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psnet.ahrq.gov/node/41679/psn-pdf
April 17, 2013 - However, there were no differences in health care–associated infection
rates compared with non-CHAIPI
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psnet.ahrq.gov/node/46378/psn-pdf
April 16, 2018 - study, trainees performed worse in two simulated patient emergencies when they were
sleep deprived compared
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psnet.ahrq.gov/node/46048/psn-pdf
July 05, 2017 - study identified longer than expected length of stay for urgent
surgical procedures on the weekend compared
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psnet.ahrq.gov/node/41561/psn-pdf
August 01, 2012 - built on earlier research to examine rates of adverse events reported to state-level reporting
systems compared
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psnet.ahrq.gov/node/74113/psn-pdf
September 15, 2015 - Compared to white patients,
Black patients were less likely to receive pain medication for moderate
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psnet.ahrq.gov/node/46669/psn-pdf
January 17, 2018 - interchange are more likely to have errors in medication
reconciliation at the time of hospital discharge compared
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psnet.ahrq.gov/node/46891/psn-pdf
December 21, 2018 - Studies have demonstrated worse clinical outcomes for patients admitted to the hospital on weekends
compared
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psnet.ahrq.gov/node/45102/psn-pdf
May 18, 2016 - injury found that hospital length of stay and
mortality were higher among patients taking warfarin compared
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psnet.ahrq.gov/node/866168/psn-pdf
January 02, 2000 - approximately 2% were mistakenly discharged from
the ED; these patients had a higher risk of death compared
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psnet.ahrq.gov/node/35929/psn-pdf
February 24, 2011 - that patients who are most comfortable with error prevention were more likely to take specific
action compared
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psnet.ahrq.gov/node/44614/psn-pdf
November 04, 2015 - effect is a well-documented phenomenon where patients admitted over the weekend have
inferior outcomes compared
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psnet.ahrq.gov/node/867849/psn-pdf
February 26, 2025 - High Reliability Organization (HRO) Principles and Patient
Safety
February 26, 2025
Vogus T, Lee M, Mossburg SE. High Reliability Organization (HRO) Principles and Patient Safety. PSNet
[internet]. 2025.
https://psnet.ahrq.gov/perspective/high-reliability-organization-hro-principles-and-patient-safety
In To Err I…
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psnet.ahrq.gov/web-mm/check-anesthesia-machine
August 01, 2006 - Check the Anesthesia Machine
Citation Text:
Saddawi-Konefka D, Cooper JB. Check the Anesthesia Machine. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML End…
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psnet.ahrq.gov/node/74253/psn-pdf
January 12, 2022 - Patient Safety Events and the Role of Patient Safety
Organizations During the COVID-19 Pandemic
January 12, 2022
Dickman R, Sharma P, Higgins D, et al. Patient Safety Events and the Role of Patient Safety Organizations
During the COVID-19 Pandemic. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/patient…
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psnet.ahrq.gov/node/49484/psn-pdf
June 01, 2005 - Two Pills, Same Drug
June 1, 2005
Horsky J, Patel VL. Two Pills, Same Drug. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/two-pills-same-drug
The Case
A 34-year-old woman with AIDS developed a fever and hypotension due to suspected pneumonia. Her past
medical history included several AIDS-related complica…
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psnet.ahrq.gov/node/49492/psn-pdf
November 01, 2005 - Reconciling Doses
November 1, 2005
Federico F. Reconciling Doses. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/reconciling-doses
Case Objectives
List the steps involved in medication reconciliation.
Describe the role of each of the stakeholders in medication reconciliation.
Discuss how medication reconc…
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psnet.ahrq.gov/node/49576/psn-pdf
January 01, 2009 - To Transfer or Not to Transfer
January 1, 2009
Pines JM. To Transfer or Not to Transfer. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/transfer-or-not-transfer
Case Objectives
Explore the benefits of the continuity of hospital care.
Understand the rules and regulations behind triage and hospital choice de…
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psnet.ahrq.gov/node/49607/psn-pdf
August 01, 2010 - Missed Patient Assignment: Is Anyone There?
August 1, 2010
Sittig DF, Campbell EM, Singh H. Missed Patient Assignment: Is Anyone There? PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/missed-patient-assignment-anyone-there
The Case
In one hospital, nurses' patient assignments were communicated by listing the…
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psnet.ahrq.gov/web-mm/over-not-so-easy
April 01, 2005 - Over Not So Easy
Citation Text:
Cucina R. Over Not So Easy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/node/33650/psn-pdf
May 01, 2007 - Patient Safety in the United Kingdom: Evolution and
Progress
May 1, 2007
Burnett S, Vincent CA. Patient Safety in the United Kingdom: Evolution and Progress. PSNet [internet].
2007.
https://psnet.ahrq.gov/perspective/patient-safety-united-kingdom-evolution-and-progress
Perspective
The dangers of health care in B…