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psnet.ahrq.gov/node/845472/psn-pdf
March 15, 2023 - In a more
modern environment, we have increasingly connected medical devices that automatically send … They would send the data to the physician to make treatment
management decisions. … Typically, our clients do not have good ways to connect RPM and send blood
pressure automatically through
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psnet.ahrq.gov/node/49513/psn-pdf
July 01, 2006 - Moving Pains
July 1, 2006
Schell H, Wachter R. Moving Pains. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/moving-pains
Case Objectives
Appreciate the risk posed by intrahospital transport
Identify key features of current transport practice and policies
Propose interventions that might improve safety of …
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psnet.ahrq.gov/node/33632/psn-pdf
April 01, 2006 - really took off—we
started getting reports from all over; people would see us at meetings or call us or send … contact us—I don't care
if they call us, see me at a meeting, use our reporting form in the mail, or send
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psnet.ahrq.gov/perspective/conversation-susan-haas-md-msc
March 01, 2019 - But it's totally different to say we're going to send you to this rural hospital to help them with their
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psnet.ahrq.gov/issue/bending-patient-safety-curve-how-much-can-ai-help
March 31, 2021 - Commentary
Bending the patient safety curve: how much can AI help?
Citation Text:
Classen DC, Longhurst CA, Thomas EJ. Bending the patient safety curve: how much can AI help? NPJ Digit Med. 2023;6(1):2. doi:10.1038/s41746-022-00731-5.
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DOI Google Schola…
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psnet.ahrq.gov/issue/reducing-administrative-harm-medicine-clinicians-and-administrators-together
February 23, 2022 - Commentary
Reducing administrative harm in medicine - clinicians and administrators together.
Citation Text:
O’Donnell WJ. Reducing administrative harm in medicine - clinicians and administrators together. N Engl J Med. 2022;386(25):2429-2432. doi:10.1056/nejmms2202174.
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…
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psnet.ahrq.gov/issue/tips-reduce-dangerous-interruptions-healthcare-staff
September 23, 2020 - Commentary
Tips to reduce dangerous interruptions by healthcare staff.
Citation Text:
Lewis TP, Smith CB, Williams-Jones P. Tips to reduce dangerous interruptions by healthcare staff. Nursing (Brux). 2012;42(11):65-7. doi:10.1097/01.NURSE.0000421387.36112.e0.
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psnet.ahrq.gov/issue/advancing-patient-safety-through-clinical-application-framework-focused-communication
December 02, 2020 - Review
Advancing patient safety through the clinical application of a framework focused on communication.
Citation Text:
Manojlovich M, Hofer TP, Krein SL. Advancing Patient Safety Through the Clinical Application of a Framework Focused on Communication. J Patient Saf. 2021;17(8):e732-e7…
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psnet.ahrq.gov/perspective/conversation-withdiane-rydrych-ma
February 26, 2025 - We send out safety alerts when there's an issue we believe they need to be aware of based on the reports … RW: When you send out a safety alert, would it be because you've seen this thing happen once or because
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psnet.ahrq.gov/issue/mind-overlap-how-system-problems-contribute-cognitive-failure-and-diagnostic-errors
August 14, 2019 - Study
Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors.
Citation Text:
Gupta A, Harrod M, Quinn M, et al. Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors. Diagnosis (Berl). 2018;5(3):151-156. doi:10.15…
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psnet.ahrq.gov/issue/formative-evaluation-video-reflexive-ethnography-method-applied-physician-nurse-dyad
December 02, 2020 - Study
Formative evaluation of the video reflexive ethnography method, as applied to the physician–nurse dyad.
Citation Text:
Manojlovich M, Frankel RM, Harrod M, et al. Formative evaluation of the video reflexive ethnography method, as applied to the physician-nurse dyad. BMJ Qual Saf. 2…
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psnet.ahrq.gov/issue/health-system-wide-initiative-decrease-opioid-related-morbidity-and-mortality
November 16, 2022 - Commentary
Emerging Classic
A health system–wide initiative to decrease opioid-related morbidity and mortality.
Citation Text:
Weiner SG, Price CN, Atalay AJ, et al. A Health System-Wide Initiative to Decrease Opioid-Related Morbidity and Mortality. Jt Comm J Qu…
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psnet.ahrq.gov/issue/smartphone-distraction-during-nursing-care-systematic-literature-review
February 09, 2022 - Review
Smartphone distraction during nursing care: systematic literature review.
Citation Text:
Fiorinelli M, Di Mario S, Surace A, et al. Smartphone distraction during nursing care: systematic literature review. Appl Nurs Res. 2021;58:151405. doi:10.1016/j.apnr.2021.151405.
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psnet.ahrq.gov/issue/understanding-complexity-safety-critical-setting-systems-approach-medication-administration
February 01, 2023 - Study
Understanding complexity in a safety critical setting: a systems approach to medication administration.
Citation Text:
Stevens EL, Hulme A, Goode N, et al. Understanding complexity in a safety critical setting: a systems approach to medication administration. Appl Ergon. 2023;110:1…
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psnet.ahrq.gov/issue/systematic-literature-review-and-narrative-synthesis-risks-medical-discharge-letters-patients
June 26, 2019 - Review
Emerging Classic
A systematic literature review and narrative synthesis on the risks of medical discharge letters for patients' safety.
Citation Text:
Schwarz CM, Hoffmann M, Schwarz P, et al. A systematic literature review and narrative synthesis on the …
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psnet.ahrq.gov/issue/achieving-climate-patient-safety-focusing-relationships
December 19, 2017 - Study
Achieving a climate for patient safety by focusing on relationships.
Citation Text:
Manojlovich M, Kerr M, Davies B, et al. Achieving a climate for patient safety by focusing on relationships. Int J Qual Health Care. 2014;26(6):579-84. doi:10.1093/intqhc/mzu068.
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…
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psnet.ahrq.gov/issue/reducing-diagnostic-errors-through-effective-communication-harnessing-power-information
March 10, 2011 - Commentary
Reducing diagnostic errors through effective communication: harnessing the power of information technology.
Citation Text:
Singh H, Naik AD, Rao R, et al. Reducing Diagnostic Errors through Effective Communication: Harnessing the Power of Information Technology. J Gen Intern…
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psnet.ahrq.gov/issue/role-technology-clinician-clinician-communication
September 09, 2015 - Commentary
The role of technology in clinician-to-clinician communication.
Citation Text:
McElroy LM, Ladner DP, Holl JL. The role of technology in clinician-to-clinician communication. BMJ Qual Saf. 2013;22(12):981-3. doi:10.1136/bmjqs-2013-002191.
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Format:
…
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psnet.ahrq.gov/issue/procuring-interoperability-achieving-high-quality-connected-and-person-centered-care
September 19, 2018 - Book/Report
Procuring Interoperability: Achieving High-Quality, Connected, and Person-Centered Care.
Citation Text:
Procuring Interoperability: Achieving High-Quality, Connected, and Person-Centered Care. Pronovost P, Johns MME, Palmer S, et al, eds. Washington, DC: National Academy of M…
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psnet.ahrq.gov/node/846915/psn-pdf
March 29, 2023 - inpatient physician may have been uncomfortable with the consulting
psychiatrist’s recommendation to send