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psnet.ahrq.gov/issue/can-patient-involvement-improve-patient-safety-cluster-randomised-control-trial-patient
December 21, 2016 - Study
Classic
Can patient involvement improve patient safety? A cluster randomised control trial of the Patient Reporting and Action for a Safe Environment (PRASE) intervention.
Citation Text:
Lawton R, O'Hara JK, Sheard L, et al. Can patient involvement improve…
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psnet.ahrq.gov/issue/tackling-ambulatory-safety-risks-through-patient-engagement-what-10000-patients-and-families
March 20, 2017 - Study
Tackling ambulatory safety risks through patient engagement: what 10,000 patients and families say about safety-related knowledge, behaviors, and attitudes after reading visit notes.
Citation Text:
Bell SK, Folcarelli P, Fossa A, et al. Tackling Ambulatory Safety Risks Through Pati…
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psnet.ahrq.gov/issue/evaluation-medium-term-consequences-implementing-commercial-computerized-physician-order
December 21, 2022 - Study
Evaluation of medium-term consequences of implementing commercial computerized physician order entry and clinical decision support prescribing systems in two 'early adopter' hospitals.
Citation Text:
Cresswell K, Bates DW, Williams R, et al. Evaluation of medium-term consequences o…
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psnet.ahrq.gov/issue/national-cluster-randomized-trial-duty-hour-flexibility-surgical-training
September 09, 2015 - Study
Classic
National cluster-randomized trial of duty-hour flexibility in surgical training.
Citation Text:
Bilimoria KY, Chung JW, Hedges L, et al. National Cluster-Randomized Trial of Duty-Hour Flexibility in Surgical Training. New Engl J Med. 2016;374(8):71…
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psnet.ahrq.gov/issue/coronavirus-disease-2019-covid-19-pandemic-central-line-associated-bloodstream-infection
June 22, 2022 - Study
Coronavirus disease 2019 (COVID-19) pandemic, central-line-associated bloodstream infection (CLABSI), and catheter-associated urinary tract infection (CAUTI): the urgent need to refocus on hardwiring prevention efforts.
Citation Text:
Fakih MG, Bufalino A, Sturm L, et al. Coronavir…
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psnet.ahrq.gov/issue/clinical-characteristics-and-short-term-outcomes-acute-kidney-injury-missed-diagnosis-older
April 20, 2022 - Study
Clinical characteristics and short-term outcomes of acute kidney injury missed diagnosis in older patients with severe COVID-19 in intensive care unit.
Citation Text:
Li Q, Hu P, Kang H, et al. Clinical characteristics and short-term outcomes of acute kidney injury missed diagnosis…
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psnet.ahrq.gov/issue/association-between-unmet-nonmedication-needs-after-hospital-discharge-and-readmission-or
September 23, 2020 - Study
Association between unmet nonmedication needs after hospital discharge and readmission or death among acute respiratory failure survivors: a multicenter prospective cohort study.
Citation Text:
Bose S, Groat D, Dinglas VD, et al. Association between unmet nonmedication needs after …
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psnet.ahrq.gov/issue/situ-simulation-tool-longitudinally-identify-and-track-latent-safety-threats-structured
June 08, 2022 - Study
In situ simulation as a tool to longitudinally identify and track latent safety threats in a structured quality improvement initiative for SARS-CoV-2 airway management: a single-center study.
Citation Text:
Jafri FN, Yang CJ, Kumar A, et al. In situ simulation as a tool to longitud…
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psnet.ahrq.gov/issue/high-reliability-organization-framework-health-care-multiyear-implementation-strategy-and
November 17, 2021 - Study
A high-reliability organization framework for health care: a multiyear implementation strategy and associated outcomes.
Citation Text:
Sculli GL, Pendley-Louis R, Neily J, et al. A high-reliability organization framework for health care: a multiyear implementation strategy and asso…
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psnet.ahrq.gov/issue/high-prevalence-medication-discrepancies-between-home-health-referrals-and-centers-medicare
December 23, 2011 - Study
High prevalence of medication discrepancies between home health referrals and Centers for Medicare and Medicaid Services home health certification and plan of care and their potential to affect safety of vulnerable elderly adults.
Citation Text:
Brody AA, Gibson B, Tresner-Kirsch D…
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psnet.ahrq.gov/issue/do-medical-inpatients-who-report-poor-service-quality-experience-more-adverse-events-and
July 14, 2021 - Study
Classic
Do medical inpatients who report poor service quality experience more adverse events and medical errors?
Citation Text:
Taylor BB, Marcantonio ER, Pagovich O, et al. Do medical inpatients who report poor service quality experience more adverse ev…
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psnet.ahrq.gov/issue/physician-intent-pharmacy-label-prevalence-and-description-discrepancies-cross-sectional
July 22, 2020 - Study
From physician intent to the pharmacy label: prevalence and description of discrepancies from a cross-sectional evaluation of electronic prescriptions.
Citation Text:
Cochran GL, Klepser DG, Morien M, et al. From physician intent to the pharmacy label: prevalence and description o…
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psnet.ahrq.gov/issue/can-patient-safety-incident-reports-be-used-compare-hospital-safety-results-quantitative
October 31, 2014 - Study
Can patient safety incident reports be used to compare hospital safety? Results from a quantitative analysis of the English National Reporting and Learning System data.
Citation Text:
Howell A-M, Burns EM, Bouras G, et al. Can Patient Safety Incident Reports Be Used to Compare Hosp…
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psnet.ahrq.gov/web-mm/critical-opportunity-lost
February 17, 2017 - Critical Opportunity Lost
Citation Text:
Genzen JR, Signorelli HN. Critical Opportunity Lost. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/node/49517/psn-pdf
August 01, 2006 - Miscalculated Risk
August 1, 2006
Strassels SA. Miscalculated Risk. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/miscalculated-risk
The Case
A healthy 36-year-old man was admitted to a teaching hospital for acute low back strain after lifting his 2-
week-old infant. He received Vicodin (hydrocodone and a…
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psnet.ahrq.gov/node/33775/psn-pdf
December 01, 2014 - African Partnerships for Patient Safety: Lessons Learned
December 1, 2014
Syed SS. African Partnerships for Patient Safety: Lessons Learned. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/african-partnerships-patient-safety-lessons-learned
Perspective
In the last 6 years I have had the privilege of sha…
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psnet.ahrq.gov/node/49466/psn-pdf
October 14, 2004 - Hard to Swallow
October 1, 2004
Driver J. Hard to Swallow. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/hard-swallow
The Case
An elderly man underwent hernia surgery. Postoperatively, the patient developed a transient ischemic
attack (TIA) and respiratory difficulties. The nurses noted that the patient, …
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psnet.ahrq.gov/node/33816/psn-pdf
October 01, 2016 - In Conversation With… Richard Platt, MD, MSc
October 1, 2016
In Conversation With… Richard Platt, MD, MSc. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-richard-platt-md-msc
Editor's note: Dr. Platt is Professor and Chair of the Harvard Medical School Department of Population
Medicine. He…
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psnet.ahrq.gov/node/49718/psn-pdf
January 01, 2015 - Too Much, Too Fast
September 1, 2014
Tuot D. Too Much, Too Fast. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/too-much-too-fast
The Case
A 68-year-old man with amyotrophic lateral sclerosis (ALS) was admitted to the intensive care unit (ICU) for
fever, tachycardia, and increased respiratory secretions. H…
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psnet.ahrq.gov/web-mm/feeling-no-pain
August 30, 2023 - Feeling No Pain
Citation Text:
Bogner MS. Feeling No Pain. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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