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psnet.ahrq.gov/node/49477/psn-pdf
April 01, 2005 - Hold the tPA
April 1, 2005
Fagan SC. Hold the tPA. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/hold-tpa
The Case
A 74-year-old woman with a history of atrial fibrillation on warfarin therapy came to the emergency
department (ED) 1 hour after the sudden onset of aphasia and right-sided weakness. A non-co…
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psnet.ahrq.gov/primer/health-care-associated-infections
December 15, 2024 - Healthcare-associated Infections
Citation Text:
Healthcare - Associated Infections. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…
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psnet.ahrq.gov/node/49441/psn-pdf
March 01, 2004 - Fumbled Handoff
March 1, 2004
Vidyarthi A. Fumbled Handoff. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/fumbled-handoff
The Case
A 73-year-old female with history of hypertension, non-insulin dependent diabetes mellitus (NIDDM), and
chronic renal insufficiency was admitted for an elective sigmoid resect…
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psnet.ahrq.gov/web-mm/two-pills-same-drug
May 27, 2011 - medications, laboratory tests, and studies for specific clinical conditions and thus contribute to the standardization
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psnet.ahrq.gov/web-mm/right-place-right-drug-wrong-strength
March 26, 2015 - Such standardization can reduce the likelihood of wrong product selection.
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psnet.ahrq.gov/node/49775/psn-pdf
November 01, 2016 - opportunities to be more judicious with order set development.(1,5) Order sets can suffer
from lack of standardization
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psnet.ahrq.gov/node/850361/psn-pdf
June 14, 2023 - reports but barriers remain such as inability to locate or identify the
treating physician or lack of standardization
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psnet.ahrq.gov/issue/development-implementation-and-dissemination-i-pass-handoff-curriculum-multisite-educational
November 12, 2014 - Study
Development, implementation, and dissemination of the I-PASS Handoff Curriculum: a multisite educational intervention to improve patient handoffs.
Citation Text:
Starmer AJ, O'Toole JK, Rosenbluth G, et al. Development, implementation, and dissemination of the I-PASS handoff curric…
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psnet.ahrq.gov/issue/development-and-implementation-cognitive-aids-critical-events-pediatric-anesthesia-society
September 27, 2017 - Commentary
The development and implementation of cognitive aids for critical events in pediatric anesthesia: the Society for Pediatric Anesthesia Critical Events Checklists.
Citation Text:
Clebone A, Burian BK, Watkins SC, et al. The Development and Implementation of Cognitive Aids for C…
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psnet.ahrq.gov/issue/zero-harm-health-care
August 12, 2020 - Commentary
Zero harm in health care.
Citation Text:
Gandhi TK, Feeley D, Schummers D. Zero Harm in Health Care. NEJM Catal Innov Care Deliv. 2020;1(2). doi:10.1056/cat.19.1137.
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DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMe…
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psnet.ahrq.gov/issue/case-birth-and-death-high-reliability-healthcare-organisation
June 18, 2013 - Commentary
A case of the birth and death of a high reliability healthcare organisation.
Citation Text:
Roberts KH, Madsen P, Desai V, et al. A case of the birth and death of a high reliability healthcare organisation. Qual Saf Health Care. 2005;14(3):216-20.
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psnet.ahrq.gov/issue/error-rating-tool-identify-and-analyse-technical-errors-and-events-laparoscopic-surgery
October 09, 2013 - Study
Error rating tool to identify and analyse technical errors and events in laparoscopic surgery.
Citation Text:
Bonrath EM, Zevin B, Dedy NJ, et al. Error rating tool to identify and analyse technical errors and events in laparoscopic surgery. Br J Surg. 2013;100(8):1080-8. doi:10.1…
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psnet.ahrq.gov/issue/lost-translation-challenges-and-opportunities-physician-physician-communication-during
April 12, 2011 - Study
Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs.
Citation Text:
Solet DJ, Norvell M, Rutan GH, et al. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoff…
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psnet.ahrq.gov/issue/patient-handoff-comprehensive-curricular-blueprint-resident-education-improve-continuity-care
November 21, 2018 - Commentary
The patient handoff: a comprehensive curricular blueprint for resident education to improve continuity of care.
Citation Text:
Wohlauer M, Arora V, Horwitz LI, et al. The patient handoff: a comprehensive curricular blueprint for resident education to improve continuity of car…
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psnet.ahrq.gov/issue/mindful-workarounds-bar-code-medication-administration
July 20, 2022 - Commentary
Mindful workarounds in bar code medication administration.
Citation Text:
Lichtner V, Dowding D. Mindful workarounds in bar code medication administration. Stud Health Technol Inform. 2022;294:740-744. doi:10.3233/shti220575.
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DOI Google Scho…
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psnet.ahrq.gov/issue/effect-lean-intervention-improve-safety-processes-and-outcomes-surgical-emergency-unit
January 04, 2010 - Study
Effect of a "Lean" intervention to improve safety processes and outcomes on a surgical emergency unit.
Citation Text:
McCulloch P, Kreckler S, New S, et al. Effect of a "Lean" intervention to improve safety processes and outcomes on a surgical emergency unit. BMJ. 2010;341:c5469.…
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psnet.ahrq.gov/issue/laboratory-medicine-handoff-gaps-experienced-primary-care-practices-report-shared-networks
September 01, 2012 - This survey-based study of primary care providers revealed a lack of standardization for the tracking … 2012
Artificial intelligence versus clinicians: systematic review of design, reporting standards
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psnet.ahrq.gov/node/42067/psn-pdf
March 18, 2013 - definition of medication errors can affect measured error rates, and medication error measurement
standards
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psnet.ahrq.gov/issue/icu-attending-handoff-practices-results-national-survey-academic-intensivists
February 06, 2019 - So many ways to be wrong: completeness and accuracy in a prospective study of OR-to-ICU handoff standardization … 2013
The Accreditation Council for Graduate Medical Education resident duty hour new standards
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psnet.ahrq.gov/issue/validation-second-victim-experience-and-support-tool-revised-neonatal-intensive-care-unit
September 24, 2017 - May 19, 2021
Standardization of pediatric noncardiac operating room to intensive care … to enhance compliance of pro re nata medication orders with Joint Commission medication management standards