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psnet.ahrq.gov/node/39090/psn-pdf
November 11, 2009 - Nurse reports of adverse events during sedation
procedures at a pediatric hospital.
November 11, 2009
Lightdale JR, Mahoney LB, Fredette ME, et al. Nurse reports of adverse events during sedation procedures
at a pediatric hospital. J Perianesth Nurs. 2009;24(5):300-6. doi:10.1016/j.jopan.2009.07.004.
https://psnet…
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psnet.ahrq.gov/node/33926/psn-pdf
March 07, 2005 - The problems of detecting medication errors in hospitals.
March 7, 2005
Barker KN, McConnell WE. The Problems of Detecting Medication Errors in Hospitals. Am J Health Syst
Pharm. 1962;19(8):360-369. doi:10.1093/ajhp/19.8.360.
https://psnet.ahrq.gov/issue/problems-detecting-medication-errors-hospitals
Perhaps the f…
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psnet.ahrq.gov/node/42355/psn-pdf
February 11, 2015 - Advancing Successful Care Transitions to Improve
Outcomes.
February 11, 2015
Society of Hospital Medicine
https://psnet.ahrq.gov/issue/project-boost-mentored-implementation-program
This Web site provides resources associated with the Better Outcomes for Older adults through Safe
Transitions project, called Projec…
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psnet.ahrq.gov/node/50580/psn-pdf
October 23, 2019 - Suspicious insulin injections, nearly a dozen deaths:
inside an unfolding investigation at a VA hospital in West
Virginia.
October 23, 2019
Rein L. Washington Post. October 5, 2019.
https://psnet.ahrq.gov/issue/suspicious-insulin-injections-nearly-dozen-deaths-inside-unfolding-
investigation-va-hospital
The Vete…
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psnet.ahrq.gov/node/50811/psn-pdf
January 15, 2020 - NHS hospitals to employ safety experts to tackle
thousands of avoidable mistakes.
January 15, 2020
Lintern S. NHS hospitals to employ safety experts to tackle thousands of avoidable mistakes. Independent.
December 25, 2019;
https://psnet.ahrq.gov/issue/nhs-hospitals-employ-safety-experts-tackle-thousands-avoidable…
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psnet.ahrq.gov/node/44733/psn-pdf
December 07, 2018 - Patient Safety in Ambulatory Settings: Technical Brief.
December 7, 2018
Evidence-based Practice Center. Rockville, MD: Agency for Healthcare Research and Quality; October 19,
2016.
https://psnet.ahrq.gov/issue/patient-safety-ambulatory-settings-technical-brief
The primary focus on patient safety research has been…
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psnet.ahrq.gov/node/40294/psn-pdf
September 24, 2016 - Hospital doctors' workflow interruptions and activities: an
observation study.
September 24, 2016
Weigl M, Müller A, Zupanc A, et al. Hospital doctors' workflow interruptions and activities: an observation
study. BMJ Qual Saf. 2011;20(6):491-7. doi:10.1136/bmjqs.2010.043281.
https://psnet.ahrq.gov/issue/hospital-d…
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psnet.ahrq.gov/node/45194/psn-pdf
December 14, 2016 - Wounded care: failure at one Indian Health Service
hospital reveals a system in crisis.
December 14, 2016
Herman B, Fei F. Mod Healthc. December 2, 2016.
https://psnet.ahrq.gov/issue/wounded-care-failure-one-indian-health-service-hospital-reveals-system-crisis
Underserved communities face challenges to receiving h…
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psnet.ahrq.gov/node/46331/psn-pdf
September 14, 2018 - Health IT Patient Safety Supplemental Items for Hospitals.
September 14, 2018
Agency for Healthcare Research and Quality. July 25, 2018.
https://psnet.ahrq.gov/issue/health-it-patient-safety-supplemental-items-hospitals
Tracking the intersection of organizational culture with health information technology use can …
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psnet.ahrq.gov/issue/stem-tide-addressing-opioid-epidemic
April 15, 2021 - Toolkit
Stem the Tide: Addressing the Opioid Epidemic.
Citation Text:
Stem the Tide: Addressing the Opioid Epidemic. Chicago, IL: American Hospital Association; 2017.
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psnet.ahrq.gov/issue/alarm-management-first-things-first-using-reliable-data-eliminate-unnecessary-alarms
July 29, 2009 - Newspaper/Magazine Article
Alarm management: first things first: using reliable data to eliminate unnecessary alarms.
Citation Text:
Alarm management: first things first: using reliable data to eliminate unnecessary alarms. Vanderveen T. Patient Saf Qual Healthc. November/December 2014;1…
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psnet.ahrq.gov/issue/national-and-state-healthcare-associated-infections-progress-report
June 11, 2014 - Book/Report
National and State Healthcare-Associated Infections Progress Report.
Citation Text:
National and State Healthcare-Associated Infections Progress Report. Atlanta, GA: Centers for Disease Control and Prevention; November 2023.
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psnet.ahrq.gov/issue/inside-canadas-secret-world-medical-error-there-lot-lying-theres-lot-cover
September 23, 2009 - Newspaper/Magazine Article
Inside Canada's secret world of medical error: 'There is a lot of lying, there's a lot of cover-up.'
Citation Text:
Inside Canada's secret world of medical error: 'There is a lot of lying, there's a lot of cover-up.' Blackwell T.
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psnet.ahrq.gov/issue/surviving-bad-diagnosis
January 19, 2022 - Newspaper/Magazine Article
Surviving a bad diagnosis.
Citation Text:
Surviving a bad diagnosis. Hobson K. US News News and World Report. September 13, 2016.
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psnet.ahrq.gov/issue/medical-misdiagnoses-put-pressure-patients-stay-engaged
October 05, 2016 - Newspaper/Magazine Article
Medical misdiagnoses put pressure on patients to stay engaged.
Citation Text:
Medical misdiagnoses put pressure on patients to stay engaged. Innes S. Arizona Daily Star. September 12, 2016.
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psnet.ahrq.gov/issue/advancement-toward-high-reliability-healthcare-awards
June 08, 2011 - Government Resource
Advancement toward High Reliability in Healthcare Awards.
Citation Text:
Advancement toward High Reliability in Healthcare Awards. Department of Defense Patient Safety Program; DoD PSP; DoD
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psnet.ahrq.gov/issue/simple-surgery-harrowing-complications
November 07, 2012 - Newspaper/Magazine Article
A simple surgery with harrowing complications.
Citation Text:
A simple surgery with harrowing complications. Miller R. News-Times. July 25, 2012.
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psnet.ahrq.gov/issue/patient-alarms-often-unheard-unheeded
August 24, 2016 - Newspaper/Magazine Article
Patient alarms often unheard, unheeded.
Citation Text:
Patient alarms often unheard, unheeded. Kowalczyk L. Boston Globe. February 13–14, 2011.
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psnet.ahrq.gov/issue/best-medical-care-us
June 27, 2018 - Newspaper/Magazine Article
The best medical care in the U.S.
Citation Text:
The best medical care in the U.S. Arnst C.
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psnet.ahrq.gov/issue/patient-safety-what-can-medicine-learn-aviation
October 30, 2008 - Newspaper/Magazine Article
Patient safety: what can medicine learn from aviation?
Citation Text:
Patient safety: what can medicine learn from aviation? O'Reilly KB. American Medical News. June 14, 2010.
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