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psnet.ahrq.gov/node/45015/psn-pdf
July 18, 2016 - Interhospital transfer handoff practices among US tertiary
care centers: a descriptive survey.
July 18, 2016
Herrigel DJ, Carroll M, Fanning C, et al. Interhospital transfer handoff practices among US tertiary care
centers: A descriptive survey. J Hosp Med. 2016;11(6):413-7. doi:10.1002/jhm.2577.
https://psnet.ahr…
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psnet.ahrq.gov/node/44638/psn-pdf
May 18, 2016 - Developing an appreciation of patient safety: analysis of
interprofessional student experiences with health
mentors.
May 18, 2016
Langlois S. Developing an appreciation of patient safety: analysis of interprofessional student experiences
with health mentors. Perspect Med Educ. 2016;5(2):88-94. doi:10.1007/s40037-0…
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psnet.ahrq.gov/node/35048/psn-pdf
June 22, 2009 - Reduction in warfarin adverse events requiring patient
hospitalization after implementation of a pharmacist-
managed anticoagulation service.
June 22, 2009
Locke C, Ravnan SL, Patel R, et al. Reduction in warfarin adverse events requiring patient hospitalization
after implementation of a pharmacist-managed anticoa…
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psnet.ahrq.gov/node/43184/psn-pdf
May 14, 2014 - Often overlooked problems with handoffs: from the
intensive care unit to the operating room.
May 14, 2014
Evans AS, Yee M-S, Hogue CW. Often overlooked problems with handoffs: from the intensive care unit to
the operating room. Anesth Analg. 2014;118(3):687-9. doi:10.1213/ANE.0000000000000075.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/47055/psn-pdf
May 23, 2018 - Surgical checklists save lives—but once in a while, they
don't. Why?
May 23, 2018
Mukherjee S. New York Times Magazine. May 9, 2018.
https://psnet.ahrq.gov/issue/surgical-checklists-save-lives-once-while-they-dont-why
Checklists can coordinate action and communication to augment safety, but human and system factor…
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psnet.ahrq.gov/web-mm/intubation-mishap
April 26, 2023 - SPOTLIGHT CASE
Intubation Mishap
Citation Text:
Weinger MB, Blike G. Intubation Mishap. 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/web-mm/preventable-transfer-hospital
March 31, 2022 - Preventable Transfer to the Hospital
Citation Text:
Agrawal G, Kashkouli P, Bakerjian D. Preventable Transfer to the Hospital. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/node/33935/psn-pdf
February 05, 2018 - The incidence and severity of adverse events affecting
patients after discharge from the hospital.
February 5, 2018
Forster AJ, Murff HJ, Peterson JF, et al. The incidence and severity of adverse events affecting patients
after discharge from the hospital. Ann Intern Med. 2003;138(3):161-7.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/46217/psn-pdf
January 30, 2018 - Safer and more appropriate opioid prescribing: a large
healthcare system's comprehensive approach.
January 30, 2018
Losby JL, Hyatt JD, Kanter MH, et al. Safer and more appropriate opioid prescribing: a large healthcare
system's comprehensive approach. J Eval Clin Pract. 2017;23(6):1173-1179. doi:10.1111/jep.12756.…
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psnet.ahrq.gov/node/47205/psn-pdf
July 25, 2018 - Teamwork and Teamwork Training in Healthcare.
July 25, 2018
Teamwork and Teamwork Training in Health care: An Integration and a Path Forward. Buljac-Samardzic M,
Dekker-van Doorn C, Maynard MT, eds. Group Org Manag. 2018;43(3):351-527.
doi:10.1177/1059601118774669.
https://psnet.ahrq.gov/issue/teamwork-and-teamwor…
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psnet.ahrq.gov/node/37342/psn-pdf
December 23, 2012 - Toward higher-performance health systems: adults'
health care experiences in seven countries, 2007.
December 23, 2012
Schoen C, Osborn R, Doty M, et al. Toward higher-performance health systems: adults' health care
experiences in seven countries, 2007. Health Aff (Millwood). 2007;26(6):w717-734.
https://psnet.ahrq…
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psnet.ahrq.gov/node/47065/psn-pdf
June 20, 2018 - The complexity, diversity, and science of primary care
teams.
June 20, 2018
Fiscella K, McDaniel SH. The complexity, diversity, and science of primary care teams. Amer Psychol.
2018;73(4):451-467. doi:10.1037/amp0000244.
https://psnet.ahrq.gov/issue/complexity-diversity-and-science-primary-care-teams
Teamwork is …
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psnet.ahrq.gov/node/36529/psn-pdf
August 09, 2011 - 5 Million Lives Campaign.
August 9, 2011
Institute for Healthcare Improvement; IHI
https://psnet.ahrq.gov/issue/5-million-lives-campaign
The Institute for Healthcare Improvement's 100,000 Lives Campaign successfully engaged more than
3,000 US hospitals in a coordinated effort to reduce preventable inpatient deaths…
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psnet.ahrq.gov/node/46912/psn-pdf
March 28, 2018 - Ignoring the Alarms: How NHS Eating Disorder Services
Are Failing Patients.
March 28, 2018
London, UK: Parliamentary and Health Service Ombudsman; 2017. ISBN: 9781528601344.
https://psnet.ahrq.gov/issue/ignoring-alarms-how-nhs-eating-disorder-services-are-failing-patients
Patients with mental health conditions fac…
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psnet.ahrq.gov/node/46409/psn-pdf
November 08, 2017 - 'No one is coming': hospice patients abandoned at
death's door.
November 8, 2017
Aleccia J; Bailey M.
https://psnet.ahrq.gov/issue/no-one-coming-hospice-patients-abandoned-deaths-door
Patient safety in ambulatory hospice care is ill defined. Reporting on safety concerns associated with
hospice care, including poo…
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psnet.ahrq.gov/node/35112/psn-pdf
June 22, 2009 - Medication safety in older adults: home-based practice
patterns.
June 22, 2009
Metlay JP, Cohen A, Polsky D, et al. Medication safety in older adults: home-based practice patterns. J Am
Geriatr Soc. 2005;53(6):976-982.
https://psnet.ahrq.gov/issue/medication-safety-older-adults-home-based-practice-patterns
This s…
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psnet.ahrq.gov/node/44868/psn-pdf
June 17, 2016 - Patient safety and the problem of many hands.
June 17, 2016
Dixon-Woods M, Pronovost P. Patient safety and the problem of many hands. BMJ Qual Saf.
2016;25(7):485-488. doi:10.1136/bmjqs-2016-005232.
https://psnet.ahrq.gov/issue/patient-safety-and-problem-many-hands
Although individual and organizational accountabi…
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psnet.ahrq.gov/node/33925/psn-pdf
December 18, 2008 - Drug-related morbidity and mortality and the economic
impact of pharmaceutical care.
December 18, 2008
Johnson JA, Bootman JL. Drug-related morbidity and mortality and the economic impact of pharmaceutical
care. Am J Health Syst Pharm. 1997;54(5):554-8.
https://psnet.ahrq.gov/issue/drug-related-morbidity-and-morta…
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psnet.ahrq.gov/node/44901/psn-pdf
March 30, 2016 - Medication safety pharmacy technician in a large, tertiary
care, community hospital.
March 30, 2016
Brown KN, Bergsbaken J, Reichard JS. Medication safety pharmacy technician in a large, tertiary care,
community hospital. Am J Health Syst Pharm. 2016;73(4):188-191. doi:10.2146/ajhp150098.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/72566/psn-pdf
January 01, 2021 - Incidence, nature and causes of avoidable significant
harm in primary care in England: retrospective case note
review.
December 16, 2020
Avery AJ, Sheehan C, Bell BG, et al. Incidence, nature and causes of avoidable significant harm in primary
care in England: retrospective case note review. BMJ Qual Saf. 2021;30(…