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psnet.ahrq.gov/node/49409/psn-pdf
July 01, 2003 - Feeling No Pain
July 1, 2003
Bogner MS. Feeling No Pain. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/feeling-no-pain
The Case
A 33-year-old female underwent hysterectomy for refractory endometriosis. For pain post-operatively, the
patient was placed on a Patient-Controlled Analgesia (PCA) pump containin…
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psnet.ahrq.gov/node/866395/psn-pdf
July 23, 2024 - Rescue Improvement Conference Innovation Summary
July 23, 2024
https://psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary
Summary
The Rescue Improvement Conference (RIC)1 was designed at the University of Michigan to address failure
to rescue with a particular focus on communication and com…
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psnet.ahrq.gov/node/866841/psn-pdf
September 23, 2024 - System Approaches to Social Determinants of Health
Screening and Intervention Innovation Summary
September 23, 2024
https://psnet.ahrq.gov/innovation/system-approaches-social-determinants-health-screening-and-
intervention-innovation
Summary
UNC Health is a nonprofit healthcare system of more than 500 clinics and…
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psnet.ahrq.gov/node/843736/psn-pdf
February 01, 2023 - Saved by ECMO
February 1, 2023
Weiss NA. Saved by ECMO . PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/saved-ecmo
The Case
A 27-year-old pregnant woman was admitted at an estimated gestational age (EGA) of 29 weeks for
increased shortness of breath. She was diagnosed with severe pulmonary arterial hyperte…
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psnet.ahrq.gov/web-mm/informed-or-misled
April 24, 2018 - Informed or Misled?
Citation Text:
White SM. Informed or Misled?
. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId…
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psnet.ahrq.gov/innovation/care-managers-use-software-aided-medication-review-protocol-frail-community-dwelling
September 13, 2023 - Elderly home health and post-hospital or skill nursing facility (SNF) clients are often frail and vulnerable
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psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
September 01, 2003 - to understand how to encourage safety-enhancing collaborative behaviors among nurses with different skill
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psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication
December 23, 2020 - Multiple Levels Involved in Prescribing the Wrong Medication
Citation Text:
Chin K, Chau V, Spero H, et al. Multiple Levels Involved in Prescribing the Wrong Medication. 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/tale-two-falls
March 27, 2024 - A Tale of Two Falls
Citation Text:
Jackson V, Satake A. A Tale of Two Falls. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged P…
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psnet.ahrq.gov/issue/effect-organizational-network-patient-safety-safety-event-reporting
October 16, 2013 - Study
The effect of an organizational network for patient safety on safety event reporting.
Citation Text:
Jeffs L, Hayes C, Smith O, et al. The effect of an organizational network for patient safety on safety event reporting. Eval Health Prof. 2014;37(3):366-78. doi:10.1177/016327871349…
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psnet.ahrq.gov/issue/what-has-airbus-a380-captain-got-do-omfs-lessons-aviation-improve-patient-safety
October 04, 2023 - Commentary
What has an Airbus A380 captain got to do with OMFS? Lessons from aviation to improve patient safety.
Citation Text:
Davidson M, Brennan PA. Leading article: What has an Airbus A380 Captain got to do with OMFS? Lessons from aviation to improve patient safety. Br J Oral Maxillo…
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psnet.ahrq.gov/issue/implementing-standardized-reporting-and-safety-checklists
September 29, 2017 - Study
Implementing standardized reporting and safety checklists.
Citation Text:
Stevens JD, Bader MK, Luna MA, et al. Cultivating quality: implementing standardized reporting and safety checklists. Am J Nurs. 2011;111(5):48-53. doi:10.1097/01.naj.0000398051.07923.69.
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psnet.ahrq.gov/issue/effect-diagnostic-accuracy-cognitive-reasoning-tools-workplace-setting-systematic-review-and
February 02, 2022 - Review
Effect on diagnostic accuracy of cognitive reasoning tools for the workplace setting: systematic review and meta-analysis.
Citation Text:
Staal J, Hooftman J, Gunput STG, et al. Effect on diagnostic accuracy of cognitive reasoning tools for the workplace setting: systematic review…
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psnet.ahrq.gov/issue/systematic-proactive-risk-assessment-hazards-surgical-wards-quantitative-study
August 15, 2013 - Study
A systematic proactive risk assessment of hazards in surgical wards: a quantitative study.
Citation Text:
Anderson O, Brodie A, Vincent CA, et al. A systematic proactive risk assessment of hazards in surgical wards: a quantitative study. Ann Surg. 2012;255(6):1086-92. doi:10.1097…
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psnet.ahrq.gov/issue/curriculum-development-and-implementation-national-interprofessional-fellowship-patient
November 18, 2016 - Commentary
Curriculum development and implementation of a national interprofessional fellowship in patient safety.
Citation Text:
Watts B, Williams L, Mills PD, et al. Curriculum Development and Implementation of a National Interprofessional Fellowship in Patient Safety. J Patient Saf. 2…
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psnet.ahrq.gov/issue/errors-abo-labeling-deceased-donor-kidneys-case-reports-and-approach-ensuring-patient-safety
June 09, 2021 - Study
Errors in ABO labeling of deceased donor kidneys: case reports and approach to ensuring patient safety.
Citation Text:
Friedman AL, Lee KC, Lee GD. Errors in ABO Labeling of Deceased Donor Kidneys: Case Reports and Approach to Ensuring Patient Safety. American Journal of Transpla…
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psnet.ahrq.gov/issue/department-veterans-affairs-chief-resident-quality-and-patient-safety-program-model-spread
September 05, 2018 - Commentary
Department of Veterans Affairs Chief Resident in Quality and Patient Safety Program: a model to spread change.
Citation Text:
Watts B, Paull DE, Williams LC, et al. Department of Veterans Affairs Chief Resident in Quality and Patient Safety Program: A Model to Spread Change. A…
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psnet.ahrq.gov/issue/nursing-practice-hospitalised-older-people-safety-and-harm
April 24, 2018 - Review
Nursing practice with hospitalised older people: safety and harm.
Citation Text:
Dahlke SA, Hunter KF, Negrin K. Nursing practice with hospitalised older people: Safety and harm. Int J Older People Nurs. 2019;14(1):e12220. doi:10.1111/opn.12220.
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psnet.ahrq.gov/issue/improving-diagnostic-performance-through-feedback-diagnosis-learning-cycle
December 16, 2020 - Commentary
Improving diagnostic performance through feedback: the Diagnosis Learning Cycle.
Citation Text:
Fernandez Branson C, Williams M, Chan TM, et al. Improving diagnostic performance through feedback: the Diagnosis Learning Cycle. BMJ Qual Saf. 2021;30(12):1002-1009. doi:10.1136/bm…
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psnet.ahrq.gov/issue/assessing-and-supporting-late-career-practitioners-four-key-questions
May 18, 2022 - Commentary
Assessing and supporting late career practitioners: four key questions.
Citation Text:
White AA, Sage WM, Mazor KM, et al. Assessing and supporting late career practitioners: four key questions. Jt Comm J Qual Patient Saf. 2020;46(10):591-595. doi:10.1016/j.jcjq.2020.07.001.
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