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psnet.ahrq.gov/issue/medicare-study-finds-teaching-hospitals-have-higher-risk-complications-findings-disputed
June 01, 2016 - Newspaper/Magazine Article 
 
 
 
 
 
 
 
 
 
 Medicare study finds teaching hospitals have higher risk of complications; findings disputed.   
 
 
 
 
 Citation Text: 
 Medicare study finds teaching hospitals have higher risk of complications; findings disputed.   Rau J. Washington Post. February 12, 2012:A03.   
 Cop… 
                                     
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psnet.ahrq.gov/node/35169/psn-pdf
July 13, 2005 - Lay use of lasers fueling complications.
July 13, 2005
Gagnon L. Dermatology Times. June 1, 2005.
https://psnet.ahrq.gov/issue/lay-use-lasers-fueling-complications
This article reports on inappropriate laser use by non-physicians for dermatological procedures. A study
presented at the American Society for Laser Me… 
                                     
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psnet.ahrq.gov/issue/better-surgeons-notes-performance
February 06, 2018 - Book/Report 
 
 
 
 
 
 
 
 
 
 Better: A Surgeon's Notes on Performance.  
 
 
 
 
 Citation Text: 
 Better: A Surgeon's Notes on Performance.  Gawande A. New York, NY: Metropolitan; 2007. 
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psnet.ahrq.gov/issue/feds-stop-public-disclosure-many-serious-hospital-errors
September 17, 2014 - Newspaper/Magazine Article 
 
 
 
 
 
 
 
 
 
 Feds stop public disclosure of many serious hospital errors. 
 
 
 
 
 Citation Text: 
 Feds stop public disclosure of many serious hospital errors. O'Donnell J. 
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.14_slideshow.ppt
May 01, 2003 - PowerPoint Presentation
Spotlight Case May 2003
Central Line Complications in an Infant
webmm.ahrq.gov
Source and Credits
	This presentation is based on the May 2003 
AHRQ WebM&M Spotlight Case in Pediatrics 
	See the full article at http://webmm.ahrq.gov  
	CME credit is available through the Web site
	Commentary… 
                                     
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psnet.ahrq.gov/sites/default/files/2023-06/under_pressure.pdf
January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_Under Pressure.pptx
Spotlight
Under Pressure: Tracheostomy Cuff Over Inflation 
Leading to Tissue Necrosis and Cuff Rupture
Source and Credits
• This presentation is based on the June 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm… 
                                     
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psnet.ahrq.gov/node/43745/psn-pdf
December 17, 2014 - Identifying hospital-wide harm: a set of ICD-9–CM-coded
conditions associated with increased cost, length of stay,
and risk of mortality.
December 17, 2014
Bankowitz RA, Doyle B, Duan M, et al. Identifying hospital-wide harm: a set of ICD-9-CM-coded conditions
associated with increased cost, length of stay, and ri… 
                                     
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psnet.ahrq.gov/node/43434/psn-pdf
August 06, 2014 - Maryland hospitals aren't reporting all errors and
complications, experts say.
August 6, 2014
Cohn M.
https://psnet.ahrq.gov/issue/maryland-hospitals-arent-reporting-all-errors-and-complications-experts-say
This news article reports weaknesses in a Maryland reporting program, including poor understanding about
wh… 
                                     
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psnet.ahrq.gov/issue/miles-go-introduction-5-million-lives-campaign
April 04, 2011 - Commentary 
 
 
 
 
 
 
 
 
 
 Miles to go: an introduction to the 5 Million Lives Campaign. 
 
 
 
 
 Citation Text: 
 McCannon J, Hackbarth AD, Griffin F. Miles to go: an introduction to the 5 Million Lives Campaign. Jt Comm J Qual Patient Saf. 2007;33(8):477-84. 
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psnet.ahrq.gov/node/33847/psn-pdf
August 01, 2017 - psnet.ahrq.gov/perspective/conversation-john-d-birkmeyer-md
https://psnet.ahrq.gov/issue/surgical-skill-and-complication-rates-after-bariatric-surgery
                                     
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psnet.ahrq.gov/node/45825/psn-pdf
March 25, 2017 - A patient safety dilemma: obesity in the surgical patient.
March 25, 2017
Goode V, Phillips E, DeGuzman P, et al. A Patient Safety Dilemma: Obesity in the Surgical Patient. AANA
J. 2016;84(6):404-412.
https://psnet.ahrq.gov/issue/patient-safety-dilemma-obesity-surgical-patient
Postoperative complications are key m… 
                                     
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psnet.ahrq.gov/node/38854/psn-pdf
August 12, 2009 - Implementation of resident work hour restrictions is
associated with a reduction in mortality and provider-
related complications on the surgical service: a
concurrent analysis of 14,610 patients.
August 12, 2009
Privette AR, Shackford SR, Osler T, et al. Implementation of resident work hour restrictions is associ… 
                                     
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psnet.ahrq.gov/issue/electronic-health-record-based-triggers-detect-adverse-events-after-outpatient-orthopaedic
December 19, 2017 - Study 
 
 
 
 
 
 
 
 
 
 Electronic health record-based triggers to detect adverse events after outpatient orthopaedic surgery. 
 
 
 
 
 Citation Text: 
 Menendez ME, Janssen SJ, Ring D. Electronic health record-based triggers to detect adverse events after outpatient orthopaedic surgery. BMJ Qual Saf. 2016;25(1):25-… 
                                     
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psnet.ahrq.gov/issue/report-card-system-using-error-profile-analysis-and-concurrent-morbidity-and-mortality-review
June 18, 2008 - Study 
 
 
 
 
 
 
 
 
 
 A report card system using error profile analysis and concurrent morbidity and mortality review: surgical outcome analysis, part II.   
 
 
 
 
 Citation Text: 
 Antonacci AC, Lam S, Lavarias V, et al. A report card system using error profile analysis and concurrent morbidity and mortality rev… 
                                     
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psnet.ahrq.gov/issue/morbidity-and-mortality-conference-based-classification-system-adverse-events-surgical
January 28, 2009 - Study 
 
 
 
 
 
 
 
 
 
 A morbidity and mortality conference-based classification system for adverse events: surgical outcome analysis: part I.   
 
 
 
 
 Citation Text: 
 Antonacci AC, Lam S, Lavarias V, et al. A morbidity and mortality conference-based classification system for adverse events: surgical outcome ana… 
                                     
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psnet.ahrq.gov/node/45943/psn-pdf
March 15, 2017 - Identifying and reducing complications after emergency
room discharge.
March 15, 2017
Hofmann PB, Bagian JP. Patient Saf Qual Healthc. February 20, 2017.
https://psnet.ahrq.gov/issue/identifying-and-reducing-complications-after-emergency-room-discharge
Emergency departments are complex environments that harbor fac… 
                                     
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psnet.ahrq.gov/node/74112/psn-pdf
April 14, 2017 - Structural racism and health inequities in the USA:
evidence and interventions.
April 14, 2017
Bailey ZD, Krieger N, Agénor M, et al. Structural racism and health inequities in the USA: evidence and
interventions. Lancet. 2017;389(10077):1453-1463. doi:10.1016/s0140-6736(17)30569-x.
https://psnet.ahrq.gov/issue/st… 
                                     
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psnet.ahrq.gov/node/38731/psn-pdf
April 30, 2014 - Preventable morbidity at a mature trauma center.
April 30, 2014
Teixeira PGR, Inaba K, Salim A, et al. Arch Surg. 2009;144(6):536-541.
https://psnet.ahrq.gov/issue/preventable-morbidity-mature-trauma-center
Patient safety in trauma poses unique challenges given the acuity of the patients and the need for rapid
ass… 
                                     
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psnet.ahrq.gov/node/47741/psn-pdf
March 06, 2019 - Association of overlapping surgery with perioperative
outcomes.
March 6, 2019
Sun E, Mello MM, Rishel CA, et al. Association of Overlapping Surgery With Perioperative Outcomes.
JAMA. 2019;321(8):762-772. doi:10.1001/jama.2019.0711.
https://psnet.ahrq.gov/issue/association-overlapping-surgery-perioperative-outcomes… 
                                     
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psnet.ahrq.gov/issue/more-750-hospitals-face-medicare-crackdown-patient-injuries
June 27, 2018 - Newspaper/Magazine Article 
 
 
 
 
 
 
 
 
 
 More than 750 hospitals face Medicare crackdown on patient injuries. 
 
 
 
 
 Citation Text: 
 More than 750 hospitals face Medicare crackdown on patient injuries. Rau J. Kaiser Health News. June 22, 2014. 
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