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psnet.ahrq.gov/web-mm/nurse-staffing-ratios-crucible-money-policy-research-and-patient-care
June 01, 2003 - In the ICU that evening, two nurses scheduled to work had called in sick. … There was only one patient care assistant scheduled on this weekend shift.
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psnet.ahrq.gov/node/49810/psn-pdf
November 01, 2017 - On the night shift, the bedside nurse went to see the patient at 3:00 AM to administer the next scheduled … The nurse administered the scheduled dose of intravenous hydromorphone.
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psnet.ahrq.gov/node/49777/psn-pdf
December 01, 2016 - that she had cut her wrists and taken some pills, the staff
member treated the call as routine and scheduled … by asking patients to promise that they
won't self-harm and will follow up as planned at the next scheduled
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psnet.ahrq.gov/node/46819/psn-pdf
January 27, 2019 - Implementing electronic health record default settings to
reduce opioid overprescribing: a pilot study.
January 27, 2019
Zivin K, White JO, Chao S, et al. Implementing Electronic Health Record Default Settings to Reduce Opioid
Overprescribing: A Pilot Study. Pain Med. 2019;20(1):103-112. doi:10.1093/pm/pnx304.
htt…
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psnet.ahrq.gov/node/848363/psn-pdf
May 03, 2023 - Impact of the percentage of overlapping surgery on
patient outcomes: a retrospective cohort study of 87,000
surgical cases.
May 3, 2023
Pitts CC, Ponce BA, Arguello AM, et al. Impact of the percentage of overlapping surgery on patient
outcomes: a retrospective cohort study of 87,000 surgical cases. Ann Surg. 2023;…
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psnet.ahrq.gov/node/47741/psn-pdf
March 06, 2019 - Association of overlapping surgery with perioperative
outcomes.
March 6, 2019
Sun E, Mello MM, Rishel CA, et al. Association of Overlapping Surgery With Perioperative Outcomes.
JAMA. 2019;321(8):762-772. doi:10.1001/jama.2019.0711.
https://psnet.ahrq.gov/issue/association-overlapping-surgery-perioperative-outcomes…
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psnet.ahrq.gov/node/50906/psn-pdf
February 19, 2020 - Implementation of a discharge education program to
improve transitions of care for patients at high risk of
medication errors.
February 19, 2020
Crannage AJ, Hennessey EK, Challen LM, et al. . Implementation of a discharge education program to
improve transitions of care for patients at high risk of medication err…
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psnet.ahrq.gov/node/45394/psn-pdf
September 07, 2016 - Caregiver fatigue: implications for patient and staff
safety—part 1 and part 2.
September 7, 2016
Blouin AS, Smith-Miller CA, Harden J, et al. Caregiver Fatigue: Implications for Patient and Staff Safety,
Part 1. J Nurs Adm. 2016;46(6):329-35. doi:10.1097/NNA.0000000000000353.
https://psnet.ahrq.gov/issue/caregive…
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psnet.ahrq.gov/node/44877/psn-pdf
April 27, 2016 - Actions Needed to Help Ensure Appropriate Medication
Continuation and Prescribing Practices.
April 27, 2016
Washington, DC: United States Government Accountability Office; January 5, 2016. Publication GAO-16-
158.
https://psnet.ahrq.gov/issue/actions-needed-help-ensure-appropriate-medication-continuation-and-
pre…
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psnet.ahrq.gov/node/34073/psn-pdf
February 17, 2011 - Effect of reducing interns' weekly work hours on sleep
and attentional failures.
February 17, 2011
Lockley SW, Cronin JW, Evans EE, et al. Effect of reducing interns' weekly work hours on sleep and
attentional failures. N Engl J Med. 2004;351(18):1829-37.
https://psnet.ahrq.gov/issue/effect-reducing-interns-weekly…
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psnet.ahrq.gov/node/40381/psn-pdf
May 25, 2011 - Medication errors in the homes of children with chronic
conditions.
May 25, 2011
Walsh KE, Mazor KM, Stille CJ, et al. Medication errors in the homes of children with chronic conditions.
Arch Dis Child. 2011;96(6):581-6. doi:10.1136/adc.2010.204479.
https://psnet.ahrq.gov/issue/medication-errors-homes-children-chr…
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psnet.ahrq.gov/node/46048/psn-pdf
July 05, 2017 - Association between elements of electronic health record
systems and the weekend effect in urgent general
surgery.
July 5, 2017
Kothari A, Brownlee SA, Blackwell RH, et al. Association Between Elements of Electronic Health Record
Systems and the Weekend Effect in Urgent General Surgery. JAMA Surg. 2017;152(6):602-…
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psnet.ahrq.gov/node/43812/psn-pdf
January 14, 2015 - Healthcare Inspection: Evaluation of the Veterans Health
Administration's National Consult Delay Review and
Associated Fact Sheet.
January 14, 2015
Daigh JD Jr. Washington, DC: VA Office of the Inspector General; December 15, 2014. Report No. 14-
04705-62.
https://psnet.ahrq.gov/issue/healthcare-inspection-evalua…
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psnet.ahrq.gov/node/46132/psn-pdf
September 24, 2017 - The "Quality Minute"—a new, brief, and structured
technique for quality improvement education during the
morbidity and mortality conference.
September 24, 2017
Hoffman RL, Morris JB, Kelz RR. The “Quality Minute”—A New, Brief, and Structured Technique for Quality
Improvement Education During the Morbidity and Mort…
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psnet.ahrq.gov/node/46579/psn-pdf
April 11, 2018 - Electronic medicine can send you test results quickly. But
what if they're scary?
April 11, 2018
Boodman SG. Washington Post. March 26, 2018.
https://psnet.ahrq.gov/issue/electronic-medicine-can-send-you-test-results-quickly-what-if-theyre-scary
Although providing patients with access to physician notes and test r…
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psnet.ahrq.gov/node/38057/psn-pdf
September 10, 2008 - Randomized controlled trial of a pictogram-based
intervention to reduce liquid medication dosing errors
and improve adherence among caregivers of young
children.
September 10, 2008
Yin S, Dreyer BP, van Schaick L, et al. Randomized controlled trial of a pictogram-based intervention to
reduce liquid medication do…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.245_slideshow.ppt
July 01, 2011 - Discharging on Warfarin
However, management of this patient also had pitfalls:
Follow-up could have been scheduled
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psnet.ahrq.gov/node/858171/psn-pdf
December 13, 2023 - Uncovering the risks of anticancer therapy through
incident report analysis using a newly developed medical
oncology incident taxonomy.
December 13, 2023
Jacobson JO, Zerillo JA, Doolin J, et al. Uncovering the risks of anticancer therapy through incident report
analysis using a newly developed medical oncology in…
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psnet.ahrq.gov/node/33601/psn-pdf
December 15, 2024 - Electronic Health Records
December 15, 2024
Electronic Health Records. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/electronic-health-records
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 safet…
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psnet.ahrq.gov/node/34769/psn-pdf
March 28, 2005 - The Challenger Launch Decision: Risky Technology,
Culture, and Deviance at NASA.
March 28, 2005
Vaughan D. Chicago, IL: University of Chicago Press; 1996. ISBN 9780226851754.
https://psnet.ahrq.gov/issue/challenger-launch-decision-risky-technology-culture-and-deviance-nasa
A model of root cause analysis on a syste…