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psnet.ahrq.gov/node/40523/psn-pdf
August 31, 2011 - A Hospital Accident: Lessons Learned – A Death, A
Conviction, and A Healing.
August 31, 2011
Texas Medical Institute of Technology. June 16, 2011.
https://psnet.ahrq.gov/issue/hospital-accident-lessons-learned-death-conviction-and-healing
This webinar covered how medical errors affect both the family and provider …
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psnet.ahrq.gov/node/36827/psn-pdf
April 25, 2007 - Adverse Drug Events in US Hospitals, 2004.
April 25, 2007
Elixhauser A, Owens P. HCUP Statistical Brief #29. Rockville, MD: Agency for Healthcare Research and
Quality; April 2007.
https://psnet.ahrq.gov/issue/adverse-drug-events-us-hospitals-2004
This report presents data on adverse drug events from the Healthcare…
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psnet.ahrq.gov/node/35074/psn-pdf
March 07, 2016 - Library-hospital pairing empowers patients, improves
safety.
March 7, 2016
https://psnet.ahrq.gov/issue/library-hospital-pairing-empowers-patients-improves-safety
This article describes the Partnering for Patient Empowerment Through Community Awareness program,
a model for utilizing libraries to educate consumers …
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psnet.ahrq.gov/node/39652/psn-pdf
June 30, 2010 - Aftercare tips for patients checking out of the hospital.
June 30, 2010
Alderman L. New York Times. June 18, 2010;B6.
https://psnet.ahrq.gov/issue/aftercare-tips-patients-checking-out-hospital
This news piece highlights efforts to improve discharge planning, enhance the safety of care transitions,
and reduce readm…
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psnet.ahrq.gov/node/35225/psn-pdf
December 17, 2008 - Wired hospitals: can high tech save your life?
December 17, 2008
Fischman J. Wired hospitals: can high tech save your life? U.S. news & world report. 2005;139(4):44-5, 49-
50, 52.
https://psnet.ahrq.gov/issue/can-high-tech-save-your-life
This article reports on activities at several hospitals that illustrate how i…
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psnet.ahrq.gov/node/40972/psn-pdf
October 03, 2017 - Hospital mistakes kept secret.
October 3, 2017
Judd A. The Atlanta Journal-Constitution. November 20, 2011.
https://psnet.ahrq.gov/issue/hospital-mistakes-kept-secret
Discussing a case of patient suicide, this news article explores the lack of transparency around patient
safety incidents in the state of Georgia.
…
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psnet.ahrq.gov/node/37299/psn-pdf
June 13, 2011 - Mother claims hospital error kept her from newborn
daughter.
June 13, 2011
Barbella M. Drug Topics. October 8, 2007.
https://psnet.ahrq.gov/issue/mother-claims-hospital-error-kept-her-newborn-daughter
This article reports how a failure to perform medication reconciliation during patient transfer led to a mother
b…
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psnet.ahrq.gov/node/40848/psn-pdf
October 12, 2011 - IBEAS: A Pioneer Study on Patient Safety in Latin
America: Towards Safer Hospital Care.
October 12, 2011
Geneva, Switzerland: World Health Organization; 2011.
https://psnet.ahrq.gov/issue/ibeas-pioneer-study-patient-safety-latin-america-towards-safer-hospital-care
This publication reports on the findings of…
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psnet.ahrq.gov/node/36393/psn-pdf
May 20, 2024 - Your Safety in our Hands in Hospital.
May 20, 2024
Patient Safety Surveillance Unit. Department of Health, Perth: Western Australia.
https://psnet.ahrq.gov/issue/your-safety-our-hands-hospital
This annual report shares the results of Western Australia's sentinel event reporting program. Medication
errors were the …
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psnet.ahrq.gov/node/49647/psn-pdf
February 01, 2012 - Amended Lab Results: Communication Slip
February 1, 2012
Mohta V. Amended Lab Results: Communication Slip. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/amended-lab-results-communication-slip
The Case
A 25-year-old woman in her first pregnancy was seen at 33 weeks' gestation with new onset hypertension
an…
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psnet.ahrq.gov/node/49766/psn-pdf
August 21, 2016 - Getting the (Right) Doctor, Right Away
August 21, 2016
Gupta K, Khanna R. Getting the (Right) Doctor, Right Away. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/getting-right-doctor-right-away
The Case
A 57-year-old woman with a history of chronic obstructive pulmonary disease underwent hip surgery.
Postop…
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psnet.ahrq.gov/primer/surgical-site-infections
December 15, 2024 - Surgical Site Infections
Citation Text:
Surgical Site Infections. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/49661/psn-pdf
August 01, 2012 - Nevertheless, the principles are similar and focused on
preventing unsafe discharges or unintended hospitalizations
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psnet.ahrq.gov/node/50930/psn-pdf
February 21, 2020 - Pharmacist Role in Patient Safety
February 21, 2020
Dopp AL, Hall KK. Pharmacist Role in Patient Safety. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/pharmacist-role-patient-safety
Background: The Evolving Role of the Pharmacist
Medication errors are highly pervasive across all settings of care,[1] w…
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psnet.ahrq.gov/web-mm/allergy-holter
May 01, 2008 - Allergy to Holter
Citation Text:
Williams M. Allergy to Holter. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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…
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psnet.ahrq.gov/node/49529/psn-pdf
February 01, 2007 - Crossed Coverage
February 1, 2007
Kayser SR. Crossed Coverage. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/crossed-coverage
The Case
A 27-year-old woman with a history of congenital heart disease was admitted for cardiac transplantation
evaluation. She had already undergone multiple surgeries, including…
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psnet.ahrq.gov/web-mm/40-k
January 12, 2011 - 40 of K
Citation Text:
Lesar TS. 40 of K. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/finding-fault-default-alert
August 28, 2024 - Finding Fault With the Default Alert
Citation Text:
Baysari M. Finding Fault With the Default Alert. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/node/42280/psn-pdf
May 17, 2013 - U.S. to delete data on life-threatening mistakes from
website.
May 17, 2013
Babcock CR. Bloomberg News. May 1, 2013.
https://psnet.ahrq.gov/issue/us-delete-data-life-threatening-mistakes-website
This news article reports that the Centers for Medicare and Medicaid Services has proposed removing
certain hospital-ac…
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psnet.ahrq.gov/node/41660/psn-pdf
September 05, 2012 - Genome detectives solve a hospital's deadly outbreak.
September 5, 2012
Kolata G. New York Times. August 22, 2012.
https://psnet.ahrq.gov/issue/genome-detectives-solve-hospitals-deadly-outbreak
Despite strict infection controls placed around a patient carrying a deadly antibiotic-resistant bacteria, 17
other patie…