-
psnet.ahrq.gov/issue/impact-drug-shortage-medication-errors-and-clinical-outcomes-pediatric-intensive-care-unit
November 16, 2022 - Study
Impact of a drug shortage on medication errors and clinical outcomes in the pediatric intensive care unit.
Citation Text:
Hughes KM, Goswami ES, Morris JL. Impact of a Drug Shortage on Medication Errors and Clinical Outcomes in the Pediatric Intensive Care Unit. J Pediatr Pharmacol…
-
psnet.ahrq.gov/issue/prevalence-and-characteristics-diagnostic-error-pediatric-critical-care-multicenter-study
December 11, 2024 - Study
Prevalence and characteristics of diagnostic error in pediatric critical care: a multicenter study.
Citation Text:
Cifra CL, Custer JW, Smith CM, et al. Prevalence and characteristics of diagnostic error in pediatric critical care: a multicenter study. Crit Care Med. 2023;51(11):14…
-
psnet.ahrq.gov/issue/can-sbar-be-implemented-high-fidelity-and-does-it-improve-communication-between-healthcare
June 22, 2022 - Review
Can SBAR be implemented with high fidelity and does it improve communication between healthcare workers? A systematic review.
Citation Text:
Lo L, Rotteau L, Shojania KG. Can SBAR be implemented with high fidelity and does it improve communication between healthcare workers? A sys…
-
psnet.ahrq.gov/issue/identification-latent-safety-threats-using-high-fidelity-simulation-based-training
June 26, 2019 - Study
Identification of latent safety threats using high-fidelity simulation-based training with multidisciplinary neonatology teams.
Citation Text:
Wetzel EA, Lang TR, Pendergrass TL, et al. Identification of Latent Safety Threats Using High-Fidelity Simulation-Based Training with Mult…
-
psnet.ahrq.gov/node/33959/psn-pdf
January 17, 2012 - Healthcare Failure Mode and Effect Analysis.
January 17, 2012
National Center for Patient Safety.
https://psnet.ahrq.gov/issue/healthcare-failure-mode-and-effect-analysis
These materials provide an introduction to the purpose of healthcare failure mode and effect analysis
(HFMEA), the steps of the HFMEA process, a…
-
psnet.ahrq.gov/node/37069/psn-pdf
December 20, 2007 - Standardising wristbands improves patient safety.
December 20, 2007
National Patient Safety Agency. Safer Practice Notice. July 2007;(24):1-2.
https://psnet.ahrq.gov/issue/standardising-wristbands-improves-patient-safety
This notice highlights the importance of standardizing wristband design and information to make…
-
psnet.ahrq.gov/node/41980/psn-pdf
January 16, 2013 - Handoff Communication Tools.
January 16, 2013
Landrigan CP, Lyons A, Gannon P, et al. FIRST Do No Harm. December 2012;1-8.
https://psnet.ahrq.gov/issue/handoff-communication-tools
This newsletter issue highlights initiatives and tools developed to improve handoff communication in
Massachusetts.
https://psnet.ahrq…
-
psnet.ahrq.gov/node/36228/psn-pdf
July 31, 2012 - How hospital design saves lives.
July 31, 2012
Blum A. Bloomberg. August 14, 2006.
https://psnet.ahrq.gov/issue/how-hospital-design-saves-lives
This article discusses how hospital design, including standardized operating rooms, better ventilation
systems, and green design can improve patient safety and decrea…
-
psnet.ahrq.gov/node/49650/psn-pdf
March 01, 2012 - Turn the Other Cheek
March 1, 2012
Starling J. Turn the Other Cheek. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/turn-other-cheek
The Case
A 56-year-old man underwent two skin biopsies to evaluate clinically concerning lesions. The first biopsy
was diagnostic for squamous cell carcinoma (SCC) and docume…
-
psnet.ahrq.gov/node/612828/psn-pdf
February 23, 2022 - Delayed Diagnosis of Kidney Transplant Complications
February 23, 2022
Kapa N, Morfín JA. Delayed Diagnosis of Kidney Transplant Complications. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/delayed-diagnosis-kidney-transplant-complications
Objectives
Recognition, early evaluation, and management of kidney …
-
psnet.ahrq.gov/node/49626/psn-pdf
May 01, 2011 - Outbreak
May 1, 2011
Rothman R, Stapleton S. Outbreak. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/outbreak
The Case
A 36-year-old healthy man developed an acute febrile illness associated with a vesicular rash. He
presented to an urgent care clinic where he was diagnosed with varicella infection ("chic…
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.236_slideshow.ppt
March 01, 2011 - Spotlight Case July 2008
Spotlight Case March 2011
Volume Too Low: In and Out
Pediatric Patient Safety
*
*
Source and Credits
This presentation is based on the March 2011
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Marlene Miller, MD, MSc…
-
psnet.ahrq.gov/node/850362/psn-pdf
June 14, 2023 - Home Medications Contribute to a Unique Opportunity for
Error on Discharge from the Hospital
June 14, 2023
Agrawal G, Nguyen DM. Home Medications Contribute to a Unique Opportunity for Error on Discharge from
the Hospital. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/home-medications-contribute-unique-opp…
-
psnet.ahrq.gov/node/33779/psn-pdf
March 01, 2015 - Handoffs and Transitions
January 22, 2014
Sehgal NL. Handoffs and Transitions. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/handoffs-and-transitions
Annual Perspective 2014
Despite recent efforts to promote clinical integration, the United States health care system remains highly
fragmented. From it…
-
psnet.ahrq.gov/node/40626/psn-pdf
July 02, 2014 - Time to sign off on signout.
July 2, 2014
Stein DM, Stetson PD. Commentary: time to sign off on signout. Acad Med. 2011;86(7):804-6.
doi:10.1097/ACM.0b013e31821d8409.
https://psnet.ahrq.gov/issue/time-sign-signout
This commentary suggests standardized sign-outs can improve communication and handoffs.
https://psne…
-
psnet.ahrq.gov/web-mm/importance-following-safe-practices-infant-feeding-and-handling-expressed-breast-milk
January 31, 2024 - Importance of Following Safe Practices for Infant Feeding and Handling Expressed Breast Milk
Citation Text:
Shauer M, Perez DG, Chagolla B. Importance of Following Safe Practices for Infant Feeding and Handling Expressed Breast Milk. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quali…
-
psnet.ahrq.gov/node/867359/psn-pdf
December 18, 2024 - Importance of Following Safe Practices for Infant Feeding
and Handling Expressed Breast Milk
December 18, 2024
Shauer M, Perez DG, Chagolla B. Importance of Following Safe Practices for Infant Feeding and Handling
Expressed Breast Milk. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/importance-following-saf…
-
psnet.ahrq.gov/web-mm/robotic-surgery-risks-vs-rewards
October 31, 2023 - SPOTLIGHT CASE
Robotic Surgery: Risks vs. Rewards
Citation Text:
Kirkpatrick T, LaGrange C. Robotic Surgery: Risks vs. Rewards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
Copy Citation
Format:
Googl…
-
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
-
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