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psnet.ahrq.gov/issue/association-changing-hospital-readmission-rates-mortality-rates-after-hospital-discharge
August 20, 2018 - Study
Classic
Association of changing hospital readmission rates with mortality rates after hospital discharge.
Citation Text:
Dharmarajan K, Wang Y, Lin Z, et al. Association of Changing Hospital Readmission Rates With Mortality Rates After Hospital Discharge. …
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psnet.ahrq.gov/issue/are-teaching-hospitals-treated-fairly-hospital-acquired-condition-reduction-program
July 11, 2018 - Study
Are teaching hospitals treated fairly in the Hospital-Acquired Condition Reduction Program?
Citation Text:
Mohajer MA, Joiner KA, Nix DE. Are Teaching Hospitals Treated Fairly in the Hospital-Acquired Condition Reduction Program? Acad Med. 2018;93(12):1827-1832. doi:10.1097/ACM.000…
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psnet.ahrq.gov/issue/what-has-been-impact-covid-19-safety-culture-case-study-large-metropolitan-teaching-hospital
May 05, 2021 - Study
What has been the impact of Covid-19 on safety culture? A case study from a large metropolitan healthcare trust.
Citation Text:
Denning M, Goh ET, Scott A, et al. What has been the impact of Covid-19 on safety culture? A case study from a large metropolitan healthcare trust. Int J …
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psnet.ahrq.gov/issue/single-room-hospital-accommodation-associated-differences-healthcare-associated-infection
June 21, 2016 - Study
Is single room hospital accommodation associated with differences in healthcare-associated infection, falls, pressure ulcers or medication errors? A natural experiment with non-equivalent controls.
Citation Text:
Simon M, Maben J, Murrells T, et al. Is single room hospital accommod…
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psnet.ahrq.gov/issue/characteristics-initial-prescription-episodes-and-likelihood-long-term-opioid-use-united
April 24, 2018 - Study
Classic
Characteristics of initial prescription episodes and likelihood of long-term opioid use—United States, 2006–2015.
Citation Text:
Shah A, Hayes CJ, Martin BC. Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use - …
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psnet.ahrq.gov/issue/dissecting-leapfrog-how-well-do-leapfrog-safe-practices-scores-correlate-hospital-compare
September 19, 2012 - Study
Classic
Dissecting Leapfrog: how well do Leapfrog Safe Practices Scores correlate with Hospital Compare ratings and penalties, and how much do they matter?
Citation Text:
Smith SN, Reichert HA, Ameling JM, et al. Dissecting Leapfrog: How Well Do Leapfrog S…
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psnet.ahrq.gov/issue/do-variations-hospital-mortality-patterns-after-weekend-admission-reflect-reduced-quality
April 12, 2019 - Study
Classic
Do variations in hospital mortality patterns after weekend admission reflect reduced quality of care or different patient cohorts? A population-based study.
Citation Text:
Concha OP, Gallego B, Hillman K, et al. Do variations in hospital mortality …
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psnet.ahrq.gov/issue/arrival-ambulance-explains-variation-mortality-time-admission-retrospective-study-admissions
January 29, 2018 - Study
Classic
Arrival by ambulance explains variation in mortality by time of admission: retrospective study of admissions to hospital following emergency department attendance in England.
Citation Text:
Anselmi L, Meacock R, Kristensen SR, et al. Arrival by amb…
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psnet.ahrq.gov/issue/development-evidence-based-framework-factors-contributing-patient-safety-incidents-hospital
June 25, 2014 - Review
Development of an evidence-based framework of factors contributing to patient safety incidents in hospital settings: a systematic review.
Citation Text:
Lawton R, McEachan RRC, Giles SJ, et al. Development of an evidence-based framework of factors contributing to patient safety …
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psnet.ahrq.gov/issue/identifying-patient-centred-recommendations-improving-patient-safety-general-practices
April 25, 2018 - Study
Identifying patient-centred recommendations for improving patient safety in General Practices in England: a qualitative content analysis of free-text responses using the Patient Reported Experiences and Outcomes of Safety in Primary Care (PREOS-PC) questionnaire.
Citation Text:
Ric…
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psnet.ahrq.gov/issue/effect-2011-vs-2003-duty-hour-regulation-compliant-models-sleep-duration-trainee-education
September 04, 2013 - Study
Effect of the 2011 vs 2003 duty hour regulation-compliant models on sleep duration, trainee education, and continuity of patient care among internal medicine house staff: a randomized trial.
Citation Text:
Desai SV, Feldman LS, Brown L, et al. Effect of the 2011 vs 2003 Duty Hour R…
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psnet.ahrq.gov/issue/national-incidence-medication-error-surgical-patients-and-after-accreditation-council
September 23, 2020 - Study
National incidence of medication error in surgical patients before and after Accreditation Council for Graduate Medical Education duty-hour reform.
Citation Text:
Vadera S, Griffith SD, Rosenbaum BP, et al. National Incidence of Medication Error in Surgical Patients Before and Afte…
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psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
January 04, 2024 - November 11, 2020
WebM&M Cases
A framework for assessing
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psnet.ahrq.gov/node/867656/psn-pdf
February 26, 2025 - Assessing the implementation of clinical process innovations: a cross-
case comparison.
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psnet.ahrq.gov/perspective/interpreting-patient-safety-literature
June 01, 2005 - For instance, various tools for assessing patient safety culture have been described in the literature
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psnet.ahrq.gov/perspective/count-and-be-counted-preparing-future-pharmacists-promote-culture-safety
April 01, 2006 - Typically, pharmacists spend little or no time assessing the patient for therapeutic or adverse drug
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psnet.ahrq.gov/perspective/conversation-chris-cebollero-bs-ccemt-p
May 26, 2021 - Leadership may be assessing challenges in their processes every year to 18 months, but a lot of the time
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psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd
June 01, 2005 - For instance, various tools for assessing patient safety culture have been described in the literature
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psnet.ahrq.gov/node/49459/psn-pdf
September 01, 2004 - Caution, Interrupted
September 1, 2004
Wears RL. Caution, Interrupted. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/caution-interrupted
The Case
A 55-year-old man with acute myelogenous leukemia and several recent hospitalizations for fever and
neutropenia presented to the emergency department (ED) with …
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psnet.ahrq.gov/node/72587/psn-pdf
December 23, 2020 - Mitigating the Risk of Intrahospital Transport for Pediatric
Patients at Risk of Physiologic Instability
December 23, 2020
Semkiw K, Anderson D, Natale JA. Mitigating the Risk of Intrahospital Transport for Pediatric Patients at
Risk of Physiologic Instability. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm…