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psnet.ahrq.gov/issue/measuring-impact-medication-related-interventions-30-day-readmission-rates-skilled-nursing
July 29, 2020 - Study
Measuring the impact of medication-related interventions on 30-day readmission rates in a skilled nursing facility.
Citation Text:
Amin PB, Bradford CD, Rizos AL, et al. Measuring the Impact of Medication-Related Interventions on 30-Day Readmission Rates in a Skilled Nursing Facili…
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psnet.ahrq.gov/issue/patient-and-physician-perspectives-deprescribing-potentially-inappropriate-medications-older
March 09, 2022 - Study
Patient and physician perspectives of deprescribing potentially inappropriate medications in older adults with a history of falls: a qualitative study.
Citation Text:
Hahn EE, Munoz-Plaza CE, Lee EA, et al. Patient and physician perspectives of deprescribing potentially inappropria…
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psnet.ahrq.gov/node/38729/psn-pdf
April 15, 2019 - CHPSO.
April 15, 2019
1215 K Street, Suite 800, Sacramento, CA 95814.
https://psnet.ahrq.gov/issue/chpso
This Website offers tools, a newsletter focusing on lessons learned from error reports, a set of specialized
checklists, and a detailed resource collection to support patient safety organization (PSO) efforts i…
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psnet.ahrq.gov/issue/development-and-pilot-evaluation-preoperative-briefing-protocol-cardiovascular-surgery
September 27, 2016 - Study
Development and pilot evaluation of a preoperative briefing protocol for cardiovascular surgery.
Citation Text:
Henrickson SE, Wadhera RK, Elbardissi AW, et al. Development and pilot evaluation of a preoperative briefing protocol for cardiovascular surgery. J Am Coll Surg. 2009;20…
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psnet.ahrq.gov/issue/disruptions-surgical-flow-and-their-relationship-surgical-errors-exploratory-investigation
August 26, 2011 - Study
Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation.
Citation Text:
Wiegmann DA, Elbardissi AW, Dearani JA, et al. Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation. Surgery. 2007;…
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psnet.ahrq.gov/issue/actions-needed-improve-newly-enrolled-veterans-access-primary-care
September 07, 2016 - Government Resource
Actions Needed to Improve Newly Enrolled Veterans' Access to Primary Care.
Citation Text:
Actions Needed to Improve Newly Enrolled Veterans' Access to Primary Care. Washington, DC: United States Government Accountability Office; March 18, 2016. Publication GAO-16-328.…
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psnet.ahrq.gov/issue/evaluation-registered-nurse-competency-processes-veterans-health-administration-facilities
April 26, 2006 - Book/Report
Evaluation of Registered Nurse Competency Processes in Veterans Health Administration Facilities.
Citation Text:
Evaluation of Registered Nurse Competency Processes in Veterans Health Administration Facilities. Washington, DC: VA Office of Inspector General; April 20, 201…
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psnet.ahrq.gov/issue/identifying-factors-leading-harm-english-general-practices-mixed-methods-study-based-patient
June 01, 2016 - Study
Identifying factors leading to harm in English general practices: a mixed-methods study based on patient experiences integrating structural equation modeling and qualitative content analysis.
Citation Text:
Ricci-Cabello I, Gangannagaripalli J, Mounce LTA, et al. Identifying Factor…
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psnet.ahrq.gov/issue/self-reported-medical-medication-and-laboratory-error-eight-countries-risk-factors
September 19, 2012 - Study
Self-reported medical, medication and laboratory error in eight countries: risk factors for chronically ill adults.
Citation Text:
Scobie A. Self-reported medical, medication and laboratory error in eight countries: risk factors for chronically ill adults. Int J Qual Health Care. 2…
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psnet.ahrq.gov/node/49638/psn-pdf
January 01, 2012 - Communication Failure—Who's in Charge?
October 1, 2011
Fackler J, Schwartz JM. Communication Failure—Who's in Charge? PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/communication-failure-whos-charge
The Case
A 20-month-old boy was admitted to the intensive care unit (ICU) following a Fontan surgical procedu…
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psnet.ahrq.gov/node/39111/psn-pdf
November 18, 2009 - Safe Use Initiative.
November 18, 2009
Food and Drug Administration
https://psnet.ahrq.gov/issue/safe-use-initiative
This Web site supports a coordinated effort to reduce preventable medication-related errors through cross-
sector interventions.
https://psnet.ahrq.gov/issue/safe-use-initiative
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psnet.ahrq.gov/node/50928/psn-pdf
February 21, 2020 - In 2020, the
Office of the National Coordinator for Health Information Technology (ONC) is expected
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psnet.ahrq.gov/node/60543/psn-pdf
May 27, 2020 - Office of the National Coordinator for Health Information Technology.
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psnet.ahrq.gov/perspective/updates-role-health-it-patient-safety
January 31, 2020 - In 2020, the Office of the National Coordinator for Health Information Technology (ONC) is expected to
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psnet.ahrq.gov/web-mm/case-patient-flow-management
February 23, 2019 - Bernheim Project Coordinator Institute for Healthcare Optimization References 1. Sentinel Event.
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psnet.ahrq.gov/node/867237/psn-pdf
December 04, 2024 - Morbidity and mortality: delays in my patient’s cancer
care.
December 4, 2024
Rahman AS. Morbidity and mortality: delays in my patient’s cancer care. Health Aff (Millwood).
2024;43(11):1605-1608. doi:10.1377/hlthaff.2024.00513.
https://psnet.ahrq.gov/issue/morbidity-and-mortality-delays-my-patients-cancer-care
Sy…
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psnet.ahrq.gov/node/845658/psn-pdf
June 08, 2023 - Simulation Articles of Influence.
June 8, 2023
Society for Simulation in Healthcare. 2017-2023.
https://psnet.ahrq.gov/issue/simulation-articles-influence
Simulation can be used to reveal teamwork coordination gaps and latent factors that contribute to failure.
This article collection has been curated by experts i…
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psnet.ahrq.gov/node/35301/psn-pdf
December 01, 2022 - Guiding Principles to Achieve Continuity in Medication
Management.
December 1, 2022
Department of Health and Aged Care. Canberra ACT: Commonwealth of Australia; 2022. ISBN 978-1-
76007-471-5.
https://psnet.ahrq.gov/issue/guiding-principles-achieve-continuity-medication-management
Originally published in 2005, the…
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psnet.ahrq.gov/node/847734/psn-pdf
April 19, 2023 - Patient safety tools for primary care.
April 19, 2023
Domdera J. Fam Pract Manag. 2023;30(2):24-28.
https://psnet.ahrq.gov/issue/patient-safety-tools-primary-care
A large segment of patients receives outpatient care. This commentary suggests that high-reliability
concepts be applied in the primary care environment…
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psnet.ahrq.gov/node/60858/psn-pdf
August 26, 2020 - When the Meds Don’t Reach the Bed
August 26, 2020
Molla M, Le K, Mendoza P. When the Meds Don’t Reach the Bed. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/when-meds-dont-reach-bed
The Case
A 69-year-old man with cognitive impairment and marginal housing was admitted for acute exacerbation of
chronic obs…