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psnet.ahrq.gov/issue/towards-reduction-medication-errors-orthopedics-and-spinal-surgery-outcomes-using-pharmacist
January 30, 2008 - Pharmacist-led intervention on the reduction of inappropriate medication use in patients with heart … failure: a systematic review of randomized trials and non-randomized intervention studies.
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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/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/web-mm/too-many-cooks-kitchen
March 07, 2018 - noncardiac surgery found that the factors most consistently predictive of adverse cardiac outcomes were heart … failure, type of surgery, serum creatinine, diabetes, history of stroke or transient ischemic attack
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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/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/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/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/49454/psn-pdf
July 01, 2004 - aspirin and beta-blockers in coronary artery disease
and angiotensin-converting enzyme inhibitors in congestive … heart failure (15), failure to treat must be
viewed as a medication error that leads to unnecessary
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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/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/node/49834/psn-pdf
July 01, 2018 - Case & Commentary—Part 1
A 51-year-old man with history of congestive heart failure (ejection fraction
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psnet.ahrq.gov/curated-library/rapid-response-systems
September 15, 2024 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
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Created By: AHRQ
Date Created: January 24, 20…
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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/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/issue/computer-assisted-process-modeling-enhance-intraoperative-safety-cardiac-surgery
July 19, 2023 - Study
Computer-assisted process modeling to enhance intraoperative safety in cardiac surgery.
Citation Text:
Tarola CL, Quin JA, Haime ME, et al. Computer-Assisted Process Modeling to Enhance Intraoperative Safety in Cardiac Surgery. JAMA Surg. 2016;151(12):1183-1186. doi:10.1001/jamasur…
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psnet.ahrq.gov/issue/hospital-acquired-functional-decline-and-clinical-outcomes-older-cardiac-surgical-patients
February 06, 2019 - Study
Hospital-acquired functional decline and clinical outcomes in older cardiac surgical patients: a multicenter prospective cohort study.
Citation Text:
Morisawa T, Saitoh M, Otsuka S, et al. Hospital-acquired functional decline and clinical outcomes in older cardiac surgical patients…