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psnet.ahrq.gov/node/44516/psn-pdf
June 10, 2018 - Managing hospitalized patients with ambulatory pumps:
findings from an ISMP survey—Part 1.
June 10, 2018
ISMP Medication Safety Alert! Acute care edition. November 19, 2015;20(23):1-5.
https://psnet.ahrq.gov/issue/managing-hospitalized-patients-ambulatory-pumps-findings-ismp-survey-part-1
Infusion therapies are in…
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psnet.ahrq.gov/node/33671/psn-pdf
July 01, 2008 - The Soil, Not the Seed: The Real Problem with Root
Cause Analysis
July 1, 2008
Spath P, Minogue W. The Soil, Not the Seed: The Real Problem with Root Cause Analysis. PSNet
[internet]. 2008.
https://psnet.ahrq.gov/perspective/soil-not-seed-real-problem-root-cause-analysis
Perspective
Throughout most of his life, …
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psnet.ahrq.gov/perspective/peacehealth-governance-journey-support-quality-and-safety
August 01, 2007 - The PeaceHealth Governance Journey in Support of Quality and Safety
John L. Haughom,
MD | August 1, 2007
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Haughom JL. The PeaceHealth Governance Journey in Support of Quality and …
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psnet.ahrq.gov/node/50696/psn-pdf
November 27, 2019 - Lorazepam was likely selected for this patient because it had been
utilized to treat anxiety during prior hospitalizations
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psnet.ahrq.gov/node/74830/psn-pdf
June 01, 2022 - The Michigan Hospital Medicine Safety Consortium (HMS)
Finds Infectious Diseases (ID) Physician Approval for
Placement of Peripherally Inserted Central Catheters
(PICCs) Prevents Unnecessary PICC Use and Reduces
Complications
February 23, 2022
https://psnet.ahrq.gov/innovation/michigan-hospital-medicine-safety-co…
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psnet.ahrq.gov/issue/evaluation-association-between-nursing-home-survey-patient-safety-culture-nhsops-measures-and
April 05, 2017 - Study
Evaluation of the association between Nursing Home Survey on Patient Safety culture (NHSOPS) measures and catheter-associated urinary tract infections: results of a national collaborative.
Citation Text:
Smith SN, Greene MT, Mody L, et al. Evaluation of the association between Nurs…
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psnet.ahrq.gov/node/33562/psn-pdf
September 15, 2024 - Rapid Response Systems
September 15, 2024
Rapid Response Systems. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/rapid-response-systems
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field.…
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psnet.ahrq.gov/node/846756/psn-pdf
March 29, 2023 - Frequency of medication administration timing error in
hospitals: a systematic review.
March 29, 2023
Pullam T, Russell CL, White-Lewis S. Frequency of medication administration timing error in hospitals: a
systematic review. J Nurs Care Qual. 2023;38(2):126-133. doi:10.1097/ncq.0000000000000668.
https://psnet.ahr…
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September 01, 2014 - Compendium of Strategies to Prevent HAIs in Acute Care
Hospitals 2014.
September 1, 2014
Infect Control Hosp Epidemiol. 2014;35(Suppl 2):s1-s178;35:460-463;797-801.
https://psnet.ahrq.gov/issue/compendium-strategies-prevent-hais-acute-care-hospitals-2014
Preventing healthcare-acquired infections (HAIs) remains a p…
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psnet.ahrq.gov/node/44172/psn-pdf
September 28, 2016 - Preventing high-alert medication errors in hospital
patients.
September 28, 2016
Anderson P, Townsend T. Am Nurse Today. May 2015;10:18-23.
https://psnet.ahrq.gov/issue/preventing-high-alert-medication-errors-hospital-patients
High-alert medications have the potential to cause serious patient harm. This article fo…
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psnet.ahrq.gov/node/34811/psn-pdf
March 28, 2005 - Medication error prevention by clinical pharmacists in two
children's hospitals.
March 28, 2005
Folli HL; Poole RL; Benitz WE; Russo JC
https://psnet.ahrq.gov/issue/medication-error-prevention-clinical-pharmacists-two-childrens-hospitals
This prospective study recorded the rate and potential for harm caused by err…
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psnet.ahrq.gov/node/37452/psn-pdf
January 09, 2008 - A randomized clinical trial to compare the use of safety
net enclosures with standard restraints in agitated
hospitalized patients.
January 9, 2008
Nawaz H, Abbas A, Sarfraz A, et al. A randomized clinical trial to compare the use of safety net enclosures
with standard restraints in agitated hospitalized patients.…
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psnet.ahrq.gov/node/50744/psn-pdf
December 18, 2019 - EMS crews brought patients to the hospital with
misplaced breathing tubes. None of them survived
December 18, 2019
Arditi L. Peoples Public Radio. December 3, 2019.
https://psnet.ahrq.gov/issue/ems-crews-brought-patients-hospital-misplaced-breathing-tubes-none-them-
survived
Emergency medical services are often p…
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psnet.ahrq.gov/node/73589/psn-pdf
August 11, 2021 - Suicide and suicide attempts on hospital grounds and
clinic areas.
August 11, 2021
Mills PD, Watts BV, Hemphill RR. Suicide and suicide attempts on hospital grounds and clinic areas. J
Patient Saf. 2021;17(5):e423-e428. doi:10.1097/pts.0000000000000356.
https://psnet.ahrq.gov/issue/suicide-and-suicide-attempts-hos…
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psnet.ahrq.gov/node/852801/psn-pdf
August 23, 2023 - Nearly all hospital pharmacists say drug shortages are
negatively impacting care; a third say impacts are
‘critical.’
August 23, 2023
McPhillips D. CNN. August 10, 2023.
https://psnet.ahrq.gov/issue/nearly-all-hospital-pharmacists-say-drug-shortages-are-negatively-impacting-
care-third-say
Drug shortages present…
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psnet.ahrq.gov/node/838312/psn-pdf
October 12, 2022 - Causes of adverse events in home mechanical
ventilation: a nursing perspective.
October 12, 2022
Lipprandt M, Liedtke W, Langanke M, et al. Causes of adverse events in home mechanical ventilation: a
nursing perspective. BMC Nurs. 2022;21(1):264. doi:10.1186/s12912-022-01038-2.
https://psnet.ahrq.gov/issue/causes-a…
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psnet.ahrq.gov/node/60237/psn-pdf
April 15, 2020 - Coronavirus strains hospitals, cancer patients face
treatment delays, uncertainty.
April 15, 2020
Stone W. Health Shots. National Public Radio. April 2, 2020.
https://psnet.ahrq.gov/issue/coronavirus-strains-hospitals-cancer-patients-face-treatment-delays-
uncertainty
Lack of access to services is emerging as a p…
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psnet.ahrq.gov/node/48134/psn-pdf
August 14, 2019 - Root cause analysis for hospital-acquired pressure injury.
August 14, 2019
Black JM. Root cause analysis for hospital-acquired pressure injury. J Wound Ostomy Continence Nurs.
2019;46(4):298-304. doi:10.1097/WON.0000000000000546.
https://psnet.ahrq.gov/issue/root-cause-analysis-hospital-acquired-pressure-injury
Pr…
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psnet.ahrq.gov/node/863763/psn-pdf
March 06, 2024 - After his wife died, he joined nurses to push for new
staffing rules in hospitals.
March 6, 2024
Wells K. Health Shots. KFF News and Michigan Public. February 22, 2024.
https://psnet.ahrq.gov/issue/after-his-wife-died-he-joined-nurses-push-new-staffing-rules-hospitals
Mandatory staffing ratios are a controversial …
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psnet.ahrq.gov/node/46522/psn-pdf
October 29, 2017 - Public reporting of surgical outcomes: surgeons,
hospitals, or both?
October 29, 2017
Jha AK. Public Reporting of Surgical Outcomes: Surgeons, Hospitals, or Both? JAMA. 2017;318(15):1429-
1430. doi:10.1001/jama.2017.13815.
https://psnet.ahrq.gov/issue/public-reporting-surgical-outcomes-surgeons-hospitals-or-both
…