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psnet.ahrq.gov/issue/survey-nurses-beliefs-about-medical-emergency-team-system-canadian-tertiary-hospital
January 04, 2012 - adverse events and hospital performance on 30-day all-cause mortality and readmission for patients with heart … failure.
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psnet.ahrq.gov/issue/association-nurse-engagement-and-nurse-staffing-patient-safety
January 22, 2016 - 2022
The quality of hospital work environments and missed nursing care is linked to heart … failure readmissions: a cross-sectional study of US hospitals.
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psnet.ahrq.gov/issue/variability-measurement-hospital-wide-mortality-rates
July 01, 2016 - adverse events and hospital performance on 30-day all-cause mortality and readmission for patients with heart … failure.
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psnet.ahrq.gov/issue/potential-harms-resulting-patient-clinician-real-time-clinical-encounters-using-video-based
February 14, 2017 - the Hospital Readmissions Reduction Program implementation with readmission and mortality outcomes in heart … failure.
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psnet.ahrq.gov/issue/delayed-time-defibrillation-after-hospital-cardiac-arrest
June 08, 2010 - August 10, 2011
Effectiveness and cost of a transitional care program for heart failure
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psnet.ahrq.gov/issue/racial-disparities-frequency-patient-safety-events-results-national-medicare-patient-safety
December 18, 2014 - adverse events and hospital performance on 30-day all-cause mortality and readmission for patients with heart … failure.
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psnet.ahrq.gov/node/49563/psn-pdf
May 01, 2008 - https://psnet.ahrq.gov/web-mm/it-safe-be-direct
The Case
A 92-year-old man with hypertension and heart … failure (HF) was evaluated by his primary care physician
(PCP) for progressive shortness of breath
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psnet.ahrq.gov/node/60168/psn-pdf
March 25, 2020 - Right Electrocardiogram, Wrong Patient
March 25, 2020
Chen C, Venugopal S. Right Electrocardiogram, Wrong Patient. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/right-electrocardiogram-wrong-patient
The Cases
Multiple electrocardiograms (EKGs) were incorrectly documented at a large urban tertiary care hosp…
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psnet.ahrq.gov/issue/distractions-cardiac-catheterisation-laboratory-impact-cardiologists-and-patient-safety
June 07, 2023 - Study
Distractions in the cardiac catheterisation laboratory: impact for cardiologists and patient safety.
Citation Text:
Mahadevan K, Cowan E, Kalsi N, et al. Distractions in the cardiac catheterisation laboratory: impact for cardiologists and patient safety. Open Heart. 2020;7(2). doi:…
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psnet.ahrq.gov/issue/surgeon-reported-conflict-intensivists-about-postoperative-goals-care
September 26, 2012 - Study
Surgeon-reported conflict with intensivists about postoperative goals of care.
Citation Text:
Olson TJP, Brasel KJ, Redmann AJ, et al. Surgeon-reported conflict with intensivists about postoperative goals of care. JAMA Surg. 2013;148(1):29-35. doi:10.1001/jamasurgery.2013.403.
Co…
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psnet.ahrq.gov/issue/postoperative-handover-problems-pitfalls-and-prevention-error
September 26, 2012 - Image/Poster
Postoperative handover: problems, pitfalls, and prevention of error.
Citation Text:
Nagpal K, Arora S, Abboudi M, et al. Postoperative handover: problems, pitfalls, and prevention of error. Ann Surg. 2010;252(1):171-6. doi:10.1097/SLA.0b013e3181dc3656.
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…
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psnet.ahrq.gov/issue/advancing-health-equity-patient-safety-reckoning-challenge-and-opportunity
February 23, 2022 - Commentary
Advancing health equity in patient safety: a reckoning, challenge and opportunity.
Citation Text:
Chin MH. Advancing health equity in patient safety: a reckoning, challenge and opportunity. BMJ Qual Saf. 2021;30(5):356-361. doi:10.1136/bmjqs-2020-012599.
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Fo…
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psnet.ahrq.gov/issue/systems-approach-analyzing-and-preventing-hospital-adverse-events
March 30, 2022 - Study
Emerging Classic
A systems approach to analyzing and preventing hospital adverse events.
Citation Text:
Leveson N, Samost A, Dekker SWA, et al. A systems approach to analyzing and preventing hospital adverse events. J Patient Saf. 2020;16(2):162-167. doi:1…
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psnet.ahrq.gov/node/60039/psn-pdf
March 11, 2020 - A 25-year-old teacher died after waiting hours at the ER.
She's not the only one who saw delays.
March 11, 2020
Linnane R, Diedrich J. Milwaukee Journal Sentinel. February 25, 2020.
https://psnet.ahrq.gov/issue/25-year-old-teacher-died-after-waiting-hours-er-shes-not-only-one-who-saw-
delays
Delays in emergency r…
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psnet.ahrq.gov/node/866395/psn-pdf
July 23, 2024 - Rescue Improvement Conference Innovation Summary
July 23, 2024
https://psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary
Summary
The Rescue Improvement Conference (RIC)1 was designed at the University of Michigan to address failure
to rescue with a particular focus on communication and com…
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psnet.ahrq.gov/issue/my-patient-ready-safe-transfer-lower-intensity-care-setting-nursing-complexity-independent
April 26, 2023 - Study
Is my patient ready for a safe transfer to a lower-intensity care setting? Nursing complexity as an independent predictor of adverse events risk after ICU discharge.
Citation Text:
Sanson G, Marino C, Valenti A, et al. Is my patient ready for a safe transfer to a lower-intensity ca…
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psnet.ahrq.gov/issue/effect-hospital-wide-measure-readmissions-reduction-program
February 14, 2017 - Study
Effect of a hospital-wide measure on the readmissions reduction program.
Citation Text:
Zuckerman RB, Maddox KEJ, Sheingold SH, et al. Effect of a Hospital-wide Measure on the Readmissions Reduction Program. N Engl J Med. 2017;377(16):1551-1558. doi:10.1056/NEJMsa1701791.
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psnet.ahrq.gov/node/46911/psn-pdf
May 02, 2018 - Errors in electronic health record–based data query of
statin prescriptions in patients with coronary artery
disease in a large, academic, multispecialty clinic
practice.
May 2, 2018
Shin EY, Ochuko P, Bhatt K, et al. Errors in Electronic Health Record-Based Data Query of Statin
Prescriptions in Patients With Cor…
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psnet.ahrq.gov/issue/mortality-due-hospital-acquired-infection-after-cardiac-surgery
February 12, 2020 - Study
Mortality due to hospital-acquired infection after cardiac surgery.
Citation Text:
Massart N, Mansour A, Ross JT, et al. Mortality due to hospital-acquired infection after cardiac surgery. J Thorac Cardiovasc Surg. 2022;163(6):2131-2140.e3. doi:10.1016/j.jtcvs.2020.08.094.
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psnet.ahrq.gov/web-mm/perils-diagnosing-stroke
August 15, 2017 - Perils in Diagnosing a Stroke
Citation Text:
Schindler JL. Perils in Diagnosing a Stroke. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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