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psnet.ahrq.gov/web-mm/painful-dilemma
September 01, 2013 - A Painful Dilemma
Citation Text:
Davison SN. A Painful Dilemma. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/innovation/remote-response-team-and-customized-alert-settings-help-improve-management-sepsis
February 26, 2025 - Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis
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May 31, 2023
Innovation
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psnet.ahrq.gov/web-mm/lost-black-hole
December 01, 2005 - Lost in the Black Hole
Citation Text:
Wachter R. Lost in the Black Hole. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/primer/discharge-planning-and-transitions-care
June 15, 2024 - Discharge Planning and Transitions of Care
Citation Text:
Bajorek SA, McElroy V. Discharge Planning and Transitions of Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/web-mm/vial-mistakes-involving-heparin
May 11, 2014 - Vial Mistakes Involving Heparin
Citation Text:
Vanderveen T. Vial Mistakes Involving Heparin. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/node/866848/psn-pdf
September 25, 2024 - In Conversation with Eric Thomas about Zero Harm:
Striving to Reduce Preventable Harms – Point,
Counterpoint, and Areas of Agreement
September 25, 2024
Thomas E, Mossburg S, Lee M. In Conversation with Eric Thomas about Zero Harm: Striving to Reduce
Preventable Harms – Point, Counterpoint, and Areas of Agreement. …
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psnet.ahrq.gov/node/866216/psn-pdf
July 10, 2024 - Health Plan Patient Safety Initiatives
July 10, 2024
Helwig A, Sousane Z, Mossburg S. Health Plan Patient Safety Initiatives. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/health-plan-patient-safety-initiatives
When we think of improving patient safety, we often think of strategies that can be implemen…
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psnet.ahrq.gov/web-mm/deciphering-code
November 16, 2022 - Deciphering the Code
Citation Text:
Goldstein MK. Deciphering the Code. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/web-mm/dropped-lung
February 06, 2012 - The Dropped Lung
Citation Text:
Heffner JR. The Dropped Lung. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/node/33665/psn-pdf
March 01, 2008 - During our first year, when use of the MPS was elective, we utilized these data to demonstrate that
complication
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psnet.ahrq.gov/node/40470/psn-pdf
December 21, 2014 - Prospective evaluation of consultant surgeon sleep
deprivation and outcomes in more than 4000 consecutive
cardiac surgical procedures.
December 21, 2014
Chu MWA, Stitt LW, Fox SA, et al. Prospective evaluation of consultant surgeon sleep deprivation and
outcomes in more than 4000 consecutive cardiac surgical proce…
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psnet.ahrq.gov/node/39959/psn-pdf
December 21, 2014 - Hospital process compliance and surgical outcomes in
Medicare beneficiaries.
December 21, 2014
Nicholas LH, Osborne NH, Birkmeyer JD, et al. Hospital process compliance and surgical outcomes in
medicare beneficiaries. Arch Surg. 2010;145(10):999-1004. doi:10.1001/archsurg.2010.191.
https://psnet.ahrq.gov/issue/hos…
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psnet.ahrq.gov/node/43524/psn-pdf
October 29, 2014 - Validating administrative data for the detection of adverse
events in older hospitalized patients.
October 29, 2014
Ackroyd-Stolarz S, Bowles SK, Giffin L. Validating administrative data for the detection of adverse events in
older hospitalized patients. Drug Healthc Patient Saf. 2014;6:101-8. doi:10.2147/DHPS.S643…
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psnet.ahrq.gov/node/43907/psn-pdf
April 27, 2015 - Association of hospital participation in a surgical
outcomes monitoring program with inpatient
complications and mortality.
April 27, 2015
Etzioni DA, Wasif N, Dueck AC, et al. Association of hospital participation in a surgical outcomes
monitoring program with inpatient complications and mortality. JAMA. 2015;313…
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psnet.ahrq.gov/node/38715/psn-pdf
February 17, 2011 - Medicare nonpayment, hospital falls, and unintended
consequences.
February 17, 2011
Inouye SK, Brown CJ, Tinetti ME. Medicare nonpayment, hospital falls, and unintended consequences. N
Engl J Med. 2009;360(23):2390-3. doi:10.1056/NEJMp0900963.
https://psnet.ahrq.gov/issue/medicare-nonpayment-hospital-falls-and-uni…
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psnet.ahrq.gov/node/45811/psn-pdf
May 08, 2017 - A National Web Conference on Improving Health IT Safety
Through the Use of Natural Language Processing to
Improve Accuracy of EHR Documentation.
May 8, 2017
Agency for Healthcare Research and Quality. February 7, 2017.
https://psnet.ahrq.gov/issue/national-web-conference-improving-health-it-safety-through-use-natu…
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psnet.ahrq.gov/node/43923/psn-pdf
April 29, 2015 - Implementation of a surgical safety checklist and
postoperative outcomes: a prospective randomized
controlled study.
April 29, 2015
Chaudhary N, Varma V, Kapoor S, et al. Implementation of a surgical safety checklist and postoperative
outcomes: a prospective randomized controlled study. J Gastrointest Surg. 2015;1…
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psnet.ahrq.gov/issue/getting-ahead-harm-it-happens-guide-about-proactive-analysis-improving-surgical-care-safety
November 30, 2016 - Book/Report
Getting Ahead of Harm Before It Happens: A Guide About Proactive Analysis for Improving Surgical Care Safety.
Citation Text:
Getting Ahead of Harm Before It Happens: A Guide About Proactive Analysis for Improving Surgical Care Safety. Wiley K, Davies JM. Edmonton, AB: Canadia…
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psnet.ahrq.gov/issue/medicare-cuts-payments-nursing-homes-whose-patients-keep-ending-hospital
June 27, 2018 - Newspaper/Magazine Article
Medicare cuts payments to nursing homes whose patients keep ending up in hospital.
Citation Text:
Medicare cuts payments to nursing homes whose patients keep ending up in hospital. Rau J. Kaiser Health News. December 3, 2018.
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psnet.ahrq.gov/issue/your-hospital-really-safe-you-think-our-updated-hospital-safety-score-can-help-you-find-out
November 23, 2016 - Newspaper/Magazine Article
Is your hospital really as safe as you think? Our updated hospital safety score can help you find out.
Citation Text:
Is your hospital really as safe as you think? Our updated hospital safety score can help you find out. Consumer Reports. March 27, 2014.
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