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psnet.ahrq.gov/node/46545/psn-pdf
March 27, 2018 - Safety culture and mortality after acute myocardial
infarction: a study of Medicare beneficiaries at 171
hospitals.
March 27, 2018
Shahian DM, Liu X, Rossi LP, et al. Safety Culture and Mortality after Acute Myocardial Infarction: A Study
of Medicare Beneficiaries at 171 Hospitals. Health Serv Res. 2018;53(2):608-…
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psnet.ahrq.gov/node/866246/psn-pdf
July 10, 2024 - "They say they listen. But do they really listen?": A
qualitative study of hospital doctors' experiences of
organisational deafness, disconnect and denial.
July 10, 2024
Creese J, Byrne JP, Conway E, et al. “They say they listen. But do they really listen?”: A qualitative study of
hospital doctors’ experiences of …
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psnet.ahrq.gov/node/39063/psn-pdf
December 17, 2009 - Safety and risk management interventions in hospitals: a
systematic review of the literature.
December 17, 2009
Dückers M, Faber M, Cruijsberg J, et al. Safety and risk management interventions in hospitals: a
systematic review of the literature. Med Care Res Rev. 2009;66(6 Suppl):90S-119S.
doi:10.1177/10775587093…
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psnet.ahrq.gov/node/37808/psn-pdf
February 22, 2011 - How do hospitalized patients feel about resident work
hours, fatigue, and discontinuity of care?
February 22, 2011
Fletcher KE, Wiest FC, Halasyamani L, et al. How do hospitalized patients feel about resident work hours,
fatigue, and discontinuity of care? J Gen Intern Med. 2008;23(5):623-8. doi:10.1007/s11606-007-…
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psnet.ahrq.gov/node/42816/psn-pdf
October 31, 2014 - Rates of medical errors and preventable adverse events
among hospitalized children following implementation of
a resident handoff bundle.
October 31, 2014
Starmer AJ, Sectish TC, Simon DW, et al. Rates of medical errors and preventable adverse events among
hospitalized children following implementation of a reside…
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psnet.ahrq.gov/node/847544/psn-pdf
April 12, 2023 - A nationwide study of the "July Effect" concerning
postpartum hemorrhage and its risk factors at teaching
hospitals across the United States.
April 12, 2023
Shahin Z, Shah GH, Apenteng BA, et al. A nationwide study of the "July Effect" concerning postpartum
hemorrhage and its risk factors at teaching hospitals acr…
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psnet.ahrq.gov/node/45435/psn-pdf
August 24, 2016 - Pharmacist–physician communications in a highly
computerised hospital: sign-off and action of electronic
review messages.
August 24, 2016
Pontefract SK, Hodson J, Marriott JF, et al. Pharmacist-Physician Communications in a Highly
Computerised Hospital: Sign-Off and Action of Electronic Review Messages. PLoS One.
…
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psnet.ahrq.gov/node/73130/psn-pdf
January 01, 2022 - Improving peripherally inserted central catheter
appropriateness and reducing device-related
complications: a quasiexperimental study in 52 Michigan
hospitals.
April 14, 2021
Chopra V, O'Malley M, Horowitz J, et al. Improving peripherally inserted central catheter appropriateness
and reducing device-related compl…
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psnet.ahrq.gov/node/844766/psn-pdf
January 01, 2020 - Validation of new ICD-10-based patient safety indicators
for identification of in-hospital complications in surgical
patients: a study of diagnostic accuracy.
September 11, 2019
McIsaac DI, Hamilton GM, Abdulla K, et al. Validation of new ICD-10-based patient safety indicators for
identification of in-hospital com…
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psnet.ahrq.gov/node/48085/psn-pdf
June 19, 2019 - A decade of preventing harm.
June 19, 2019
Woeltje KF, Olenski LK, Donatelli M, et al. A Decade of Preventing Harm. Jt Comm J Qual Patient Saf.
2019;45(7):480-486. doi:10.1016/j.jcjq.2019.04.007.
https://psnet.ahrq.gov/issue/decade-preventing-harm
Preventable patient safety problems continue to challenge health ca…
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psnet.ahrq.gov/node/41884/psn-pdf
December 21, 2014 - Supratherapeutic dosing of acetaminophen among
hospitalized patients.
December 21, 2014
Zhou L, Maviglia SM, Mahoney LM, et al. Supratherapeutic dosing of acetaminophen among hospitalized
patients. Arch Intern Med. 2012;172(22):1721-8.
https://psnet.ahrq.gov/issue/supratherapeutic-dosing-acetaminophen-among-hospit…
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psnet.ahrq.gov/node/40910/psn-pdf
November 09, 2011 - The effect of hospital electronic health record adoption on
nurse-assessed quality of care and patient safety.
November 9, 2011
Kutney-Lee A, Kelly D. The effect of hospital electronic health record adoption on nurse-assessed quality of
care and patient safety. J Nurs Adm. 2011;41(11):466-72. doi:10.1097/NNA.0b013e…
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psnet.ahrq.gov/node/38760/psn-pdf
July 08, 2009 - Nurses' perceptions of safety culture in long-term care
settings.
July 8, 2009
Wagner LM, Capezuti E, Rice JC. Nurses' perceptions of safety culture in long-term care settings. J Nurs
Scholarsh. 2009;41(2):184-192. doi:10.1111/j.1547-5069.2009.01270.x.
https://psnet.ahrq.gov/issue/nurses-perceptions-safety-culture…
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psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary
September 23, 2024 - Rescue Improvement Conference Innovation Summary
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July 23, 2024
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psnet.ahrq.gov/node/33600/psn-pdf
June 16, 2024 - Patient Safety 101
June 16, 2024
Patient Safety 101. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/patient-safety-101
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in…
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psnet.ahrq.gov/node/39491/psn-pdf
March 22, 2011 - The published literature on handoffs in hospitals:
deficiencies identified in an extensive review.
March 22, 2011
Cohen MD, Hilligoss B. The published literature on handoffs in hospitals: deficiencies identified in an
extensive review. Qual Saf Health Care. 2010;19(6):493-7. doi:10.1136/qshc.2009.033480.
https://p…
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psnet.ahrq.gov/node/46334/psn-pdf
August 09, 2017 - Maternal deaths at MetroWest hospital prompt state
probes.
August 9, 2017
Kowalczyk L. Boston Globe. July 29, 2017.
https://psnet.ahrq.gov/issue/maternal-deaths-metrowest-hospital-prompt-state-probes
Maternal death is a sentinel event. This news article reports on two incidents at one hospital that prompted
inves…
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psnet.ahrq.gov/node/36360/psn-pdf
October 28, 2010 - Pharmacist staffing, technology use, and implementation
of medication safety practices in rural hospitals.
October 28, 2010
Casey M, Moscovice I, Davidson G. Pharmacist staffing, technology use, and implementation of medication
safety practices in rural hospitals. J Rural Health. 2006;22(4):321-30.
https://psnet.a…
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psnet.ahrq.gov/node/45110/psn-pdf
May 11, 2016 - Hospital discharge: it's one of the most dangerous
periods for patients.
May 11, 2016
Rau J. Washington Post. April 29, 2016.
https://psnet.ahrq.gov/issue/hospital-discharge-its-one-most-dangerous-periods-patients
Transitions in care between inpatient and outpatient settings are an increasing concern for patient s…
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psnet.ahrq.gov/node/39421/psn-pdf
July 19, 2010 - Hospital RNs' experiences with disruptive behavior: a
qualitative study.
July 19, 2010
Walrath JM, Dang D, Nyberg D. Hospital RNs' experiences with disruptive behavior: a qualitative study. J
Nurs Care Qual. 2010;25(2):105-116. doi:10.1097/NCQ.0b013e3181c7b58e.
https://psnet.ahrq.gov/issue/hospital-rns-experiences…