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psnet.ahrq.gov/node/45190/psn-pdf
February 15, 2017 - Biases in detection of apparent "weekend effect" on
outcome with administrative coding data: population
based study of stroke.
February 15, 2017
Li L, Rothwell PM, Study OV. Biases in detection of apparent "weekend effect" on outcome with
administrative coding data: population based study of stroke. BMJ. 2016;353:…
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psnet.ahrq.gov/issue/medical-errors-mandatory-reporting-voluntary-reporting-or-both
February 28, 2024 - Commentary
Medical errors: mandatory reporting, voluntary reporting, or both?
Citation Text:
Grepperud S. Medical Errors: Mandatory Reporting, Voluntary Reporting, or Both? European Journal of Law and Economics. 2005;20(1). doi:10.1007/s10657-005-1019-8.
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psnet.ahrq.gov/sites/default/files/2024-08/spotlight_case_a_fatal_twist_in_pseudohyperkalemia_slides.pptx
January 01, 2024 - Spotlight
Spotlight
A Fatal Twist in Pseudohyperkalemia
1
Source and Credits
This presentation is based on the August 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Justin L. Devera, MD, David K. Barnes, MD, FACEP, and William R. Le…
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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/right-left-neither
November 16, 2022 - SPOTLIGHT CASE
Right? Left? Neither!
Citation Text:
Chassin MR, Howell EA. Right? Left? Neither!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/node/40725/psn-pdf
October 16, 2012 - Association of ICU or hospital admission with
unintentional discontinuation of medications for chronic
diseases.
October 16, 2012
Bell CM, Brener SS, Gunraj N, et al. Association of ICU or hospital admission with unintentional
discontinuation of medications for chronic diseases. JAMA. 2011;306(8):840-7.
doi:10.10…
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psnet.ahrq.gov/issue/discontinuity-and-disaster-gaps-and-negotiation-culpability-medication-delivery
June 24, 2020 - Commentary
Discontinuity and disaster: gaps and the negotiation of culpability in medication delivery.
Citation Text:
Dekker SWA. Discontinuity and disaster: gaps and the negotiation of culpability in medication delivery. J Law Med Ethics. 2007;35(3):463-70.
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psnet.ahrq.gov/issue/strategies-learning-failure
September 25, 2024 - Commentary
Classic
Strategies for learning from failure.
Citation Text:
Edmondson A. Strategies of learning from failure. Harv Bus Rev. 2011;89(4):48-55, 137.
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psnet.ahrq.gov/issue/patient-safety-7
November 16, 2015 - Book/Report
Patient Safety.
Citation Text:
Patient Safety. Sixth Report of Session 2008–09. House of Commons Health Committee. London, England: The Stationery Office; July 3, 2009. Publication HC 151-I.
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psnet.ahrq.gov/issue/nurses-role-patient-safety
June 09, 2011 - Commentary
Nurses' role in patient safety.
Citation Text:
Hughes RG, Clancy CM. Nurses' role in patient safety. J Nurs Care Qual. 2009;24(1):1-4. doi:10.1097/NCQ.0b013e31818f55c7.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote …
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psnet.ahrq.gov/issue/systematic-review-incidence-and-characteristics-preventable-adverse-drug-events-ambulatory
July 15, 2010 - Review
Systematic review of the incidence and characteristics of preventable adverse drug events in ambulatory care.
Citation Text:
Thomsen LA, Winterstein AG, S⊘ndergaard B, et al. Systematic Review of the Incidence and Characteristics of Preventable Adverse Drug Events in Ambulatory …
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psnet.ahrq.gov/issue/nursing-student-errors-and-near-misses-three-years-data
October 20, 2021 - Study
Nursing student errors and near misses: three years of data.
Citation Text:
Silvestre JH, Spector ND. Nursing student errors and near misses: three years of data. J Nurs Educ. 2023;62(1):12-19. doi:10.3928/01484834-20221109-05.
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psnet.ahrq.gov/issue/ambulance-stretcher-adverse-events
March 23, 2011 - Study
Ambulance stretcher adverse events.
Citation Text:
Wang HE, Weaver MD, Abo BN, et al. Ambulance stretcher adverse events. Qual Saf Health Care. 2009;18(3):213-216. doi:10.1136/qshc.2007.024562.
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psnet.ahrq.gov/node/38956/psn-pdf
March 18, 2015 - Safety in Doses.
March 18, 2015
London, UK: National Patient Safety Agency; 2009. ISBN: 9781906624088.
https://psnet.ahrq.gov/issue/safety-doses
This publication analyzes 72,482 medication incidents reported to the National Health Service and
highlights areas for improvement and prevention.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/41998/psn-pdf
January 30, 2013 - Involving Patients in Improving Safety.
January 30, 2013
London, UK: The Health Foundation; January 2013.
https://psnet.ahrq.gov/issue/involving-patients-improving-safety
This review analyzes research on engaging patients in safety improvement and details which strategies are
most effective.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/39591/psn-pdf
March 21, 2016 - Annual Benchmarking Report: Malpractice Risks in
Surgery.
March 21, 2016
Cambridge, MA: CRICO/RMF Strategies; 2010.
https://psnet.ahrq.gov/issue/annual-benchmarking-report-malpractice-risks-surgery
Analyzing data from 3300 surgical malpractice cases, this report describes errors across the continuum of
surgical c…
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psnet.ahrq.gov/node/37765/psn-pdf
May 24, 2015 - The Rebecca O'Malley Report.
May 24, 2015
Cork, Ireland: Health Information and Quality Authority; March 21, 2008.
https://psnet.ahrq.gov/issue/rebecca-omalley-report
This report analyzes the findings of a diagnostic error investigation and provides numerous
recommendations to improve standards for treating sympto…
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psnet.ahrq.gov/node/37560/psn-pdf
March 28, 2018 - Learning from Investigations.
March 28, 2018
Commission for Healthcare Audit and Inspection. London, England; Healthcare Commission: 2008. ISBN
9781845621636.
https://psnet.ahrq.gov/issue/learning-investigations
Analyzing health care failures from 2004-2007 in the United Kingdom, this report identifies common them…
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psnet.ahrq.gov/issue/using-six-sigma-reduce-medication-errors-home-delivery-pharmacy-service
November 18, 2015 - Study
Using Six Sigma to reduce medication errors in a home-delivery pharmacy service.
Citation Text:
Castle L, Franzblau-Isaac E, Paulsen J. Using Six Sigma to reduce medication errors in a home-delivery pharmacy service. Jt Comm J Qual Patient Saf. 2005;31(6):319-24.
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psnet.ahrq.gov/issue/complication-rates-weekends-and-weekdays-us-hospitals
August 31, 2011 - Study
Complication rates on weekends and weekdays in US hospitals.
Citation Text:
Bendavid E, Kaganova Y, Needleman J, et al. Complication rates on weekends and weekdays in US hospitals. Am J Med. 2007;120(5):422-8.
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