-jack-needleman-phd
Editor's note: Jack Needleman, PhD, is a Professor in the Department of Health Policy and Management
at UCLA School of P…