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psnet.ahrq.gov/node/33568/psn-pdf
June 15, 2024 - Root Cause Analysis
June 15, 2024
Root Cause Analysis. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/root-cause-analysis
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed…
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psnet.ahrq.gov/perspective/risk-management-and-patient-safety
December 01, 2010 - notified after "trigger" events.( 16 ) A list of 13 triggers that should lead to communication between residents
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psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
August 01, 2012 - This list should be accessible to faculty, residents, and advanced practice practitioners (APPs), in
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psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_managing_complexity_in_diagnosis_-_slides_final.pptx
January 01, 2024 - Theory-guided teaching: Implementation of a clinical reasoning curriculum in residents.
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psnet.ahrq.gov/perspective/implementing-fall-prevention-program
November 29, 2023 - The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents
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psnet.ahrq.gov/web-mm/crossing-line
December 01, 2012 - June 28, 2023
Educational targets to reduce medication errors by general surgery residents
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psnet.ahrq.gov/perspective/conversation-withsorrel-king
March 01, 2007 - Residents review them aloud so all members of the care team (including the patients and family members
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psnet.ahrq.gov/web-mm/e-cigarette-explosion-patient-room
March 15, 2023 - by individual clients who are competent, facilities with significant numbers of cognitively impaired residents
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psnet.ahrq.gov/node/854849/psn-pdf
October 31, 2023 - Hripcsak et al discovered that less than 20% of nurse’s notes were viewed by attending physicians
and residents
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psnet.ahrq.gov/node/33668/psn-pdf
May 01, 2008 - Here,
our residents all write their notes five floors away from the patients because that's where the
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psnet.ahrq.gov/innovation/cleveland-clinic-pairs-advanced-practice-registered-nurses-and-paramedics-provide-home
October 30, 2024 - Innovations
Missouri Quality Initiative (MOQI) Reduces Hospitalizations Among Nursing Home Residents
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psnet.ahrq.gov/node/49735/psn-pdf
June 01, 2015 - doctor thought that the patient might have coronary heart disease.(14) In a different study, medical
residents
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psnet.ahrq.gov/web-mm/emergent-triage-miss
March 06, 2015 - 2020
Impact of a pharmacist-administered deprescribing intervention on nursing home residents
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psnet.ahrq.gov/node/33744/psn-pdf
February 01, 2013 - This is
an opportunity for the students and residents on your team to learn how to communicate information
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psnet.ahrq.gov/web-mm/recurrent-hypoglycemia-care-transition-failure
December 23, 2020 - May 8, 2024
Prescribing decision making by medical residents on night shifts: a qualitative
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psnet.ahrq.gov/web-mm/elopement
July 14, 2010 - 2012
Pursuing professional accountability: an evidence-based approach to addressing residents
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psnet.ahrq.gov/web-mm/dangerous-shift
July 24, 2013 - SPOTLIGHT CASE
Dangerous Shift
Citation Text:
Patterson ES. Dangerous Shift. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endno…
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psnet.ahrq.gov/web-mm/case-mistaken-intubation
July 01, 2016 - SPOTLIGHT CASE
The Case of Mistaken Intubation
Citation Text:
Silveira MJ. The Case of Mistaken Intubation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
Google Scholar BibTeX End…
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psnet.ahrq.gov/node/73526/psn-pdf
July 28, 2021 - Medication Errors in Retail Pharmacies: Wrong Patient,
Wrong Instructions.
July 28, 2021
Li C, Marquez K. Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/medication-errors-retail-pharmacies-wrong-patient-wrong-instructions
The Case
…
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psnet.ahrq.gov/node/33583/psn-pdf
March 01, 2023 - Simulation Training
March 1, 2023
Edward JJ, Nichols A, Bakerjian D. Simulation Training. PSNet [internet]. 2023.
https://psnet.ahrq.gov/primer/simulation-training
Originally published in 2014 by researchers at the University of California, San Francisco. Updated in
March 2023, by Jennifer J. Edwards, MS, RN, CHSE…