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psnet.ahrq.gov/node/42867/psn-pdf
February 13, 2014 - Medication regimen complexity and hospital readmission
for an adverse drug event.
February 13, 2014
Willson MN, Greer CL, Weeks DL. Medication regimen complexity and hospital readmission for an adverse
drug event. Ann Pharmacother. 2014;48(1):26-32. doi:10.1177/1060028013510898.
https://psnet.ahrq.gov/issue/medica…
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psnet.ahrq.gov/node/38252/psn-pdf
November 26, 2008 - Hospital ethical climate and teamwork in acute care: the
moderating role of leaders.
November 26, 2008
Rathert C, Fleming DA. Hospital ethical climate and teamwork in acute care: the moderating role of
leaders. Health Care Manag Rev. 2008;33(4):323-331. doi:10.1097/01.HCM.0000318769.75018.8d.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/39245/psn-pdf
January 20, 2010 - Adverse Events in Hospitals: Public Disclosure of
Information About Events.
January 20, 2010
Wright S. Washington, DC: US Department of Health and Human Services, Office of the Inspector General;
January 5, 2010. Report No. OEI-06-09-00360.
https://psnet.ahrq.gov/issue/adverse-events-hospitals-public-disclosure-in…
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psnet.ahrq.gov/node/40292/psn-pdf
March 16, 2011 - Patterns of unexpected in-hospital deaths: a root cause
analysis.
March 16, 2011
Lynn LA, Curry P. Patterns of unexpected in-hospital deaths: a root cause analysis. Patient Saf Surg.
2011;5(1):3. doi:10.1186/1754-9493-5-3.
https://psnet.ahrq.gov/issue/patterns-unexpected-hospital-deaths-root-cause-analysis
This l…
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psnet.ahrq.gov/node/36965/psn-pdf
February 15, 2011 - Strategic work-arounds to accommodate new technology:
the case of smart pumps in hospital care.
February 15, 2011
McAlearney AS, Vrontos J, Schneider PJ, et al. Strategic Work-Arounds to Accommodate New
Technology. J Patient Saf. 2008;3(2). doi:10.1097/01.jps.0000242987.93789.63.
https://psnet.ahrq.gov/issue/strat…
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psnet.ahrq.gov/node/42163/psn-pdf
May 19, 2013 - Frontline hospital workers and the worker safety/patient
safety nexus.
May 19, 2013
Sokas R, Braun B, Chenven L, et al. Frontline hospital workers and the worker safety/patient safety nexus.
Jt Comm J Qual Patient Saf. 2013;39(4):185-192.
https://psnet.ahrq.gov/issue/frontline-hospital-workers-and-worker-safetypat…
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psnet.ahrq.gov/node/37739/psn-pdf
June 07, 2008 - Health-Care-Associated Infections in Hospitals:
Leadership Needed from HHS to Prioritize Prevention
Practices and Improve Data on these Infections.
June 7, 2008
Washington, DC: United States Government Accountability Office; March 31, 2008. Publication GAO-08-
283.
https://psnet.ahrq.gov/issue/health-care-associa…
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psnet.ahrq.gov/node/39902/psn-pdf
December 29, 2014 - Clinical handover incident reporting in one UK general
hospital.
December 29, 2014
Pezzolesi C, Schifano F, Pickles J, et al. Clinical handover incident reporting in one UK general hospital. Int
J Qual Health Care. 2010;22(5):396-401. doi:10.1093/intqhc/mzq048.
https://psnet.ahrq.gov/issue/clinical-handover-incide…
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psnet.ahrq.gov/node/36976/psn-pdf
June 15, 2011 - Evaluation of an intervention aimed at improving
voluntary incident reporting in hospitals.
June 15, 2011
Evans S, Smith B, Esterman A, et al. Evaluation of an intervention aimed at improving voluntary incident
reporting in hospitals. Qual Saf Health Care. 2007;16(3):169-75.
https://psnet.ahrq.gov/issue/evaluation…
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psnet.ahrq.gov/node/37564/psn-pdf
June 12, 2008 - The medical emergency team system: a two hospital
comparison.
June 12, 2008
Young L, Donald M, Parr M, et al. The Medical Emergency Team system: a two hospital comparison.
Resuscitation. 2008;77(2):180-8. doi:10.1016/j.resuscitation.2007.11.016.
https://psnet.ahrq.gov/issue/medical-emergency-team-system-two-hospit…
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psnet.ahrq.gov/node/43060/psn-pdf
June 27, 2016 - Medication administration errors in hospitals—challenges
and recommendations for their measurement.
June 27, 2016
McLeod M, Barber N, Franklin BD. National Quality Measures Clearinghouse: Expert Commentaries;
March 10, 2014.
https://psnet.ahrq.gov/issue/medication-administration-errors-hospitals-challenges-and-rec…
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psnet.ahrq.gov/node/47649/psn-pdf
January 09, 2019 - ASH Clinical Practice Guidelines on Venous
Thromboembolism.
January 9, 2019
Washington DC; American Society of Hematology.
https://psnet.ahrq.gov/issue/ash-clinical-practice-guidelines-venous-thromboembolism
The American Society of Hematology produced a series of guidelines on prophylaxis for venous
thromboemboli…
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psnet.ahrq.gov/perspective/conversation-witheric-g-poon-md-mph
September 01, 2008 - In Conversation with…Eric G. Poon, MD, MPH
September 1, 2008
Also Read an Essay
Citation Text:
In Conversation with…Eric G. Poon, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 20…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.155_slideshow.ppt
July 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case July 2007
Resuscitation Errors:
A Shocking Problem
Source and Credits
This presentation is based on the July 2007
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available online
Commentary by: Benjamin Abella, MD, MPhil, …
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psnet.ahrq.gov/node/33651/psn-pdf
June 01, 2007 - In Conversation with...Diane Rydrych, MA
June 1, 2007
In Conversation with..Diane Rydrych, MA. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/conversation-withdiane-rydrych-ma
Editor's Note: Diane Rydrych, MA, is Assistant Director of the Division of Health Policy at the Minnesota
Department of Health,…
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psnet.ahrq.gov/issue/comparing-catheter-associated-urinary-tract-infection-prevention-programs-between-veterans
December 21, 2017 - Study
Comparing catheter-associated urinary tract infection prevention programs between Veterans Affairs nursing homes and non–Veterans Affairs nursing homes.
Citation Text:
Mody L, Greene T, Saint S, et al. Comparing Catheter-Associated Urinary Tract Infection Prevention Programs Betwee…
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psnet.ahrq.gov/node/73398/psn-pdf
June 30, 2021 - In Conversation With... Anjali Joseph, PhD, EDAC and
Molly M. Scanlon, PhD, FAIA, FACHA
June 30, 2021
In Conversation With.. Anjali Joseph, PhD, EDAC and Molly M. Scanlon, PhD, FAIA, FACHA. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/perspective/conversation-anjali-joseph-phd-edac-and-molly-m-scanlon-phd-faia-
…
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psnet.ahrq.gov/issue/patient-safety-out-hours-primary-care-review-patient-records
June 16, 2021 - Study
Patient safety in out-of-hours primary care: a review of patient records.
Citation Text:
Smits M, Huibers L, Kerssemeijer B, et al. Patient safety in out-of-hours primary care: a review of patient records. BMC Health Serv Res. 2010;10:335. doi:10.1186/1472-6963-10-335.
Copy Cit…
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psnet.ahrq.gov/issue/quality-improvement-and-patient-care-checklists-intrahospital-transfers-involving-pediatric
September 23, 2020 - Study
Quality improvement and patient care checklists in intrahospital transfers involving pediatric surgery patients.
Citation Text:
Nakayama DK, Lester SS, Rich DR, et al. Quality improvement and patient care checklists in intrahospital transfers involving pediatric surgery patients.…
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psnet.ahrq.gov/issue/effect-hospital-command-centre-patient-safety-interrupted-time-series-study
July 20, 2022 - Study
Effect of a hospital command centre on patient safety: an interrupted time series study.
Citation Text:
Effect of a hospital command centre on patient safety: an interrupted time series study. Mebrahtu TF, McInerney CD, Benn J, et al. BMJ Health Care Inform. 2023;30(1):e100653…