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psnet.ahrq.gov/node/43711/psn-pdf
November 26, 2014 - The impact of hospital-acquired conditions on Medicare
program payments.
November 26, 2014
Kandilov AMG, Coomer NM, Dalton K. The impact of hospital-acquired conditions on Medicare program
payments. Medicare Medicaid Res Rev. 2014;4(4). doi:10.5600/mmrr.004.04.a01.
https://psnet.ahrq.gov/issue/impact-hospital-acqu…
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psnet.ahrq.gov/node/43547/psn-pdf
July 03, 2016 - Health care-associated infections among critically ill
children in the US, 2007-2012.
July 3, 2016
Patrick SW, Kawai AT, Kleinman K, et al. Health care-associated infections among critically ill children in
the US, 2007-2012. Pediatrics. 2014;134(4):705-712. doi:10.1542/peds.2014-0613.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/38429/psn-pdf
February 03, 2011 - Methicillin-resistant Staphylococcus aureus central
line–associated bloodstream infections in US intensive
care units, 1997-2007.
February 3, 2011
Burton DC, Edwards JR, Horan TC, et al. Methicillin-resistant Staphylococcus aureus central line-
associated bloodstream infections in US intensive care units, 1997-200…
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psnet.ahrq.gov/issue/toolkit-reducing-central-line-associated-blood-stream-infections
October 01, 2024 - Toolkit
Toolkit for Reducing Central Line-Associated Blood Stream Infections.
Citation Text:
Agency for Healthcare Research and Quality. Toolkit for Reducing Central Line-Associated Blood Stream Infections. March 2023.
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psnet.ahrq.gov/issue/eliminating-central-line-associated-bloodstream-infections-national-patient-safety-imperative
March 21, 2012 - Study
Eliminating central line-associated bloodstream infections: a national patient safety imperative.
Citation Text:
Berenholtz SM, Lubomski LH, Weeks K, et al. Eliminating central line-associated bloodstream infections: a national patient safety imperative. Infect Control Hosp Epidem…
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psnet.ahrq.gov/web-mm/departure-central-line-ritual
October 13, 2018 - Departure From Central Line Ritual
Citation Text:
Ballard DW, Vinson DR, Mark DG. Departure From Central Line Ritual. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/node/39641/psn-pdf
September 20, 2011 - Adherence to Surgical Care Improvement Project
measures and the association with postoperative
infections.
September 20, 2011
Stulberg JJ, Delaney CP, Neuhauser D, et al. Adherence to surgical care improvement project measures
and the association with postoperative infections. JAMA. 2010;303(24):2479-85.
doi:10.1…
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psnet.ahrq.gov/node/37791/psn-pdf
September 29, 2017 - Controversy and quality improvement: lingering
questions about ethics, oversight, and patient safety
research.
September 29, 2017
Kass N, Pronovost P, Sugarman J, et al. Controversy and quality improvement: lingering questions about
ethics, oversight, and patient safety research. Jt Comm J Qual Patient Saf. 2008;3…
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psnet.ahrq.gov/node/37613/psn-pdf
March 12, 2008 - Implementing patient safety interventions in your
hospital: what to try and what to avoid.
March 12, 2008
Ranji SR, Shojania KG. Implementing patient safety interventions in your hospital: what to try and what to
avoid. Med Clin North Am. 2008;92(2):275-93, vii-viii. doi:10.1016/j.mcna.2007.10.007.
https://psnet.a…
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psnet.ahrq.gov/node/38359/psn-pdf
May 27, 2010 - A surgical safety checklist to reduce morbidity and
mortality in a global population.
May 27, 2010
Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a
global population. N Engl J Med. 2009;360(5):491-9. doi:10.1056/NEJMsa0810119.
https://psnet.ahrq.gov/issue/su…
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psnet.ahrq.gov/node/37768/psn-pdf
April 27, 2010 - The wisdom and justice of not paying for "preventable
complications."
April 27, 2010
Pronovost P, Goeschel CA, Wachter R. The wisdom and justice of not paying for "preventable
complications". JAMA. 2008;299(18):2197-9. doi:10.1001/jama.299.18.2197.
https://psnet.ahrq.gov/issue/wisdom-and-justice-not-paying-prevent…
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psnet.ahrq.gov/node/44388/psn-pdf
October 14, 2015 - Implementation of the Centers for Medicare & Medicaid
Services' nonpayment policy for preventable hospital-
acquired conditions in rural and nonrural US hospitals.
October 14, 2015
Bae S-H, Yoder LH. Implementation of the Centers for Medicare & Medicaid Services' Nonpayment Policy
for Preventable Hospital-Acquired…
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psnet.ahrq.gov/issue/building-culture-safety-health-care
April 15, 2021 - Book/Report
Building a Culture of Safety in Health Care.
Citation Text:
Building a Culture of Safety in Health Care. Chicago, IL: American Hospital Association: May 2023.
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psnet.ahrq.gov/issue/save-lives-clean-your-hands
July 14, 2021 - Multi-use Website
World Hand Hygiene Day.
Citation Text:
World Hand Hygiene Day. World Health Organization
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psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-occult-hemothorax-following-complicated-central-line
April 01, 2008 - Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest
Citation Text:
Raff G, Goudy B. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest. PSNet [internet]. Rockvil…
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psnet.ahrq.gov/node/42853/psn-pdf
January 15, 2014 - Eliminating central line-associated bloodstream
infections: a national patient safety imperative.
January 15, 2014
Berenholtz SM, Lubomski LH, Weeks K, et al. Eliminating central line-associated bloodstream infections: a
national patient safety imperative. Infect Control Hosp Epidemiol. 2014;35(1):56-62. doi:10.108…
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psnet.ahrq.gov/issue/aspen-parenteral-nutrition-safety-summit
February 17, 2015 - Special or Theme Issue
ASPEN Parenteral Nutrition Safety Summit.
Citation Text:
ASPEN Parenteral Nutrition Safety Summit. Andris DA, Mirtallo JM, Guenter P, eds. JPEN J Parenter Enteral Nutr. 2012;36(2 Suppl):1S-62S.
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psnet.ahrq.gov/issue/nurse-accidentally-kills-premature-son-swine-flu-victim-spain
July 17, 2013 - Newspaper/Magazine Article
Nurse accidentally kills premature son of swine flu victim in Spain.
Citation Text:
Nurse accidentally kills premature son of swine flu victim in Spain. Tremlett G. Guardian.co.uk; July 13, 2009.
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psnet.ahrq.gov/node/49734/psn-pdf
May 01, 2015 - Departure From Central Line Ritual
May 1, 2015
Ballard DW, Vinson DR, Mark DG. Departure From Central Line Ritual. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/departure-central-line-ritual
The Case
A 55-year-old man with a history of poorly controlled diabetes mellitus, pancreatic insufficiency, and alco…
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psnet.ahrq.gov/node/33751/psn-pdf
January 01, 2014 - Strengthening the Business Case for Patient Safety
May 1, 2013
Lindenauer PK. Strengthening the Business Case for Patient Safety. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/strengthening-business-case-patient-safety
Perspective
After more than a decade in the national spotlight, the problem of pati…