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3821. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2020-10/final_slides_oct_2020_spotlight_case_inpt_stroke_mngt_in_adolescent_with_type1_diabetes.pdf
      January 01, 2020 - Spotlight Spotlight Inpatient Stroke Management in a Patient with Type 1 Diabetes and Home Insulin Pump Source and Credits • This presentation is based on the October 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Berit B…

3822. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33876/psn-pdf
      August 01, 2018 - Building a Safety Program in a Vast Health Care Network March 1, 2019 Phrampus P. Building a Safety Program in a Vast Health Care Network. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/building-safety-program-vast-health-care-network Perspective Background As hospital-based health care in the United …

3823. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49414/psn-pdf
      September 01, 2003 - Making Do September 1, 2003 Bradley LD. Making Do. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/making-do The Case A 56-year-old female with dysfunctional uterine bleeding and possible retained intrauterine device (IUD) was scheduled for elective hysteroscopy and dilation and curettage (D&C). Of note, sh…

3824. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49826/psn-pdf
      April 01, 2018 - Air on the Side of Caution April 1, 2018 Robertson JM, Pozner CN. Air on the Side of Caution. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/air-side-caution The Case A young woman with morbid obesity was scheduled for cardiac catheterization to evaluate shortness of breath and chest pain. A decision was m…

3825. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33659/psn-pdf
      October 01, 2007 - Making Just Culture a Reality: One Organization's Approach October 1, 2007 Page AH. Making Just Culture a Reality: One Organization's Approach. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/making-just-culture-reality-one-organizations-approach Perspective We've all been there...something goes wrong,…

3826. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49742/psn-pdf
      September 01, 2015 - A Fumbled Handoff to Inpatient Rehab September 1, 2015 Ashcraft LE, Kahn JM. A Fumbled Handoff to Inpatient Rehab. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/fumbled-handoff-inpatient-rehab The Case An 18-year-old man with no significant past medical history sustained a traumatic brain injury after a mo…

3827. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33687/psn-pdf
      August 01, 2009 - Workarounds and Resiliency on the Front Lines of Health Care August 1, 2009 Tucker AL. Workarounds and Resiliency on the Front Lines of Health Care. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/workarounds-and-resiliency-front-lines-health-care Perspective Frontline health care providers are challen…

3828. Computerized Provider Order Entry | PSNet
      psnet.ahrq.gov/primer/computerized-provider-order-entry
      March 15, 2025 - Computerized Provider Order Entry Citation Text: Computerized Provider Order Entry. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…

3829. Strategies and Approaches for Tracking Improvements in Patient Safety | PSNet
      psnet.ahrq.gov/primer/strategies-and-approaches-tracking-improvements-patient-safety
      June 15, 2024 - Strategies and Approaches for Tracking Improvements in Patient Safety Citation Text: Shaikh U. Strategies and Approaches for Tracking Improvements in Patient Safety . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citat…

3830. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33564/psn-pdf
      March 15, 2025 - Computerized Provider Order Entry March 15, 2025 Computerized Provider Order Entry. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/computerized-provider-order-entry PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice…

3831. Radiation Safety | PSNet
      psnet.ahrq.gov/primer/radiation-safety
      September 15, 2024 - Radiation Safety Citation Text: Radiation Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Downl…

3832. A prospective observational study of physician handoff for intensive-care-unit-to-ward patient transfers. | PSNet
      psnet.ahrq.gov/issue/prospective-observational-study-physician-handoff-intensive-care-unit-ward-patient-transfers
      October 08, 2013 - Study A prospective observational study of physician handoff for intensive-care-unit-to-ward patient transfers. Citation Text: Li P, Stelfox HT, Ghali WA. A Prospective Observational Study of Physician Handoff for Intensive-Care-Unit-to-Ward Patient Transfers. Am J Med. 2011;124(9). do…

3833. Humanizing harm: using a restorative approach to heal and learn from adverse events. | PSNet
      psnet.ahrq.gov/issue/humanizing-harm-using-restorative-approach-heal-and-learn-adverse-events
      November 30, 2022 - Commentary Humanizing harm: using a restorative approach to heal and learn from adverse events. Citation Text: Wailling J, Kooijman A, Hughes J, et al. Humanizing harm: Using a restorative approach to heal and learn from adverse events. Health Expect. 2022;25(4):1192-1199. doi:10.1111/he…

3834. Assessing the effectiveness of engaging patients and their families in the three-step fall prevention process across modalities of an evidence-based fall prevention toolkit: an implementation science study. | PSNet
      psnet.ahrq.gov/issue/assessing-effectiveness-engaging-patients-and-their-families-three-step-fall-prevention
      February 19, 2020 - Study Assessing the effectiveness of engaging patients and their families in the three-step fall prevention process across modalities of an evidence-based fall prevention toolkit: an implementation science study. Citation Text: Duckworth M, Adelman JS, Belategui K, et al. Assessing the E…

3835. Laboratory safety monitoring of chronic medications in ambulatory care settings. | PSNet
      psnet.ahrq.gov/issue/laboratory-safety-monitoring-chronic-medications-ambulatory-care-settings
      January 06, 2017 - Study Laboratory safety monitoring of chronic medications in ambulatory care settings. Citation Text: Hurley JS, Roberts M, Solberg LI, et al. Brief report: Laboratory safety monitoring of chronic medications in ambulatory care settings. J Gen Intern Med. 2005;20(4). doi:10.1111/j.1525…

3836. Prescribers' perspectives on including reason for use information on prescriptions and medication labels: a qualitative thematic analysis. | PSNet
      psnet.ahrq.gov/issue/prescribers-perspectives-including-reason-use-information-prescriptions-and-medication-labels
      July 14, 2021 - Study Prescribers' perspectives on including reason for use information on prescriptions and medication labels: a qualitative thematic analysis. Citation Text: Whaley C, Bancsi A, Ho JM-W, et al. Prescribers’ perspectives on including reason for use information on prescriptions and medic…

3837. A qualitative study of prescribing errors among multi-professional prescribers within an e-prescribing system. | PSNet
      psnet.ahrq.gov/issue/qualitative-study-prescribing-errors-among-multi-professional-prescribers-within-e
      December 02, 2020 - Study A qualitative study of prescribing errors among multi-professional prescribers within an e-prescribing system. Citation Text: Alshahrani F, Marriott JF, Cox AR. A qualitative study of prescribing errors among multi-professional prescribers within an e-prescribing system. Int J Clin…

3838. Characteristics of critical incident reporting systems in primary care: an international survey. | PSNet
      psnet.ahrq.gov/issue/characteristics-critical-incident-reporting-systems-primary-care-international-survey
      September 07, 2022 - Study Characteristics of critical incident reporting systems in primary care: an international survey. Citation Text: Höcherl A, Lüttel D, Schütze D, et al. Characteristics of critical incident reporting systems in primary care: an international survey. J Patient Saf. 2022;18(1):e85-e91.…

3839. Impact of the communication and patient hand-off tool SBAR on patient safety: a systematic review. | PSNet
      psnet.ahrq.gov/issue/impact-communication-and-patient-hand-tool-sbar-patient-safety-systematic-review
      July 07, 2021 - Review Classic Impact of the communication and patient hand-off tool SBAR on patient safety: a systematic review. Citation Text: Müller M, Jürgens J, Redaèlli M, et al. Impact of the communication and patient hand-off tool SBAR on patient safety: a systematic re…

3840. Does Nursing Home Compare reflect patient safety in nursing homes? | PSNet
      psnet.ahrq.gov/issue/does-nursing-home-compare-reflect-patient-safety-nursing-homes
      February 10, 2015 - Study Does Nursing Home Compare reflect patient safety in nursing homes? Citation Text: Brauner D, Werner RM, Shippee TP, et al. Does Nursing Home Compare Reflect Patient Safety In Nursing Homes? Health Aff (Millwood). 2018;37(11):1770-1778. doi:10.1377/hlthaff.2018.0721. Copy Citation…