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psnet.ahrq.gov/node/40637/psn-pdf
October 03, 2012 - Surgical site infections in colon surgery: the patient, the
procedure, the hospital, and the surgeon.
October 3, 2012
Hübner M, Diana M, Zanetti G, et al. Surgical site infections in colon surgery: the patient, the procedure,
the hospital, and the surgeon. Arch Surg. 2011;146(11):1240-5. doi:10.1001/archsurg.2011.1…
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psnet.ahrq.gov/node/60356/psn-pdf
May 20, 2020 - How the pandemic is reshaping hospital architecture and
design.
May 20, 2020
Booker C. PBSNewshour Weekend. May 10, 2020.
https://psnet.ahrq.gov/issue/how-pandemic-reshaping-hospital-architecture-and-design
Built environment characteristics can contribute to the spread of infection. This news segment discusses
de…
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psnet.ahrq.gov/node/60565/psn-pdf
June 03, 2020 - The public has been forgiving. But hospitals got some
things wrong.
June 3, 2020
Ofri D. The public has been forgiving. But hospitals got some things wrong. New York Times. 2020; May
21.
https://psnet.ahrq.gov/issue/public-has-been-forgiving-hospitals-got-some-things-wrong
The complexity of the COVID-19 crisis cr…
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psnet.ahrq.gov/node/39751/psn-pdf
August 11, 2010 - Interpreting adverse drug reaction (ADR) reports as
hospital patient safety incidents.
August 11, 2010
Davies EC, Green CF, Mottram DR, et al. Interpreting adverse drug reaction (ADR) reports as hospital
patient safety incidents. Br J Clin Pharmacol. 2010;70(1):102-8. doi:10.1111/j.1365-2125.2010.03671.x.
https://…
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psnet.ahrq.gov/node/50757/psn-pdf
December 18, 2019 - As university hospital hounds debtors, doctors say it's
doing harm.
December 18, 2019
Garcia-Navarro L. Weekend Edition Sunday. National Public Radio. December 1, 2019.
https://psnet.ahrq.gov/issue/university-hospital-hounds-debtors-doctors-say-its-doing-harm
Financial harms occur in health care due to a variety o…
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psnet.ahrq.gov/node/41040/psn-pdf
January 04, 2012 - Implementing an electronic medical record with
computerized prescriber order entry at a critical access
hospital.
January 4, 2012
Horning R. Implementing an electronic medical record with computerized prescriber order entry at a critical
access hospital. Am J Health Syst Pharm. 2011;68(23):2288-92. doi:10.2146/ajh…
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psnet.ahrq.gov/node/42203/psn-pdf
April 17, 2013 - What do hospital staff in the UK think are the causes of
penicillin medication errors?
April 17, 2013
Wilcock M, Harding G, Moore L, et al. What do hospital staff in the UK think are the causes of penicillin
medication errors? Int J Clin Pharm. 2012;35(1). doi:10.1007/s11096-012-9708-1.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/42477/psn-pdf
August 07, 2013 - Review into the Quality of Care and Treatment Provided
by 14 Hospital Trusts in England: Overview Report.
August 7, 2013
Keogh B. London, UK: National Health Service; July 2013.
https://psnet.ahrq.gov/issue/review-quality-care-and-treatment-provided-14-hospital-trusts-england-
overview-report
Outlining findings f…
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psnet.ahrq.gov/node/43621/psn-pdf
October 22, 2014 - Multidisciplinary in-hospital teams improve patient
outcomes: a review.
October 22, 2014
Epstein NE. Multidisciplinary in-hospital teams improve patient outcomes: A review. Surg Neurol Int.
2014;5(Suppl 7):S295-303. doi:10.4103/2152-7806.139612.
https://psnet.ahrq.gov/issue/multidisciplinary-hospital-teams-improve…
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psnet.ahrq.gov/node/846459/psn-pdf
March 22, 2023 - Few hospitals are willing to bear the cost of providing
psychiatric care for kids.
March 22, 2023
Schorsch K, Karp S. WBEZ Chicago. March 9, 2023.
https://psnet.ahrq.gov/issue/few-hospitals-are-willing-bear-cost-providing-psychiatric-care-kids
Pediatric mental health is a patient safety concern. This news story ou…
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psnet.ahrq.gov/node/38561/psn-pdf
April 15, 2009 - Health-Care–Associated Infections in Hospitals:
Continuing Leadership Needed from HHS to Prioritize
Prevention Practices and Improve Data on These
Infections.
April 15, 2009
Subcommittee on Health Care, Committee on Finance, US Senate, Government Accountability Office,
GAO-09-516T (March 18, 2009)
https://psnet.…
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psnet.ahrq.gov/node/40537/psn-pdf
June 15, 2011 - Rural nurses' safeguarding work: reembodying patient
safety.
June 15, 2011
MacKinnon K. Rural nurses' safeguarding work: reembodying patient safety. ANS Adv Nurs Sci.
2011;34(2):119-129. doi:10.1097/ANS.0b013e3182186b86.
https://psnet.ahrq.gov/issue/rural-nurses-safeguarding-work-reembodying-patient-safety
Rural …
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psnet.ahrq.gov/node/46605/psn-pdf
January 24, 2018 - The impact of interruptions on medication errors in
hospitals: an observational study of nurses.
January 24, 2018
Johnson M, Sanchez P, Langdon R, et al. The impact of interruptions on medication errors in hospitals: an
observational study of nurses. J Nurs Manag. 2017;25(7):498-507. doi:10.1111/jonm.12486.
https:…
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psnet.ahrq.gov/node/34788/psn-pdf
March 28, 2005 - Cost of medication-related problems at a university
hospital.
March 28, 2005
Schneider PJ; Gift MG; Lee YP; Rothermich EA; Sill BE
https://psnet.ahrq.gov/issue/cost-medication-related-problems-university-hospital
This study used retrospective chart review to determine estimated costs of defined medication-related
…
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psnet.ahrq.gov/node/866869/psn-pdf
October 02, 2024 - Core Elements of Hospital Diagnostic Excellence (DxEx).
October 2, 2024
Core Elements of Hospital Diagnostic Excellence (DxEx). Centers for Disease Control and Prevention.
https://psnet.ahrq.gov/issue/core-elements-hospital-diagnostic-excellence-dxex
Diagnostic excellence is an expansion of the diagnostic error red…
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psnet.ahrq.gov/node/838147/psn-pdf
July 01, 2020 - Care Compare.
July 1, 2020
Centers for Medicare and Medicaid Services.
https://psnet.ahrq.gov/issue/care-compare
The Centers for Medicare & Medicaid Services (CMS) support transparency through the provision of
publicly available information on the quality of health care service in the United States. This portal en…
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psnet.ahrq.gov/node/49788/psn-pdf
March 01, 2017 - Correct Treatment Plan for Incorrect Diagnosis: A
Pharmacist Intervention
March 1, 2017
Nelson SD. Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention. PSNet [internet].
2017.
https://psnet.ahrq.gov/web-mm/correct-treatment-plan-incorrect-diagnosis-pharmacist-intervention
The Case
A 48-year…
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psnet.ahrq.gov/web-mm/fumbled-handoff
September 01, 2006 - Fumbled Handoff
Citation Text:
Vidyarthi A. Fumbled Handoff. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/issue/teamstepps-diagnosis-improvement
July 17, 2024 - July 17, 2024
Preventable Hospitalizations: A Window Into Primary and Preventive Care
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psnet.ahrq.gov/issue/measure-dx-resource-identify-analyze-and-learn-diagnostic-safety-events
August 01, 2012 - October 23, 2019
Preventable Hospitalizations: A Window Into Primary and Preventive Care