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  1. psnet.ahrq.gov/perspective/conversation-paul-aylin-mbchb
    June 01, 2017 - In Conversation With… Paul Aylin, MBChB June 1, 2017  Also Read an Essay Citation Text: In Conversation With… Paul Aylin, MBChB. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy …
  2. psnet.ahrq.gov/web-mm/aspergillus-mediastinitis-endocarditis-pediatric-patient-complicating-cardiac-surgery-and
    November 16, 2022 - Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure. Citation Text: Partridge E, Dodson D, Reilly M, et al. Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure.. PSNet [inter…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49588/psn-pdf
    August 01, 2009 - Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care August 1, 2009 Rich V. Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/nurse-staffing-ratios-crucible-money-policy-research-and-patient-care Case…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49540/psn-pdf
    August 21, 2007 - Resuscitation Errors: A Shocking Problem August 21, 2007 Edelson DP, Abella BS. Resuscitation Errors: A Shocking Problem. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/resuscitation-errors-shocking-problem Case Objectives Appreciate that delays in defibrillation can have significant negative effects on sur…
  5. psnet.ahrq.gov/web-mm/danger-disruption
    July 29, 2020 - Danger in Disruption Citation Text: Fontaine DK. Danger in Disruption. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedI…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50929/psn-pdf
    February 26, 2020 - Discharged with IV antibiotics: When issues arise, who manages the complications? February 26, 2020 Donnelley M, Gintjee TJ, Go J. Discharged with IV antibiotics: When issues arise, who manages the complications? PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/discharged-iv-antibiotics-when-issues-arise-who-…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49592/psn-pdf
    October 01, 2009 - Danger in Disruption October 1, 2009 Fontaine DK. Danger in Disruption. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/danger-disruption The Case A 23-month-old toddler was severely dehydrated after vomiting due to gastric outlet obstruction. She had metabolic alkalosis (pH = 7.58), and her last peripheral…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38022/psn-pdf
    August 27, 2008 - Hospitals try to calm doctors' outbursts: medical road rage affecting patient safety, group says. August 27, 2008 Kowalczyk L. https://psnet.ahrq.gov/issue/hospitals-try-calm-doctors-outbursts-medical-road-rage-affecting-patient- safety-group-says This article describes how physician outbursts can affect patient …
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/845655/psn-pdf
    March 08, 2023 - Crisis in the Lakeshore Hospital ER. March 8, 2023 Derfel A. Montreal Gazette. February 24- March 1, 2023 https://psnet.ahrq.gov/issue/crisis-lakeshore-hospital-er Emergency room failures are often rooted in system weaknesses. This series examines six patient deaths associated with emergency care that, w…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60810/psn-pdf
    August 12, 2020 - Hospitals Can Take Key Steps to Improve Safe Use of Digital Systems. August 12, 2020 Philadelphia, PA: Pew Charitable Trusts; July 21, 2020. https://psnet.ahrq.gov/issue/hospitals-can-take-key-steps-improve-safe-use-digital-systems Tracking problems with health information technology (Health IT) is an important st…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41302/psn-pdf
    April 18, 2012 - A review of patient safety measures based on routinely collected hospital data. April 18, 2012 Tsang C, Palmer WL, Bottle A, et al. A review of patient safety measures based on routinely collected hospital data. Am J Med Qual. 2012;27(2):154-69. doi:10.1177/1062860611414697. https://psnet.ahrq.gov/issue/review-pat…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39091/psn-pdf
    June 28, 2011 - Integration of prospective and retrospective methods for risk analysis in hospitals. June 28, 2011 Kessels-Habraken M, van der Schaaf TW, De Jonge J, et al. Integration of prospective and retrospective methods for risk analysis in hospitals. Int J Qual Health Care. 2009;21(6):427-32. doi:10.1093/intqhc/mzp043. ht…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48054/psn-pdf
    June 26, 2019 - Lessons learned from a death outside a hospital's doorstep. June 26, 2019 Palmer J. Patient Saf Qual Healthc. May/June 2019. https://psnet.ahrq.gov/issue/lessons-learned-death-outside-hospitals-doorstep Organizations must learn from adverse events to prevent similar incidents. Reporting on lessons to be learned f…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44415/psn-pdf
    October 28, 2015 - Medication discrepancies at pediatric hospital discharge. October 28, 2015 Gattari TB, Krieger LN, Hu HM, et al. Medication Discrepancies at Pediatric Hospital Discharge. Hosp Pediatr. 2015;5(8):439-45. doi:10.1542/hpeds.2014-0085. https://psnet.ahrq.gov/issue/medication-discrepancies-pediatric-hospital-discharge …
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40407/psn-pdf
    October 04, 2011 - Insights into the climate of safety towards the prevention of falls among hospital staff. October 4, 2011 Black AA, Brauer SG, Bell RAR, et al. Insights into the climate of safety towards the prevention of falls among hospital staff. J Clin Nurs. 2011;20(19-20):2924-30. doi:10.1111/j.1365-2702.2010.03535.x. https:…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39675/psn-pdf
    January 19, 2011 - A 5-year analysis of rapid response system activation at an in-hospital haemodialysis unit. January 19, 2011 Galhotra S, Devita MA, Dew MA, et al. A 5-year analysis of rapid response system activation at an in- hospital haemodialysis unit. Qual Saf Health Care. 2010;19(6):e38. doi:10.1136/qshc.2008.031666. https:/…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47466/psn-pdf
    October 17, 2018 - ASHP guidelines on preventing medication errors in hospitals. October 17, 2018 Billstein-Leber M, Carrillo CJD, Cassano AT, et al. ASHP Guidelines on Preventing Medication Errors in Hospitals. Am J Health-Syst Pharm. 2018;75(19):1493-1517. doi:10.2146/ajhp170811. https://psnet.ahrq.gov/issue/ashp-guidelines-preven…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72781/psn-pdf
    February 24, 2021 - Reducing prescribing errors in hospitalized children on the ketogenic diet. February 24, 2021 Siegel BI, Johnson M, Dawson TE, et al. Reducing prescribing errors in hospitalized children on the ketogenic diet. Pediatr Neurol. 2020;115:42-47. doi:10.1016/j.pediatrneurol.2020.11.009. https://psnet.ahrq.gov/issue/red…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/861776/psn-pdf
    January 31, 2024 - The Sunday story: when hospitals don't say sorry. January 31, 2024 Rascoe A, Gorenstein D. National Public Radio. January 21, 2024. https://psnet.ahrq.gov/issue/sunday-story-when-hospitals-dont-say-sorry Openness about making mistakes is a challenge in health care due to fear of litigation and career damage. This …
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60166/psn-pdf
    March 25, 2020 - For 4 days, the hospital thought he had just pneumonia. It was coronavirus. March 25, 2020 Goldstein J, Salcedo A. For 4 days, the hospital thought he had just pneumonia. It was coronavirus. New York Times. 2020;March 10. https://psnet.ahrq.gov/issue/4-days-hospital-thought-he-had-just-pneumonia-it-was-coronavirus…

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