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psnet.ahrq.gov/node/46717/psn-pdf
April 16, 2018 - Reduction in opioid prescribing through evidence-based
prescribing guidelines.
April 16, 2018
Howard R, Waljee JF, Brummett CM, et al. Reduction in Opioid Prescribing Through Evidence-Based
Prescribing Guidelines. JAMA Surg. 2018;153(3):285-287. doi:10.1001/jamasurg.2017.4436.
https://psnet.ahrq.gov/issue/reductio…
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psnet.ahrq.gov/node/35044/psn-pdf
September 27, 2017 - Decisions about critical events in device-related
scenarios as a function of expertise.
September 27, 2017
Laxmisan A, Malhotra S, Keselman A, et al. Decisions about critical events in device-related scenarios as a
function of expertise. J Biomed Inform. 2005;38(3):200-12.
https://psnet.ahrq.gov/issue/decisions-ab…
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psnet.ahrq.gov/node/847720/psn-pdf
April 19, 2023 - In situ simulation-based team training and its significance
for transfer of learning to clinical practice--a qualitative
focus group interview study of anaesthesia personnel.
April 19, 2023
Finstad AS, Aase I, Bjørshol CA, et al. In situ simulation-based team training and its significance for
transfer of learning …
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psnet.ahrq.gov/node/844535/psn-pdf
February 15, 2023 - Association between unmet nonmedication needs after
hospital discharge and readmission or death among
acute respiratory failure survivors: a multicenter
prospective cohort study.
February 15, 2023
Bose S, Groat D, Dinglas VD, et al. Association between unmet nonmedication needs after hospital
discharge and readmi…
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psnet.ahrq.gov/node/842765/psn-pdf
January 18, 2023 - Patient identification of diagnostic safety blindspots and
participation in "good catches" through shared visit
notes.
January 18, 2023
Bell SK, Bourgeois FC, Dong J, et al. Patient identification of diagnostic safety blindspots and participation
in "good catches" through shared visit notes. Milbank Q. 2022;100(4)…
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psnet.ahrq.gov/node/44409/psn-pdf
January 22, 2016 - "Anybody on this list that you're more worried about?"
Qualitative analysis exploring the functions of questions
during end of shift handoffs.
January 22, 2016
O'Brien CM, Flanagan ME, Bergman AA, et al. "Anybody on this list that you're more worried about?"
Qualitative analysis exploring the functions of question…
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psnet.ahrq.gov/basic-page/ucsf-cmeceu-trainee-certification
June 30, 2021 - You may request a copy of your certificates from regemail@ucsf.edu and they will be mailed to you,
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psnet.ahrq.gov/innovation/handshake-antimicrobial-stewardship-model-recognize-and-prevent-diagnostic-errors
September 08, 2021 - diagnostic recommendation from the HS-ASP team (e.g., recommendations to consider alternative diagnoses, request
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psnet.ahrq.gov/node/45528/psn-pdf
October 26, 2016 - Implementing the RISE second victim support programme
at the Johns Hopkins Hospital: a case study.
October 26, 2016
Edrees HH, Connors C, Paine LA, et al. Implementing the RISE second victim support programme at the
Johns Hopkins Hospital: a case study. BMJ Open. 2016;6(9):e011708. doi:10.1136/bmjopen-2016-011708.
…
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psnet.ahrq.gov/node/46987/psn-pdf
August 01, 2018 - Between demarcation and discretion: the medical-
administrative boundary as a locus of safety in high-
volume organisational routines.
August 1, 2018
Grant S, Guthrie B. Between demarcation and discretion: The medical-administrative boundary as a locus
of safety in high-volume organisational routines. Soc Sci Med.…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.29_slideshow.ppt
September 01, 2003 - Message Acknowledgment
Failure to acknowledge receipt
Anesthesiologist fails to acknowledge surgeon’s request
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psnet.ahrq.gov/node/49592/psn-pdf
October 01, 2009 - Danger in Disruption
October 1, 2009
Fontaine DK. Danger in Disruption. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/danger-disruption
The Case
A 23-month-old toddler was severely dehydrated after vomiting due to gastric outlet obstruction. She had
metabolic alkalosis (pH = 7.58), and her last peripheral…
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psnet.ahrq.gov/web-mm/crossing-borderline
June 01, 2022 - hours of appropriate behavior, the day before her birthday, they granted permission for the patient’s request … BPD can become angry and oppositional when challenged, and the staff may have supported the patient’s request
-
psnet.ahrq.gov/node/49526/psn-pdf
December 01, 2006 - hours of appropriate behavior, the day before her birthday, they
granted permission for the patient’s request … can become angry and oppositional when challenged, and the staff may have supported the patient’s
request
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psnet.ahrq.gov/node/49452/psn-pdf
July 01, 2004 - He was handed a "Request for Consultation" form, on
which there was only one word: "Holter." … Standardized procedure request forms that require patient
identification and travel with the patient
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psnet.ahrq.gov/web-mm/danger-disruption
July 29, 2020 - Danger in Disruption
Citation Text:
Fontaine DK. Danger in Disruption. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedI…
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psnet.ahrq.gov/node/42040/psn-pdf
September 28, 2016 - The intended and unintended consequences of
communication systems on general internal medicine
inpatient care delivery: a prospective observational case
study of five teaching hospitals.
September 28, 2016
Wu RC, Lo V, Morra D, et al. The intended and unintended consequences of communication systems on
general in…
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psnet.ahrq.gov/node/45754/psn-pdf
September 01, 2018 - Addressing ambulatory safety and malpractice: the
Massachusetts PROMISES project.
September 1, 2018
Schiff G, Nieva HR, Griswold P, et al. Addressing Ambulatory Safety and Malpractice: The Massachusetts
PROMISES Project. Health Serv Res. 2016;51 Suppl 3:2634-2641. doi:10.1111/1475-6773.12621.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/50698/psn-pdf
November 27, 2019 - It is not clear whether the timing of this patient’s request to leave against medical
advice influenced … staff was attempting to contact the primary medical team (i.e. eloped), there would be
little time to request
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psnet.ahrq.gov/node/49622/psn-pdf
March 01, 2011 - black marks
on these 30-day reports and asks the original ordering provider to enter a new consult request … receive an automatic notice of the cancellation, which would then prompt her to enter
another referral request