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psnet.ahrq.gov/node/50614/psn-pdf
October 30, 2019 - You avoid injury to the lung—that
dreaded complication of pneumothorax.
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psnet.ahrq.gov/node/40538/psn-pdf
January 11, 2013 - Patient Safety Measures: Complications.
January 11, 2013
Washington, DC: National Quality Forum; December 2012.
https://psnet.ahrq.gov/issue/patient-safety-measures-complications
This Web site provides information about patient safety measures endorsed by the National Quality Forum.
https://psnet.ahrq.gov/issue/pa…
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psnet.ahrq.gov/node/60681/psn-pdf
January 01, 2022 - Failure to rescue deteriorating patients: a systematic
review of root causes and improvement strategies.
July 16, 2020
Burke JR, Downey C, Almoudaris AM. Failure to rescue deteriorating patients: a systematic review of root
causes and improvement strategies. J Patient Saf. 2022;18(1):e140-e155.
doi:10.1097/pts.000…
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psnet.ahrq.gov/issue/impact-date-stamping-patient-safety-measurement-patients-undergoing-cabg-experience-ahrq
December 21, 2014 - Study
Impact of date stamping on patient safety measurement in patients undergoing CABG: experience with the AHRQ Patient Safety Indicators.
Citation Text:
Glance LG, Li Y, Osler T, et al. Impact of date stamping on patient safety measurement in patients undergoing CABG: experience wit…
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psnet.ahrq.gov/web-mm/central-line-clot
August 04, 2021 - The majority of thrombotic episodes in the pediatric population occur as a complication of central venous
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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/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/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/primers-0
March 15, 2025 - Primers
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.
Latest Primers
Clinical Decision Support Systems
March…
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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/assessment-healthcare-professionals-knowledge-managing-emergency-complications-patients
March 14, 2018 - Slideset
Assessment of healthcare professionals' knowledge of managing emergency complications in patients with a tracheostomy.
Citation Text:
Casserly P, Lang E, Fenton JE, et al. Assessment of healthcare professionals' knowledge of managing emergency complications in patients with a …
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psnet.ahrq.gov/issue/adverse-events-medicine-easy-count-complicated-understand-and-complex-prevent
July 15, 2009 - Commentary
Adverse events in medicine: easy to count, complicated to understand, and complex to prevent.
Citation Text:
Amalberti R, Benhamou D, Auroy Y, et al. Adverse events in medicine: easy to count, complicated to understand, and complex to prevent. J Biomed Inform. 2011;44(3):390…
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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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Format:
Google Scholar Pub…
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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…