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psnet.ahrq.gov/node/43664/psn-pdf
September 01, 2016 - Insights into the problem of alarm fatigue with
physiologic monitor devices: a comprehensive
observational study of consecutive intensive care unit
patients.
September 1, 2016
Drew BJ, Harris P, Zègre-Hemsey JK, et al. Insights into the problem of alarm fatigue with physiologic
monitor devices: a comprehensive ob…
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psnet.ahrq.gov/node/46851/psn-pdf
January 23, 2019 - To care is human—collectively confronting the clinician-
burnout crisis.
January 23, 2019
Dzau VJ, Kirch DG, Nasca TJ. To Care Is Human — Collectively Confronting the Clinician-Burnout Crisis.
New Engl J Med. 2018;378(4):312-314. doi:10.1056/nejmp1715127.
https://psnet.ahrq.gov/issue/care-human-collectively-confro…
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psnet.ahrq.gov/node/45116/psn-pdf
February 15, 2017 - Postoperative adverse events inconsistently improved by
the World Health Organization surgical safety checklist: a
systematic literature review of 25 studies.
February 15, 2017
de Jager E, McKenna C, Bartlett L, et al. Postoperative adverse events inconsistently improved by the
World Health Organization surgical s…
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psnet.ahrq.gov/node/39231/psn-pdf
January 13, 2010 - The Checklist Manifesto: How to Get Things Right.
January 13, 2010
Gawande A. New York, NY: Metropolitan Books; 2009. ISBN: 9780805091748.
https://psnet.ahrq.gov/issue/checklist-manifesto-how-get-things-right
Harvard surgeon Atul Gawande has emerged as this generation's preeminent physician–author, through
his art…
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psnet.ahrq.gov/node/37417/psn-pdf
March 28, 2012 - Medication use leading to emergency department visits
for adverse drug events in older adults.
March 28, 2012
Budnitz DS, Shehab N, Kegler SR, et al. Medication use leading to emergency department visits for
adverse drug events in older adults. Ann Intern Med. 2007;147(11):755-765.
https://psnet.ahrq.gov/issue/med…
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psnet.ahrq.gov/node/46098/psn-pdf
July 24, 2017 - Prospective evaluation of a multifaceted intervention to
improve outcomes in intensive care: the Promoting
Respect and Ongoing Safety through Patient Engagement
Communication and Technology study.
July 24, 2017
Dykes PC, Rozenblum R, Dalal A, et al. Prospective Evaluation of a Multifaceted Intervention to Improve
…
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psnet.ahrq.gov/node/37768/psn-pdf
April 27, 2010 - The wisdom and justice of not paying for "preventable
complications."
April 27, 2010
Pronovost P, Goeschel CA, Wachter R. The wisdom and justice of not paying for "preventable
complications". JAMA. 2008;299(18):2197-9. doi:10.1001/jama.299.18.2197.
https://psnet.ahrq.gov/issue/wisdom-and-justice-not-paying-prevent…
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psnet.ahrq.gov/node/45402/psn-pdf
November 01, 2017 - Potentially preventable 30-day hospital readmissions at a
children's hospital.
November 1, 2017
Toomey SL, Peltz A, Loren S, et al. Potentially Preventable 30-Day Hospital Readmissions at a Children's
Hospital. Pediatrics. 2016;138(2). doi:10.1542/peds.2015-4182.
https://psnet.ahrq.gov/issue/potentially-preventabl…
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psnet.ahrq.gov/node/73252/psn-pdf
January 01, 2022 - Why test results are still getting "lost" to follow-up: a
qualitative study of implementation gaps.
May 12, 2021
Zimolzak AJ, Shahid U, Giardina TD, et al. Why test results are still getting "lost" to follow-up: a qualitative
study of implementation gaps. J Gen Intern Med. 2022;37(1):137-144. doi:10.1007/s11606-021…
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psnet.ahrq.gov/node/852808/psn-pdf
August 30, 2023 - Ginger capsules (250 mg four times
daily) may reduce nausea but have no apparent benefit in reducing
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psnet.ahrq.gov/sites/default/files/2023-08/spotlight_case_prolonged_dka_in_pregnancy_-_slides_-_revised.pdf
January 01, 2023 - – Ginger capsules (250 mg four times daily) may reduce nausea but have no apparent benefit in
reducing
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psnet.ahrq.gov/web-mm/spinal-epidural-abscess
November 13, 2019 - The National Academy of Science, Engineering, and Medicine made recommendations about reducing diagnostic
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psnet.ahrq.gov/web-mm/resuscitation-errors-shocking-problem
October 19, 2022 - June 7, 2017
A dynamic risk management approach for reducing harm from invasive bedside
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psnet.ahrq.gov/node/49685/psn-pdf
May 01, 2013 - Polypharmacy
May 1, 2013
Guglielmo JB. Polypharmacy. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/polypharmacy
The Case
A 65-year-old man with schizophrenia receives his routine outpatient psychiatric care through an agency.
His case manager visits him weekly regarding medication adherence, which include…
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psnet.ahrq.gov/perspective/strengthening-business-case-patient-safety
May 01, 2013 - research that all of us face is not becoming too wedded to any particular solution for improving quality, reducing … harm, or reducing health care costs.
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psnet.ahrq.gov/sites/default/files/2021-09/spotlight_lost_in_transitions_of_care_09.22.2021_final.pdf
January 01, 2021 - Conversions Intelligently
37
Utilizing OME (1)
• To switch from one opioid to another with the goal of reducing … equianalgesic dose)
Utilizing OME: Equianalgesic Calculations (6)
Step 3: Account for cross-tolerance by reducing
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psnet.ahrq.gov/node/41175/psn-pdf
December 31, 2014 - Design and implementation of an automated email
notification system for results of tests pending at
discharge.
December 31, 2014
Dalal A, Schnipper JL, Poon EG, et al. Design and implementation of an automated email notification
system for results of tests pending at discharge. J Am Med Inform Assoc. 2012;19(4):52…
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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/node/42966/psn-pdf
November 21, 2018 - The next organizational challenge: finding and addressing
diagnostic error.
November 21, 2018
Graber ML, Trowbridge RL, Myers JS, et al. The next organizational challenge: finding and addressing
diagnostic error. Jt Comm J Qual Patient Saf. 2014;40(3):102-10.
https://psnet.ahrq.gov/issue/next-organizational-challe…
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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…