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psnet.ahrq.gov/node/40468/psn-pdf
May 26, 2011 - Hospitals overhaul ERs to reduce mistakes.
May 26, 2011
Landro L.
https://psnet.ahrq.gov/issue/hospitals-overhaul-ers-reduce-mistakes
This newspaper article reports on efforts to reduce errors in emergency medicine, including improving
physician–nurse communication, adopting timeouts before discharge, and using tr…
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psnet.ahrq.gov/node/867359/psn-pdf
December 18, 2024 - Importance of Following Safe Practices for Infant Feeding
and Handling Expressed Breast Milk
December 18, 2024
Shauer M, Perez DG, Chagolla B. Importance of Following Safe Practices for Infant Feeding and Handling
Expressed Breast Milk. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/importance-following-saf…
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psnet.ahrq.gov/node/39066/psn-pdf
October 28, 2021 - Hospital Performance Report.
October 28, 2021
Trenton, NJ: New Jersey Department of Health and Senior Services.
https://psnet.ahrq.gov/issue/hospital-performance-report
Detailing results of an error reporting initiative in New Jersey, these reports explain how consumers can
use this information and provides tips f…
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psnet.ahrq.gov/node/37785/psn-pdf
May 02, 2018 - Considering insulin pens for routine hospital use?
Consider this...
May 2, 2018
ISMP Medication Safety Alert! Acute Care Edition. May 8, 2008;13:1-3.
https://psnet.ahrq.gov/issue/considering-insulin-pens-routine-hospital-use-consider
This article describes common problems associated with insulin pen injectors and …
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psnet.ahrq.gov/node/36421/psn-pdf
August 05, 2008 - What pilots can teach hospitals about patient safety.
August 5, 2008
Murphy K
https://psnet.ahrq.gov/issue/what-pilots-can-teach-hospitals-about-patient-safety
This article discusses lessons the airline industry has learned about communication, teamwork, and error
reporting and how they might be applicable to heal…
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psnet.ahrq.gov/node/33769/psn-pdf
June 01, 2014 - Patient Advocacy in Patient Safety: Have Things
Changed?
June 1, 2014
Haskell H. Patient Advocacy in Patient Safety: Have Things Changed? PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/patient-advocacy-patient-safety-have-things-changed
Perspective
In 1981, a cancer patient named Paula Carroll founded…
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psnet.ahrq.gov/node/33635/psn-pdf
July 01, 2006 - In Conversation with...Allan Frankel, MD
July 1, 2006
In Conversation with..Allan Frankel, MD. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-withallan-frankel-md
Dr. Robert Wachter, Editor, AHRQ WebM&M: Tell us a little bit about how you became interested in this
kind of work.
Dr. Allan …
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psnet.ahrq.gov/curated-library/diagnostic-error
August 10, 2025 - Breadcrumb
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Diagnostic Error
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Created By: Karen Cosby, AHRQ
Date Created: May 8, …
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psnet.ahrq.gov/web-mm/sepsis-resulting-delays-treatment-and-miscommunication-among-specialists
February 26, 2025 - Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists
Citation Text:
Shi L, Noren E. Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Se…
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psnet.ahrq.gov/node/37407/psn-pdf
September 02, 2014 - HSMR: A New Approach for Measuring Hospital Mortality
Trends in Canada.
September 2, 2014
Ottowa, Ontario, CA: Canadian Institute for Health Information; 2007. ISBN 9781554651832.
https://psnet.ahrq.gov/issue/hsmr-new-approach-measuring-hospital-mortality-trends-canada
This report describes a new metric used to an…
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psnet.ahrq.gov/node/37753/psn-pdf
May 02, 2018 - Some red rules shouldn't rule in hospitals.
May 2, 2018
ISMP Medication Safety Alert! Acute Care Edition. April 24, 2008;13:1-3.
https://psnet.ahrq.gov/issue/some-red-rules-shouldnt-rule-hospitals
This article provides a set of criteria for health care professionals to develop and implement red rules as an
effecti…
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psnet.ahrq.gov/node/37320/psn-pdf
November 07, 2007 - Ambulance crew in Chicago got lost trying to find
hospital.
November 7, 2007
News Services. Washington Post. October 25, 2007
https://psnet.ahrq.gov/issue/ambulance-crew-chicago-got-lost-trying-find-hospital
An emergency crew from a suburb failed to efficiently transport a marathon runner in cardiac arre…
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psnet.ahrq.gov/node/41003/psn-pdf
April 16, 2018 - Gap assessment of hospitals' adoption of the just culture
principles.
April 16, 2018
Barger DM; Marella W; Charney FJ.
https://psnet.ahrq.gov/issue/gap-assessment-hospitals-adoption-just-culture-principles
This article reports that Pennsylvania health care organizations overestimated their adoption of just culture…
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psnet.ahrq.gov/node/39630/psn-pdf
June 23, 2010 - Using Workforce Practices to Drive Quality Improvement:
A Guide for Hospitals.
June 23, 2010
McHugh M, Garman A, McAlearney A, Song P, Harrison M. Chicago, IL: Health Research & Educational
Trust; June 2010.
https://psnet.ahrq.gov/issue/using-workforce-practices-drive-quality-improvement-guide-hospitals
This publ…
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psnet.ahrq.gov/node/836842/psn-pdf
April 07, 2022 - Assessing the impact of virtual medication history
technicians on medication reconciliation discrepancies.
April 7, 2022
Gadallah A, McGinnis B, Nguyen B, et al. Assessing the impact of virtual medication history technicians on
medication reconciliation discrepancies. Int J Clin Pharm. 2021;43(5):1404-1411. doi:10.…
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psnet.ahrq.gov/node/46542/psn-pdf
June 19, 2018 - Improving admission medication reconciliation with
pharmacists or pharmacy technicians in the emergency
department: a randomised controlled trial.
June 19, 2018
Pevnick JM, Nguyen C, Jackevicius CA, et al. Improving admission medication reconciliation with
pharmacists or pharmacy technicians in the emergency depar…
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psnet.ahrq.gov/node/43475/psn-pdf
July 18, 2016 - A cross-sectional analysis investigating organizational
factors that influence near-miss error reporting among
hospital pharmacists.
July 18, 2016
Patterson ME, Pace HA. A Cross-sectional Analysis Investigating Organizational Factors That Influence
Near-Miss Error Reporting Among Hospital Pharmacists. J Patient Sa…
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psnet.ahrq.gov/node/42895/psn-pdf
December 18, 2014 - National trends in patient safety for four common
conditions, 2005–2011.
December 18, 2014
Wang Y, Eldridge N, Metersky M, et al. National trends in patient safety for four common conditions, 2005-
2011. N Engl J Med. 2014;370(4):341-51. doi:10.1056/NEJMsa1300991.
https://psnet.ahrq.gov/issue/national-trends-patie…
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psnet.ahrq.gov/node/39176/psn-pdf
December 16, 2009 - A reduction in cardiac arrests and duration of clinical
instability after implementation of a paediatric rapid
response system.
December 16, 2009
Hanson CC, Randolph GD, Erickson JA, et al. A reduction in cardiac arrests and duration of clinical
instability after implementation of a paediatric rapid response syste…
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psnet.ahrq.gov/node/43914/psn-pdf
March 13, 2015 - Medication-related emergency department visits in
pediatrics: a prospective observational study.
March 13, 2015
Zed PJ, Black KJL, Fitzpatrick EA, et al. Medication-related emergency department visits in pediatrics: a
prospective observational study. Pediatrics. 2015;135(3):435-43. doi:10.1542/peds.2014-1827.
http…