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psnet.ahrq.gov/topics-0
March 03, 2025 - Topics
Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content. The Patient Safety 101 Primer provides an overview of the patient safety field and covers key definitions and concepts.
Featured Topics in Patient Safety
Updated Date: March 3, 2025
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psnet.ahrq.gov/node/37016/psn-pdf
September 15, 2011 - Postoperative complications due to a retained surgical
sponge.
September 15, 2011
Sarda AK, Pandey D, Neogi S, et al. Postoperative complications due to a retained surgical sponge.
Singapore Med J. 2007;48(6):e160-4.
https://psnet.ahrq.gov/issue/postoperative-complications-due-retained-surgical-sponge
The authors…
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psnet.ahrq.gov/issue/busy-day-effect-perinatal-complications-delivery-weekends-retrospective-cohort-study
January 16, 2019 - Study
A 'busy day' effect on perinatal complications of delivery on weekends: a retrospective cohort study.
Citation Text:
Snowden JM, Kozhimannil KB, Muoto I, et al. A 'busy day' effect on perinatal complications of delivery on weekends: a retrospective cohort study. BMJ Qual Saf. 2017;…
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psnet.ahrq.gov/node/49539/psn-pdf
June 01, 2007 - anesthesia and suffered the adverse outcome of
permanent unilateral hearing loss with tinnitus, an unusual complication … discussion
took place; it does not absolve the clinician or the hospital from potential liability if a complication
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psnet.ahrq.gov/node/73130/psn-pdf
January 01, 2022 - Improving peripherally inserted central catheter
appropriateness and reducing device-related
complications: a quasiexperimental study in 52 Michigan
hospitals.
April 14, 2021
Chopra V, O'Malley M, Horowitz J, et al. Improving peripherally inserted central catheter appropriateness
and reducing device-related compl…
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psnet.ahrq.gov/node/37358/psn-pdf
January 02, 2017 - Reducing surgical complications.
January 2, 2017
Griffin F. Reducing surgical complications. Jt Comm J Qual Patient Saf. 2007;33(11):660-5.
https://psnet.ahrq.gov/issue/reducing-surgical-complications
The author supports the Institute for Healthcare Improvement’s 5 Million Lives Campaign by
recommending several ch…
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psnet.ahrq.gov/node/33751/psn-pdf
January 01, 2014 - but it has traditionally rewarded hospitals for poor outcomes by
assigning patients who develop a complication … to a higher paying diagnosis related group (DRG), whether
or not the complication was preventable.
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psnet.ahrq.gov/perspective/health-care-acquired-urinary-tract-infection-problem-and-solutions
November 01, 2008 - reason of the initial admission, they had forgotten—because they spent most of their time dealing with complication … after complication. … Even if you leave aside the infectious complication, I would argue that the noninfectious complications … In part, it depends upon what complication we're trying to tackle.
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psnet.ahrq.gov/node/49798/psn-pdf
July 01, 2017 - group, fellowship-trained gastroenterologists are prepared to perform routine colonoscopies
with low complication
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psnet.ahrq.gov/node/35773/psn-pdf
March 15, 2006 - The association between hospital characteristics and
rates of preventable complications and adverse events.
March 15, 2006
Thornlow DK; Stukenborg GJ.
https://psnet.ahrq.gov/issue/association-between-hospital-characteristics-and-rates-preventable-
complications-and-adverse
Using the Agency for Healthcare Research…
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psnet.ahrq.gov/web-mm/delay-treatment-failure-contact-patient-leads-significant-complications
February 01, 2004 - SPOTLIGHT CASE
Delay in Treatment: Failure to Contact Patient Leads to Significant Complications
Citation Text:
Shapiro DS. Delay in Treatment: Failure to Contact Patient Leads to Significant Complications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departmen…
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psnet.ahrq.gov/issue/rate-occult-specimen-provenance-complications-routine-clinical-practice
January 05, 2012 - Study
Rate of occult specimen provenance complications in routine clinical practice.
Citation Text:
Pfeifer JD, Liu J. Rate of occult specimen provenance complications in routine clinical practice. Am J Clin Pathol. 2013;139(1):93-100. doi:10.1309/AJCP50WEZHWIFCIV.
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F…
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psnet.ahrq.gov/issue/complications-and-death-start-new-academic-year-there-july-phenomenon
February 13, 2008 - Study
Complications and death at the start of the new academic year: is there a July phenomenon?
Citation Text:
Inaba K, Recinos G, Teixeira PGR, et al. Complications and death at the start of the new academic year: is there a July phenomenon? J Trauma. 2010;68(1):19-22. doi:10.1097/TA.…
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psnet.ahrq.gov/issue/medication-errors-and-patient-complications-continuous-renal-replacement-therapy
June 25, 2009 - Study
Medication errors and patient complications with continuous renal replacement therapy.
Citation Text:
Barletta JF, Barletta G-M, Brophy PD, et al. Medication errors and patient complications with continuous renal replacement therapy. Pediatr Nephrol. 2006;21(6):842-5.
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psnet.ahrq.gov/node/38620/psn-pdf
January 03, 2017 - Hospital complications: linking payment reduction to
preventability.
January 3, 2017
Averill RE, Hughes JS, Goldfield NI, et al. Hospital complications: linking payment reduction to
preventability. Jt Comm J Qual Patient Saf. 2009;35(5):283-5.
https://psnet.ahrq.gov/issue/hospital-complications-linking-payment-red…
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psnet.ahrq.gov/node/42584/psn-pdf
September 11, 2013 - Cardiac surgical ICU care: eliminating "preventable"
complications.
September 11, 2013
Shake JG, Pronovost P, Whitman GJR. Cardiac surgical ICU care: eliminating "preventable" complications.
J Card Surg. 2013;28(4):406-13. doi:10.1111/jocs.12124.
https://psnet.ahrq.gov/issue/cardiac-surgical-icu-care-eliminating-p…
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psnet.ahrq.gov/web-mm/management-csf-leaks-after-elective-spine-surgery-routine-laminectomy-leads-fatal-discitis
March 09, 2022 - MD, Richard Price, MD, PhD, Kee D Kim, MD Introduction Cerebrospinal fluid (CSF) leaks are a serious complication … supplement to other measures. 73 However, lumbar subarachnoid drainage has been reported to have a complication
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psnet.ahrq.gov/node/41182/psn-pdf
February 29, 2012 - Medicare study finds teaching hospitals have higher risk
of complications; findings disputed.
February 29, 2012
Rau J. Washington Post. February 12, 2012:A03.
https://psnet.ahrq.gov/issue/medicare-study-finds-teaching-hospitals-have-higher-risk-complications-
findings-disputed
This news article describes problems…
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psnet.ahrq.gov/node/49504/psn-pdf
March 01, 2006 - But is location a factor in the
occurrence of the complication reported in the aforementioned case?
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psnet.ahrq.gov/issue/patient-safety-dilemma-obesity-surgical-patient
October 29, 2012 - Study
A patient safety dilemma: obesity in the surgical patient.
Citation Text:
Goode V, Phillips E, DeGuzman P, et al. A Patient Safety Dilemma: Obesity in the Surgical Patient. AANA J. 2016;84(6):404-412.
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