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psnet.ahrq.gov/node/74029/psn-pdf
January 01, 2022 - patient-safety-strategies-psychiatry-and-how-they-construct-notion-preventable-harm-scoping
https://psnet.ahrq.gov/issue/patient-safety-events-and-harms-during-medical-and-surgical-hospitalizations-persons-serious
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psnet.ahrq.gov/node/73214/psn-pdf
May 05, 2021 - https://psnet.ahrq.gov/issue/modification-potentially-inappropriate-prescribing-following-fall-related-hospitalizations
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psnet.ahrq.gov/node/848819/psn-pdf
May 10, 2023 - After 12 months of follow-up, the researchers did not
find any significant difference in hospitalizations
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psnet.ahrq.gov/curated-library/diagnostic-errors-case-studies
September 01, 2025 - year-old man with a history of untreated depression and suicide attempts (but no history of psychiatric hospitalizations
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psnet.ahrq.gov/web-mm/duplicate-insulin-order
May 04, 2012 - National estimates of insulin-related hypoglycemia and errors leading to emergency department visits and hospitalizations
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psnet.ahrq.gov/web-mm/central-line-clot
August 04, 2021 - Trends in maternal mortality and severe maternal morbidity during delivery-related hospitalizations
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psnet.ahrq.gov/issue/safety-risks-associated-lack-integration-and-interfacing-hospital-health-information
December 21, 2022 - Study
Safety risks associated with the lack of integration and interfacing of hospital health information technologies: a qualitative study of hospital electronic prescribing systems in England.
Citation Text:
Cresswell K, Mozaffar H, Lee L, et al. Safety risks associated with the lack o…
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psnet.ahrq.gov/issue/assessing-controlled-substance-prescribing-errors-pediatric-teaching-hospital-analysis-safety
August 02, 2010 - Study
Assessing controlled substance prescribing errors in a pediatric teaching hospital: an analysis of the safety of analgesic prescription practice in the transition from the hospital to home.
Citation Text:
Lee BH, Lehmann CU, Jackson E, et al. Assessing controlled substance prescr…
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psnet.ahrq.gov/issue/medicare-and-medicaid-programs-hospital-and-critical-access-hospital-cah-changes-promote
August 28, 2024 - Regulation
Medicare and Medicaid Programs; Hospital and Critical Access Hospital (CAH) Changes to Promote Innovation, Flexibility, and Improvement in Patient Care; Proposed Rule.
Citation Text:
Medicare and Medicaid Programs; Hospital and Critical Access Hospital (CAH) Changes to Promote…
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psnet.ahrq.gov/issue/association-safety-program-improving-antibiotic-use-antibiotic-use-and-hospital-onset
July 20, 2022 - Study
Association of a Safety Program for Improving Antibiotic Use with antibiotic use and hospital-onset Clostridioides difficile infection rates among US hospitals
Citation Text:
Tamma PD, Miller MA, Dullabh P, et al. Association of a safety program for improving antibiotic use with an…
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psnet.ahrq.gov/issue/private-patient-rooms-and-hospital-acquired-methicillin-resistant-staphylococcus-aureus
March 11, 2020 - Study
Private patient rooms and hospital-acquired methicillin-resistant Staphylococcus aureus: hospital-level analysis of administrative data from the United States.
Citation Text:
Park S-H, Stockbridge EL, Miller TL, et al. Private patient rooms and hospital-acquired methicillin-resista…
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psnet.ahrq.gov/issue/what-needed-sustain-improvements-hospital-practices-post-covid-19-qualitative-study
August 10, 2022 - Study
What is needed to sustain improvements in hospital practices post-COVID-19? A qualitative study of interprofessional dissonance in hospital infection prevention and control.
Citation Text:
Gilbert GL, Kerridge I. What is needed to sustain improvements in hospital practices post-COV…
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psnet.ahrq.gov/node/60248/psn-pdf
April 22, 2020 - https://psnet.ahrq.gov/issue/lock-it-medicine-safety-your-home
https://psnet.ahrq.gov/issue/emergency-hospitalizations-unsupervised-prescription-medication-ingestions-young-children
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psnet.ahrq.gov/node/49857/psn-pdf
March 01, 2019 - National estimates of insulin-related hypoglycemia and errors
leading to emergency department visits and hospitalizations
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psnet.ahrq.gov/node/49835/psn-pdf
January 01, 2020 - kidney disease often have underlying systemic diseases such as diabetes, which put them at
risk for hospitalizations
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psnet.ahrq.gov/perspective/health-care-worker-presenteeism-challenge-patient-safety
November 03, 2015 - June 19, 2024
Rate of sepsis hospitalizations after misdiagnosis in adult emergency department
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psnet.ahrq.gov/node/47307/psn-pdf
December 12, 2018 - Are teaching hospitals treated fairly in the Hospital-
Acquired Condition Reduction Program?
December 12, 2018
Mohajer MA, Joiner KA, Nix DE. Are Teaching Hospitals Treated Fairly in the Hospital-Acquired Condition
Reduction Program? Acad Med. 2018;93(12):1827-1832. doi:10.1097/ACM.0000000000002399.
https://psnet.…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.191_slideshow.ppt
January 01, 2009 - Spotlight Case July 2008
Spotlight Case January 2009
To Transfer or Not to Transfer
Source and Credits
This presentation is based on the January 2009
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Jesse M. Pines, MD, MBA, MSCE
University o…
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psnet.ahrq.gov/node/44434/psn-pdf
June 21, 2016 - Hospital board and management practices are strongly
related to hospital performance on clinical quality
metrics.
June 21, 2016
Tsai TC, Jha AK, Gawande AA, et al. Hospital board and management practices are strongly related to
hospital performance on clinical quality metrics. Health Aff (Millwood). 2015;34(8):130…
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psnet.ahrq.gov/node/48168/psn-pdf
July 24, 2019 - Changes in hospital safety following penalties in the US
Hospital Acquired Condition Reduction Program:
retrospective cohort study.
July 24, 2019
Sankaran R, Sukul D, Nuliyalu U, et al. Changes in hospital safety following penalties in the US Hospital
Acquired Condition Reduction Program: retrospective cohort stud…