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psnet.ahrq.gov/node/49664/psn-pdf
January 01, 2013 - Empty Handoff
September 1, 2012
Goldman A, Catchpole K. Empty Handoff. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/empty-handoff
The Case
A 29-year-old man with "brittle diabetes" was admitted to the surgery service for incision and drainage of a
leg wound. The patient's medical history included chronic…
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psnet.ahrq.gov/web-mm/pathologic-mistake
February 15, 2010 - Pathologic Mistake
Citation Text:
Alaghehbandan R, Raab SS. Pathologic Mistake. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/web-mm/impact-communication-medication-errors
August 01, 2009 - The Impact of Communication on Medication Errors
Citation Text:
Branch J, Hiner D, Jackson V. The Impact of Communication on Medication Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/node/49720/psn-pdf
December 01, 2014 - A Stroke of Error
December 1, 2014
Barrett KM. A Stroke of Error. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/stroke-error
Case Objectives
State the key clinical factors to assess in a patient with suspected stroke.
Appreciate the relationship between elevated blood pressure and stroke in the acute sett…
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psnet.ahrq.gov/node/848110/psn-pdf
April 26, 2023 - Failure to Ensure Patient Safety Leads to Patient Falls in
Nursing Homes.
April 26, 2023
Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/failure-ensure-patient-safety-leads-patient-falls-nursing-homes
Disclosure of Relevant Financial R…
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psnet.ahrq.gov/issue/toolkit-decolonization-non-icu-patients-devices
November 15, 2023 - Toolkit
Toolkit for Decolonization of Non-ICU Patients with Devices.
Citation Text:
Agency for Healthcare Research and Quality. Toolkit for Decolonization of Non-ICU Patients with Devices.
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psnet.ahrq.gov/issue/preventing-and-managing-impact-anesthesia-awareness
May 27, 2020 - Sentinel Event Alerts
Preventing, and managing the impact of, anesthesia awareness.
Citation Text:
Preventing, and managing the impact of, anesthesia awareness. Sentinel Event Alert. 2004;32:1-3.
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psnet.ahrq.gov/node/46424/psn-pdf
March 20, 2018 - Electronic triggers to identify delays in follow-up of
mammography: harnessing the power of big data in
health care.
March 20, 2018
Murphy DR, Meyer AND, Vaghani V, et al. Electronic Triggers to Identify Delays in Follow-Up of
Mammography: Harnessing the Power of Big Data in Health Care. J Am Coll Radiol. 2018;15(…
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psnet.ahrq.gov/node/46985/psn-pdf
July 02, 2019 - The impact of automated notification on follow-up of
actionable tests pending at discharge: a cluster-
randomized controlled trial.
July 2, 2019
Dalal A, Schaffer A, Gershanik EF, et al. The Impact of Automated Notification on Follow-up of Actionable
Tests Pending at Discharge: a Cluster-Randomized Controlled Tria…
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psnet.ahrq.gov/node/43264/psn-pdf
June 18, 2014 - CDC central-line bloodstream infection prevention efforts
produced net benefits of at least $640 million during
1990–2008.
June 18, 2014
Scott D, Sinkowitz-Cochran R, Wise ME, et al. CDC central-line bloodstream infection prevention efforts
produced net benefits of at least $640 Million during 1990-2008. Health Af…
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psnet.ahrq.gov/issue/tackling-disrespectful-unprofessional-provider-behaviors
January 13, 2021 - Newspaper/Magazine Article
Tackling disrespectful, unprofessional provider behaviors.
Citation Text:
Tackling Disrespectful, Unprofessional Provider Behaviors. ED Manage. 2016;28(6):S1-S4.
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psnet.ahrq.gov/issue/jcahos-safety-goals-clock-ticking-will-your-ed-be-compliant
April 10, 2019 - Commentary
JCAHO's safety goals—the clock is ticking, will your ED be compliant?
Citation Text:
JCAHO's safety goals--the clock is ticking, will your ED be compliant? ED Manag. 2005;17(7):73-5.
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psnet.ahrq.gov/node/41187/psn-pdf
October 16, 2012 - A pharmacist-led information technology intervention for
medication errors (PINCER): a multicentre, cluster
randomised, controlled trial and cost-effectiveness
analysis.
October 16, 2012
Avery A, Rodgers S, Cantrill JA, et al. A pharmacist-led information technology intervention for medication
errors (PINCER): a …
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psnet.ahrq.gov/node/42472/psn-pdf
August 07, 2013 - Anticoagulant medication errors in nursing homes:
characteristics, causes, outcomes, and association with
patient harm.
August 7, 2013
Desai RJ, Williams CE, Greene SB, et al. Anticoagulant medication errors in nursing homes:
characteristics, causes, outcomes, and association with patient harm. J Healthc Risk Mana…
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psnet.ahrq.gov/node/48168/psn-pdf
July 24, 2019 - Changes in hospital safety following penalties in the US
Hospital Acquired Condition Reduction Program:
retrospective cohort study.
July 24, 2019
Sankaran R, Sukul D, Nuliyalu U, et al. Changes in hospital safety following penalties in the US Hospital
Acquired Condition Reduction Program: retrospective cohort stud…
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psnet.ahrq.gov/node/41223/psn-pdf
March 21, 2012 - High-profile investigations into hospital safety problems
in England did not prompt patients to switch providers.
March 21, 2012
Laverty AA, Smith PC, Pape UJ, et al. High-profile investigations into hospital safety problems in England
did not prompt patients to switch providers. Health Aff (Millwood). 2012;31(3):5…
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psnet.ahrq.gov/node/39948/psn-pdf
December 21, 2014 - Wrong-site and wrong-patient procedures in the Universal
Protocol era: analysis of a prospective database of
physician self-reported occurrences.
December 21, 2014
Stahel PF, Sabel A, Victoroff MS, et al. Wrong-site and wrong-patient procedures in the universal protocol
era: analysis of a prospective database of p…
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psnet.ahrq.gov/node/41461/psn-pdf
April 05, 2013 - Residents' response to duty-hour regulations—a follow-
up national survey.
April 5, 2013
Drolet BC, Christopher DA, Fischer SA. Residents' response to duty-hour regulations--a follow-up national
survey. N Engl J Med. 2012;366(24):e35. doi:10.1056/NEJMp1202848.
https://psnet.ahrq.gov/issue/residents-response-duty-h…
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psnet.ahrq.gov/node/39620/psn-pdf
September 20, 2011 - The relationship between patients' perception of care and
measures of hospital quality and safety.
September 20, 2011
Isaac T, Zaslavsky AM, Cleary PD, et al. The relationship between patients' perception of care and
measures of hospital quality and safety. Health Serv Res. 2010;45(4):1024-40. doi:10.1111/j.1475-
…
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psnet.ahrq.gov/node/46027/psn-pdf
July 02, 2019 - Dissecting Leapfrog: how well do Leapfrog Safe Practices
Scores correlate with Hospital Compare ratings and
penalties, and how much do they matter?
July 2, 2019
Smith SN, Reichert HA, Ameling JM, et al. Dissecting Leapfrog: How Well Do Leapfrog Safe Practices
Scores Correlate With Hospital Compare Ratings and Pena…