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psnet.ahrq.gov/issue/organisational-culture-variation-across-hospitals-and-connection-patient-safety-climate
March 17, 2010 - Study
Organisational culture: variation across hospitals and connection to patient safety climate.
Citation Text:
Speroff T, Nwosu S, Greevy R, et al. Organisational culture: variation across hospitals and connection to patient safety climate. Qual Saf Health Care. 2010;19(6):592-6. do…
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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.
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psnet.ahrq.gov/node/60604/psn-pdf
June 17, 2020 - The limits of current A.I. in health care: patient safety
policing in hospitals.
June 17, 2020
Furrow BR. NE Univ Law Rev. 2020;12(1):1-55.
https://psnet.ahrq.gov/issue/limits-current-ai-health-care-patient-safety-policing-hospitals
Artificial intelligence (AI) has the potential to improve the use of big data to e…
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psnet.ahrq.gov/node/43150/psn-pdf
April 30, 2014 - Children's Hospital investigated five patient deaths from
deadly fungal disease in 2009.
April 30, 2014
Duffy J, Harris J, Gade L, et al. Mucormycosis outbreak associated with hospital linens. The Pediatric
infectious disease journal. 2014;33(5):472-6. doi:10.1097/INF.0000000000000261.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/45800/psn-pdf
January 18, 2017 - Inpatient Notes: mistakes in the
hospital—communicating, apologizing, and beyond.
January 18, 2017
Kachalia A. Web Exclusives. Annals for Hospitalists Inpatient Notes - Mistakes in the Hospital-
Communicating, Apologizing, and Beyond. Ann Intern Med. 2016;165(12):HO2-HO3. doi:10.7326/M16-
2545.
https://psnet.ahrq…
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psnet.ahrq.gov/node/45658/psn-pdf
November 09, 2016 - Hospitals installed more sinks to stop infections. The
sinks can make the problem worse.
November 9, 2016
Branswell H. STAT. October 25, 2016.
https://psnet.ahrq.gov/issue/hospitals-installed-more-sinks-stop-infections-sinks-can-make-problem-worse
Hospitals have sought to improve hand hygiene with interventions su…
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psnet.ahrq.gov/node/846762/psn-pdf
March 29, 2023 - Hospital ‘black boxes’ put surgical practices under the
microscope.
March 29, 2023
Sadick B. Wall Street Journal. March 19, 2023.
https://psnet.ahrq.gov/issue/hospital-black-boxes-put-surgical-practices-under-microscope
Safety information systems that track action in real time can reveal a trove of data about how …
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psnet.ahrq.gov/node/73396/psn-pdf
June 16, 2021 - The impact of the built environment on patient falls in
hospital rooms: an integrative review.
June 16, 2021
Pati D, Valipoor S, Lorusso L, et al. The impact of the built environment on patient falls in hospital rooms:
an integrative review. J Patient Saf. 2021;17(4):273-281. doi:10.1097/pts.0000000000000613.
http…
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psnet.ahrq.gov/node/35672/psn-pdf
June 28, 2010 - How many hospital pharmacy medication dispensing
errors go undetected?
June 28, 2010
Cina J, Gandhi TK, Churchill WW, et al. How many hospital pharmacy medication dispensing errors go
undetected? Jt Comm J Qual Patient Saf. 2006;32(2):73-80.
https://psnet.ahrq.gov/issue/how-many-hospital-pharmacy-medication-dispen…
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psnet.ahrq.gov/node/44082/psn-pdf
April 22, 2015 - Impact of including readmissions for qualifying events in
the Patient Safety Indicators.
April 22, 2015
Davies SM, Saynina O, Baker LC, et al. Impact of including readmissions for qualifying events in the patient
safety indicators. Am J Med Qual. 2015;30(2):114-8. doi:10.1177/1062860613518341.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/34870/psn-pdf
April 18, 2016 - Unintended medication discrepancies at the time of
hospital admission.
April 18, 2016
Cornish PL, Knowles SR, Marchesano R, et al. Unintended medication discrepancies at the time of hospital
admission. Arch Intern Med. 2005;165(4):424-9.
https://psnet.ahrq.gov/issue/unintended-medication-discrepancies-time-hospita…
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psnet.ahrq.gov/node/45981/psn-pdf
June 21, 2017 - State sepsis mandates—a new era for regulation of
hospital quality.
June 21, 2017
Hershey TB, Kahn JM. State Sepsis Mandates - A New Era for Regulation of Hospital Quality. N Engl J
Med. 2017;376(24):2311-2313. doi:10.1056/NEJMp1611928.
https://psnet.ahrq.gov/issue/state-sepsis-mandates-new-era-regulation-hospital…
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psnet.ahrq.gov/node/72608/psn-pdf
December 23, 2020 - Incidence of Adverse Events in Indian Health Service
Hospitals.
December 23, 2020
Office of the Inspector General: Washington DC; December 2020. OIG report OEI-06-17-00530.
https://psnet.ahrq.gov/issue/incidence-adverse-events-indian-health-service-hospitals
Challenges beset safe care delivery for indigenous …
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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-…
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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…
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psnet.ahrq.gov/issue/chpso-2019-annual-report
March 20, 2024 - Book/Report
CHPSO Annual Reports.
Citation Text:
CHPSO Annual Reports. California Hospital Patient Safety Organization: Sacramento, CA; 2024.
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psnet.ahrq.gov/issue/managing-costs-clinical-negligence-trusts
March 28, 2018 - Book/Report
Managing the Costs of Clinical Negligence in Trusts.
Citation Text:
Managing the Costs of Clinical Negligence in Trusts. Comptroller and Auditor General, Department of Health; London, UK: National Audit Office; 2017. ISBN: 9781786041395.
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psnet.ahrq.gov/issue/unaccountable-what-hospitals-wont-tell-you-and-how-transparency-can-revolutionize-health-care
July 07, 2021 - Book/Report
Unaccountable: What Hospitals Won't Tell You and How Transparency Can Revolutionize Health Care.
Citation Text:
Unaccountable: What Hospitals Won't Tell You and How Transparency Can Revolutionize Health Care. Makary M. New York, NY: Bloomsbury Press; 2012. ISBN: 9781608198368…
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psnet.ahrq.gov/issue/mrsa-infections
September 26, 2018 - Commentary
MRSA Infections.
Citation Text:
Zeller JL, Burke AE, Glass RM. JAMA patient page. MRSA infections. JAMA. 2007;298(15):1826.
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psnet.ahrq.gov/issue/nurse-vaught-sentenced-deadly-medical-error
January 25, 2023 - Newspaper/Magazine Article
Nurse Vaught sentenced for deadly medical error.
Citation Text:
Nurse Vaught sentenced for deadly medical error. DePeau-Wilson M. MedPage Today. May 13, 2022.
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