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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43429/psn-pdf
    October 11, 2016 - CA sitting on millions in hospital fines. October 11, 2016 Clark C. https://psnet.ahrq.gov/issue/ca-sitting-millions-hospital-fines Although California has collected an estimated $15 million in penalties from hospitals for adverse events, this news piece describes how much of the money has yet to be allocated or s…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36417/psn-pdf
    April 12, 2011 - Excess mortality caused by medical injury. April 12, 2011 Meurer LN, Yang H, Guse CE, et al. Excess mortality caused by medical injury. Ann Fam Med. 2006;4(5):410-6. https://psnet.ahrq.gov/issue/excess-mortality-caused-medical-injury The authors describe a state-based review of discharge diagnoses to identify medi…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49786/psn-pdf
    March 01, 2017 - A bleeding risk index for estimating the probability of major bleeding in hospitalized patient starting
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42378/psn-pdf
    August 15, 2013 - Surgical adverse events: a systematic review. August 15, 2013 Anderson O, Davis R, Hanna GB, et al. Surgical adverse events: a systematic review. Am J Surg. 2013;206(2):253-62. doi:10.1016/j.amjsurg.2012.11.009. https://psnet.ahrq.gov/issue/surgical-adverse-events-systematic-review This systematic review estimates…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34919/psn-pdf
    February 25, 2009 - Changes in prognosis after the first postoperative complication. February 25, 2009 Silber JH, Rosenbaum PR, Trudeau ME, et al. Changes in prognosis after the first postoperative complication. Med Care. 2005;43(2):122-31. https://psnet.ahrq.gov/issue/changes-prognosis-after-first-postoperative-complication The aut…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36401/psn-pdf
    December 22, 2010 - Epidemiology of medication-related adverse events in nursing homes. December 22, 2010 Handler S, Wright RM, Ruby CM, et al. Epidemiology of medication-related adverse events in nursing homes. Am J Geriatr Pharmacother. 2006;4(3):264-72. https://psnet.ahrq.gov/issue/epidemiology-medication-related-adverse-events-nu…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43642/psn-pdf
    November 05, 2014 - Exploring the Costs of Unsafe Care in the NHS: A Report Prepared for the Department of Health. November 5, 2014 London, UK: Frontier Economics Ltd; October 2014. https://psnet.ahrq.gov/issue/exploring-costs-unsafe-care-nhs-report-prepared-department-health This report provides an overview of evidence on preventabl…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42648/psn-pdf
    October 09, 2013 - The cost of poor blood specimen quality and errors in preanalytical processes. October 9, 2013 Green SF. The cost of poor blood specimen quality and errors in preanalytical processes. Clin Biochem. 2013;46(13-14):1175-9. doi:10.1016/j.clinbiochem.2013.06.001. https://psnet.ahrq.gov/issue/cost-poor-blood-specimen-q…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47678/psn-pdf
    December 19, 2018 - When mistakes happen. December 19, 2018 Beck DL. ASH Clinical News. December 1, 2018. https://psnet.ahrq.gov/issue/when-mistakes-happen This article provides an overview of efforts to understand and improve patient safety and covers topics such as the epidemiology of error, its impact on the individuals involved, …
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45047/psn-pdf
    April 13, 2016 - Is misdiagnosis inevitable? April 13, 2016 Page L. Medscape Business of Medicine. March 28, 2016. https://psnet.ahrq.gov/issue/misdiagnosis-inevitable This news article reports on the prevalence of diagnostic error and describes characteristics that contribute to the problem, including insufficient clinician famil…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41758/psn-pdf
    October 10, 2012 - The Broselow tape as an effective medication dosing instrument: a review of the literature. October 10, 2012 Meguerdichian MJ, Clapper TC. The Broselow tape as an effective medication dosing instrument: a review of the literature. J Pediatr Nurs. 2012;27(4):416-420. doi:10.1016/j.pedn.2012.04.009. https://psnet.ah…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49785/psn-pdf
    February 01, 2017 - Refused Medication Error February 1, 2017 Foley M. Refused Medication Error. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/refused-medication-error The Case A 59-year-old man was admitted to the hospital with acute renal failure and mental status changes. He was alert to self and place only. The patient h…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49394/psn-pdf
    April 01, 2003 - Premature or Overdue? April 1, 2003 Thomas J, Hannah M. Premature or Overdue? PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/premature-or-overdue The Case A 32-year-old woman, gravida 3, para 1, presented for prenatal care at 24 weeks. Her past medical history was unremarkable, and results of her prenatal …
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47348/psn-pdf
    September 05, 2018 - Hospital-Acquired Condition Reduction Program (HACRP). September 5, 2018 QualityNet. Centers for Medicare and Medicaid Services. https://psnet.ahrq.gov/issue/hospital-acquired-condition-hac-reduction-program Eliminating hospital-acquired harm requires policy, organizational, and individual approaches to motivate …
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40642/psn-pdf
    July 27, 2011 - Prevalence of adverse drug events in ambulatory care: a systematic review. July 27, 2011 Taché S, Sönnichsen A, Ashcroft DM. Prevalence of adverse drug events in ambulatory care: a systematic review. Ann Pharmacother. 2011;45(7-8):977-89. doi:10.1345/aph.1P627. https://psnet.ahrq.gov/issue/prevalence-adverse-drug-…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43215/psn-pdf
    May 28, 2014 - When medical students make errors. May 28, 2014 https://psnet.ahrq.gov/issue/when-medical-students-make-errors This newspaper article highlights the need for medical students to be educated about how to disclose errors to patients and families when mistakes occur, even if the patient was not harmed. https://psnet.…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40416/psn-pdf
    June 27, 2018 - Reducing alarm hazards: selection and implementation of alarm notification systems. June 27, 2018 Gee T, Moorman BA. Patient Saf Qual Healthc. March/April 2011;8:14-17. https://psnet.ahrq.gov/issue/reducing-alarm-hazards-selection-and-implementation-alarm-notification- systems Highlighting dangers presented by al…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39991/psn-pdf
    November 02, 2011 - Measuring the cost of hospital adverse patient safety events. November 2, 2011 Carey K, Stefos T. Measuring the cost of hospital adverse patient safety events. Health Econ. 2011;20(12):1417-30. doi:10.1002/hec.1680. https://psnet.ahrq.gov/issue/measuring-cost-hospital-adverse-patient-safety-events This analysis o…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39783/psn-pdf
    August 25, 2010 - Ethics, oversight and quality improvement initiatives. August 25, 2010 Taylor HA, Pronovost PJ, Sugarman J. Ethics, oversight and quality improvement initiatives. Quality and Safety in Health Care. 2010;19(4). doi:10.1136/qshc.2009.038034. https://psnet.ahrq.gov/issue/ethics-oversight-and-quality-improvement-initia…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37533/psn-pdf
    April 22, 2011 - Systematic evaluation of errors occurring during the preparation of intravenous medication. April 22, 2011 Parshuram CS, To T, Seto W, et al. Systematic evaluation of errors occurring during the preparation of intravenous medication. CMAJ. 2008;178(1):42-8. doi:10.1503/cmaj.061743. https://psnet.ahrq.gov/issue/sys…

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