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psnet.ahrq.gov/web-mm/unhappy-patient-leaves-against-medical-advice
January 31, 2024 - The Unhappy Patient Leaves Against Medical Advice.
Citation Text:
Nichols A. The Unhappy Patient Leaves Against Medical Advice.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/node/852808/psn-pdf
August 30, 2023 - Prolonged DKA in Pregnancy: A Case of Communication
Breakdown.
August 30, 2023
Marshall S, Boe NM. Prolonged DKA in Pregnancy: A Case of Communication Breakdown. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown
Disclosure of Relevant Financial Relationship…
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psnet.ahrq.gov/sites/default/files/2023-08/spotlight_case_prolonged_dka_in_pregnancy_-_slides_-_revised.pdf
January 01, 2023 - Spotlight
Spotlight
Prolonged DKA in Pregnancy: A Case of Communication
Breakdown
Source and Credits
• This presentation is based on the August 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Sarah Marshall, MD and Nina M. …
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psnet.ahrq.gov/web-mm/buprenorphine-and-medically-ill-patient
August 20, 2018 - Buprenorphine and the Medically Ill Patient
Citation Text:
McCance-Katz EF. Buprenorphine and the Medically Ill Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/node/33818/psn-pdf
November 01, 2016 - In Conversation With… Andrew Bindman, MD
November 1, 2016
In Conversation With… Andrew Bindman, MD. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-andrew-bindman-md
Editor's note: Dr. Bindman was appointed as Director of the Agency for Healthcare Research and Quality
(AHRQ) in May 2016. P…
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psnet.ahrq.gov/web-mm/complaints-safety-surveillance
May 05, 2021 - Complaints as Safety Surveillance
Citation Text:
Morris JL, Bismark M. Complaints as Safety Surveillance. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/node/847934/psn-pdf
April 26, 2023 - Patient Safety Indicators
April 26, 2023
Tokareva I, Romano P. Patient Safety Indicators. PSNet [internet]. 2023.
https://psnet.ahrq.gov/primer/patient-safety-indicators
Background
Over the past 25 years, policymakers and providers, payers, and purchasers of health care have
increasingly focused attention on pati…
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psnet.ahrq.gov/web-mm/other-side
May 01, 2007 - SPOTLIGHT CASE
The Other Side
Citation Text:
Vincent CA. The Other Side. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/result-stopped-here
December 01, 2006 - The Result Stopped Here
Citation Text:
Astion ML. The Result Stopped Here. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/perspective/role-undergraduate-nursing-education-patient-safety
November 27, 2023 - Perspective
Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units
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psnet.ahrq.gov/issue/towards-high-reliability-organising-healthcare-strategy-building-organisational-capacity
January 06, 2016 - Commentary
Towards high-reliability organising in healthcare: a strategy for building organisational capacity.
Citation Text:
Aboumatar HJ, Weaver SJ, Rees D, et al. Towards high-reliability organising in healthcare: a strategy for building organisational capacity. BMJ Qual Saf. 2017;26(…
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psnet.ahrq.gov/issue/beyond-communication-role-standardized-protocols-changing-health-care-environment
October 12, 2011 - Study
Beyond communication: the role of standardized protocols in a changing health care environment.
Citation Text:
Vardaman JM, Cornell P, Gondo MB, et al. Beyond communication: the role of standardized protocols in a changing health care environment. Health Care Manage Rev. 2012;37…
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psnet.ahrq.gov/issue/nursing-and-physician-attire-possible-source-nosocomial-infections
July 01, 2016 - Study
Nursing and physician attire as possible source of nosocomial infections.
Citation Text:
Wiener-Well Y, Galuty M, Rudensky B, et al. Nursing and physician attire as possible source of nosocomial infections. Am J Infect Control. 2011;39(7):555-9. doi:10.1016/j.ajic.2010.12.016.
…
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psnet.ahrq.gov/issue/patterns-and-predictors-medication-discrepancies-primary-care
October 19, 2022 - Study
Patterns and predictors of medication discrepancies in primary care.
Citation Text:
Coletti DJ, Stephanou H, Mazzola N, et al. Patterns and predictors of medication discrepancies in primary care. J Eval Clin Pract. 2015;21(5):831-9. doi:10.1111/jep.12387.
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psnet.ahrq.gov/issue/factors-influencing-perioperative-nurses-error-reporting-preferences
June 23, 2010 - Study
Factors influencing perioperative nurses' error reporting preferences.
Citation Text:
Espin S, Regehr G, Levinson W, et al. Factors influencing perioperative nurses' error reporting preferences. AORN J. 2007;85(3):527-43.
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psnet.ahrq.gov/issue/wrong-site-craniotomy-analysis-35-cases-and-systems-prevention
November 16, 2022 - Study
Wrong-site craniotomy: analysis of 35 cases and systems for prevention.
Citation Text:
Cohen FL, Mendelsohn D, Bernstein M. Wrong-site craniotomy: analysis of 35 cases and systems for prevention. J Neurosurg. 2010;113(3):461-73. doi:10.3171/2009.10.JNS091282.
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psnet.ahrq.gov/issue/what-prevents-incident-disclosure-and-what-can-be-done-promote-it
February 20, 2012 - Study
What prevents incident disclosure, and what can be done to promote it?
Citation Text:
Iedema R, Allen S, Sorensen R, et al. What prevents incident disclosure, and what can be done to promote it? Jt Comm J Qual Patient Saf. 2011;37(9):409-417.
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G…
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psnet.ahrq.gov/issue/improving-acceptance-computerized-prescribing-alerts-ambulatory-care
July 10, 2008 - Study
Improving acceptance of computerized prescribing alerts in ambulatory care.
Citation Text:
Shah N, Seger AC, Seger DL, et al. Improving acceptance of computerized prescribing alerts in ambulatory care. J Am Med Inform Assoc. 2006;13(1):5-11.
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psnet.ahrq.gov/issue/reporting-hazards-and-near-misses-ambulatory-care-setting
October 19, 2011 - Study
Reporting of hazards and near-misses in the ambulatory care setting.
Citation Text:
Schnall R, Bakken S. Reporting of hazards and near-misses in the ambulatory care setting. J Nurs Care Qual. 2011;26(4):328-334. doi:10.1097/NCQ.0b013e3182109204.
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…
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psnet.ahrq.gov/issue/explicitly-addressing-implicit-bias-inpatient-rounds-student-and-faculty-reflections
November 11, 2020 - Commentary
Explicitly addressing implicit bias on inpatient rounds: student and faculty reflections.
Citation Text:
Carter RG, Lake S. Explicitly addressing implicit bias on inpatient rounds: student and faculty reflections. Pediatrics. 2023;151(5). doi:10.1542/peds.2023-061585.
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