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psnet.ahrq.gov/perspective/conversation-amy-j-starmer-md-mph
May 31, 2023 - April 1, 2018
Crossing the communication chasm: challenges and opportunities in transitions
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psnet.ahrq.gov/perspective/identifying-safety-events-prehospital-setting
May 16, 2022 - 31, 2022
Annual Perspective
Communication During Transitions … Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions
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psnet.ahrq.gov/node/33572/psn-pdf
December 15, 2024 - Checklists
December 15, 2024
Checklists. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/checklists
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in 2024.
Background
…
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psnet.ahrq.gov/perspective/patient-safety-office-based-care-settings
January 31, 2024 - Quality and safety challenges arise due to gaps in continuity of care, transitions in care, and communication … 27, 2024
Annual Perspective
Communication During Transitions
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psnet.ahrq.gov/web-mm/procedure-complications-who-responsible-follow
July 31, 2023 - Procedure Complications – Who is Responsible for Follow up?
Citation Text:
Chalupsky M, Wei H, Marquet E. Procedure Complications – Who is Responsible for Follow up?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
Copy Cita…
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psnet.ahrq.gov/web-mm/safeguarding-diagnostic-testing-point-care
September 30, 2011 - Safeguarding Diagnostic Testing at the Point of Care
Citation Text:
Kost GJ, Ehrmeyer SS. Safeguarding Diagnostic Testing at the Point of Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy Citation
Format:
…
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psnet.ahrq.gov/node/854848/psn-pdf
October 31, 2023 - Delay in Malignancy Diagnosis Reflects Systemic Failures
October 31, 2023
Mieu H, Olson KA. Delay in Malignancy Diagnosis Reflects Systemic Failures. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures
The Case
A 32-year-old man presented to the hospital with…
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psnet.ahrq.gov/node/49857/psn-pdf
March 01, 2019 - Duplicate Insulin Order
March 1, 2019
Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/duplicate-insulin-order
The Case
A 45-year-old man with a history of insulin-dependent diabetes mellitus was seen in the emergency
department (ED) for complaints of letharg…
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psnet.ahrq.gov/web-mm/when-indications-drug-administration-blur
May 26, 2021 - SPOTLIGHT CASE
When the Indications for Drug Administration Blur
Citation Text:
Munsch J, Doroy A. When the Indications for Drug Administration Blur . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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…
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psnet.ahrq.gov/web-mm/cultural-dimensions-depression
September 01, 2018 - WebM&M Cases
Steroids and Safety: Preventing Medication Adverse Events During Transitions
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psnet.ahrq.gov/web-mm/high-risk-medications-high-risk-transfers
December 21, 2017 - Development and implementation of a risk identification tool to facilitate critical care transitions
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psnet.ahrq.gov/perspective/acgmes-2017-revision-common-program-requirements
January 31, 2018 - They allow work at home as part of the 80-hour weekly maximum; optimize the quality of care transitions
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psnet.ahrq.gov/web-mm/critical-order-set-change-and-critical-limb-ischemia
July 02, 2019 - Using an online quiz-based reinforcement system to teach healthcare quality and patient safety and care transitions
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psnet.ahrq.gov/perspective/patient-safety-medical-nursing-and-other-clinical-education
January 31, 2020 - 27, 2024
Annual Perspective
Communication During Transitions
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psnet.ahrq.gov/web-mm/forgotten-med
July 01, 2006 - March 10, 2021
Crossing the communication chasm: challenges and opportunities in transitions
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psnet.ahrq.gov/node/73229/psn-pdf
May 26, 2021 - These differences create potential discrepancies in transitions of care (i.e., OR to
ICU) and inconsistencies
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psnet.ahrq.gov/node/33709/psn-pdf
July 01, 2011 - what-have-we-learned-about-safe-inpatient-handovers
Perspective
The care of hospitalized patients is marked by numerous transitions
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psnet.ahrq.gov/node/50769/psn-pdf
February 15, 2017 - traditional medicines, healthcare-associated infections,
adverse birth outcomes, inappropriate care transitions
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psnet.ahrq.gov/node/49706/psn-pdf
January 01, 2015 - However, several potential problems may arise when a patient transitions out of the hospital while
continuing
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psnet.ahrq.gov/sites/default/files/2020-08/too_many_cooks_spotlight_pdf.pdf
January 01, 2020 - Intraoperative Care Transitions Are Not Associated with Postoperative Adverse
Outcomes.