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psnet.ahrq.gov/node/49808/psn-pdf
October 01, 2017 - High-Risk Medications, High-Risk Transfers
October 1, 2017
Staggers N. High-Risk Medications, High-Risk Transfers. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/high-risk-medications-high-risk-transfers
The Case
A 47-year-old woman with history of primary pulmonary arterial hypertension (PAH) was admitted …
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psnet.ahrq.gov/web-mm/misplaced-vial-medication-kit-variability-contributes-medication-error-during-patient
March 12, 2021 - Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport
Citation Text:
MacDowell P, McGee E. Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Q…
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psnet.ahrq.gov/innovation/system-approaches-social-determinants-health-screening-and-intervention-innovation
July 23, 2024 - System Approaches to Social Determinants of Health Screening and Intervention Innovation Summary
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September 23, 2024
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psnet.ahrq.gov/primer/individual-clinician-performance-issues
March 15, 2025 - Individual Clinician Performance Issues
Citation Text:
Individual Clinician Performance Issues. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles
December 15, 2024 - Improving Patient Safety and Team Communication through Daily Huddles
Citation Text:
Shaikh U. Improving Patient Safety and Team Communication through Daily Huddles. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/web-mm/resuscitate-or-not
November 01, 2011 - To Resuscitate or Not?
Citation Text:
Wu AW, Pronovost P. To Resuscitate or Not?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/node/49580/psn-pdf
March 21, 2009 - Medication Reconciliation Victory After an Avoidable
Error
March 21, 2009
Cutler TW. Medication Reconciliation Victory After an Avoidable Error. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/medication-reconciliation-victory-after-avoidable-error
The Case
A 91-year-old woman, previously active and indepen…
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psnet.ahrq.gov/web-mm/toxic-tachycardia
March 01, 2005 - Toxic Tachycardia
Citation Text:
Wartofsky L. Toxic Tachycardia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/issue/situ-simulation-tool-longitudinally-identify-and-track-latent-safety-threats-structured
June 08, 2022 - Study
In situ simulation as a tool to longitudinally identify and track latent safety threats in a structured quality improvement initiative for SARS-CoV-2 airway management: a single-center study.
Citation Text:
Jafri FN, Yang CJ, Kumar A, et al. In situ simulation as a tool to longitud…
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psnet.ahrq.gov/perspective/connies-story-nurses-personal-experience-mrsa
June 29, 2023 - Connie's Story: A Nurse's Personal Experience with MRSA
April 1, 2008
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Lehfeldt C. Connie's Story: A Nurse's Personal Experience with MRSA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and…
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psnet.ahrq.gov/issue/factors-associated-mental-health-outcomes-among-health-care-workers-exposed-coronavirus
March 24, 2019 - Study
Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019.
Citation Text:
Lai J, Ma S, Wang Y, et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open. 20…
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psnet.ahrq.gov/innovation/implementation-medication-reconciliation-risk-stratification-tool-integrated-within
April 12, 2023 - EMERGING INNOVATIONS
Implementation of a medication reconciliation risk stratification tool integrated within an electronic health record: a case series of three academic medical centers.
Citation Text:
Chu ES, El-Kareh R, Biondo A, et al. Implementation of a medication reconciliation risk stratif…
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psnet.ahrq.gov/issue/safety-risks-associated-lack-integration-and-interfacing-hospital-health-information
December 21, 2022 - Study
Safety risks associated with the lack of integration and interfacing of hospital health information technologies: a qualitative study of hospital electronic prescribing systems in England.
Citation Text:
Cresswell K, Mozaffar H, Lee L, et al. Safety risks associated with the lack o…
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psnet.ahrq.gov/issue/sustained-user-engagement-health-information-technology-long-road-implementation-system
December 21, 2022 - Study
Sustained user engagement in health information technology: the long road from implementation to system optimization of computerized physician order entry and clinical decision support systems for prescribing in hospitals in England.
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Cresswell K, Lee L, Mozaffar H, e…
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psnet.ahrq.gov/innovation/clinician-collaboration-improve-clinical-decision-support-clickbusters-initiative
October 21, 2020 - EMERGING INNOVATIONS
Clinician collaboration to improve clinical decision support: the Clickbusters initiative.
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Clinician collaboration to improve clinical decision support: the Clickbusters initiative. Mc Coy AB, Russo EM, Johnson KB, et al. Clinician collaboration to improve clini…
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psnet.ahrq.gov/issue/do-medical-inpatients-who-report-poor-service-quality-experience-more-adverse-events-and
July 14, 2021 - Study
Classic
Do medical inpatients who report poor service quality experience more adverse events and medical errors?
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Taylor BB, Marcantonio ER, Pagovich O, et al. Do medical inpatients who report poor service quality experience more adverse ev…
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psnet.ahrq.gov/issue/emergency-physicians-views-direct-notification-laboratory-and-radiology-results-patients
March 23, 2012 - Study
Emergency physicians' views of direct notification of laboratory and radiology results to patients using the internet: a multisite survey.
Citation Text:
Callen J, Giardina TD, Singh H, et al. Emergency physicians' views of direct notification of laboratory and radiology results to…
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psnet.ahrq.gov/issue/tackling-ambulatory-safety-risks-through-patient-engagement-what-10000-patients-and-families
March 20, 2017 - Study
Tackling ambulatory safety risks through patient engagement: what 10,000 patients and families say about safety-related knowledge, behaviors, and attitudes after reading visit notes.
Citation Text:
Bell SK, Folcarelli P, Fossa A, et al. Tackling Ambulatory Safety Risks Through Pati…
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psnet.ahrq.gov/issue/national-cluster-randomized-trial-duty-hour-flexibility-surgical-training
September 09, 2015 - Study
Classic
National cluster-randomized trial of duty-hour flexibility in surgical training.
Citation Text:
Bilimoria KY, Chung JW, Hedges L, et al. National Cluster-Randomized Trial of Duty-Hour Flexibility in Surgical Training. New Engl J Med. 2016;374(8):71…
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psnet.ahrq.gov/issue/management-and-patient-safety-complex-elderly-patients-primary-care-during-covid-19-pandemic
April 20, 2022 - Study
Management and patient safety of complex elderly patients in primary care during the COVID-19 pandemic in the UK-Qualitative assessment.
Citation Text:
Alboksmaty A, Kumar S, Parekh R, et al. Management and patient safety of complex elderly patients in primary care during the COVID…