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psnet.ahrq.gov/node/45081/psn-pdf
February 14, 2017 - Quasi-experimental evaluation of the effectiveness of a
large-scale readmission reduction program.
February 14, 2017
Jenq GY, Doyle MM, Belton BM, et al. Quasi-Experimental Evaluation of the Effectiveness of a Large-Scale
Readmission Reduction Program. JAMA Intern Med. 2016;176(5):681-90.
doi:10.1001/jamainternmed…
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psnet.ahrq.gov/node/46394/psn-pdf
August 29, 2018 - Sustained user engagement in health information
technology: the long road from implementation to system
optimization of computerized physician order entry and
clinical decision support systems for prescribing in
hospitals in England.
August 29, 2018
Cresswell K, Lee L, Mozaffar H, et al. Sustained User Engagement…
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psnet.ahrq.gov/node/43803/psn-pdf
January 29, 2015 - Creating a high-reliability health care system: improving
performance on core processes of care at Johns Hopkins
Medicine.
January 29, 2015
Pronovost P, Armstrong M, Demski R, et al. Creating a high-reliability health care system: improving
performance on core processes of care at Johns Hopkins Medicine. Acad Med.…
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psnet.ahrq.gov/node/40289/psn-pdf
March 16, 2011 - Unintentional therapeutic errors involving insulin in the
ambulatory setting reported to poison centers.
March 16, 2011
Spiller HA, Borys DJ, Ryan ML, et al. Unintentional therapeutic errors involving insulin in the ambulatory
setting reported to poison centers. Ann Pharmacother. 2011;45(1):17-22. doi:10.1345/aph.1…
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psnet.ahrq.gov/node/47006/psn-pdf
October 13, 2018 - Assessment of the safety of discharging select patients
directly home from the intensive care unit: a multicenter
population-based cohort study.
October 13, 2018
Stelfox HT, Soo A, Niven DJ, et al. Assessment of the Safety of Discharging Select Patients Directly Home
From the Intensive Care Unit: A Multicenter Pop…
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psnet.ahrq.gov/node/836885/psn-pdf
May 16, 2022 - Management of Cardiac Arrest in Unconventional
Locations.
May 16, 2022
Agrawal G, Molla M. Management of Cardiac Arrest in Unconventional Locations. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/management-cardiac-arrest-unconventional-locations
The Case
Case #1: An 80-year-old man with history of Parkins…
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psnet.ahrq.gov/node/50720/psn-pdf
December 04, 2019 - Flu shot mix-up at Oklahoma facility leaves 10
hospitalized
December 4, 2019
The Associated Press. NBC News. November 8, 2019.
https://psnet.ahrq.gov/issue/flu-shot-mix-oklahoma-facility-leaves-10-hospitalized
Patients at residential care facilities are particularly vulnerable to harm from medication errors. This …
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psnet.ahrq.gov/node/33920/psn-pdf
December 12, 2018 - Policy Positions and Guidelines.
December 12, 2018
Amercian Society of Health-System Pharmacists; ASHP.
https://psnet.ahrq.gov/issue/policy-positions-and-guidelines
This searchable listing of the American Society of Health-System Pharmacists policy and guideline
collection provides user access to various content a…
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psnet.ahrq.gov/node/39780/psn-pdf
January 04, 2017 - The First Annual HealthGrades Pediatric Patient Safety in
American Hospitals Study.
January 4, 2017
Reed K, May R. Golden, CO: Health Grades, Inc; 2010.
https://psnet.ahrq.gov/issue/first-annual-healthgrades-pediatric-patient-safety-american-hospitals-study
This report analyzed Agency for Healthcare Research and Q…
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psnet.ahrq.gov/node/43360/psn-pdf
September 29, 2017 - Antimicrobial Stewardship Toolkit.
September 29, 2017
Chicago, IL: American Hospital Association Physician Leadership Forum; July 2014.
https://psnet.ahrq.gov/issue/antimicrobial-stewardship-toolkit
Antimicrobial stewardship has been promoted as an element of patient safety. This toolkit provides
resources for hos…
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psnet.ahrq.gov/perspective/wild-west-patient-safety-office-based-anesthesia
April 01, 2003 - The Wild West: Patient Safety in Office-Based Anesthesia
Rainu Kaushal, MD MPH; Sekhar Upadhyayula, MD; David M. Gaba, MD; Lucian L. Leape, MD | May 1, 2006
View more articles from the same authors.
Citation Text:
Kaushal R, Upadhyayula S, Gaba DM, et al. The Wild…
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psnet.ahrq.gov/node/33673/psn-pdf
September 01, 2008 - The Role of Bar Coding and Smart Pumps in Safety
September 1, 2008
Rothschild JM, Keohane C. The Role of Bar Coding and Smart Pumps in Safety. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/role-bar-coding-and-smart-pumps-safety
Perspective
Medication safety in hospitals depends on the successful execu…
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psnet.ahrq.gov/primer/patient-safety-101
January 16, 2025 - Patient Safety 101
Citation Text:
Patient Safety 101. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
D…
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psnet.ahrq.gov/perspective/medias-role-patient-safety
April 27, 2022 - The Media’s Role in Patient Safety
April 27, 2022
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Millenson ML, Dowell P, Mossburg SE. The Media’s Role in Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcar…
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psnet.ahrq.gov/perspective/conversation-michael-l-millenson
April 27, 2022 - In Conversation With... Michael L. Millenson
April 27, 2022
Also Read the Essay
Citation Text:
In Conversation With.. Michael L. Millenson. PSNet [internet]. 2022.In Conversation With... Michael L. Millenson. PSNet [internet]. Rockville (MD): Agency for Healthcar…
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psnet.ahrq.gov/web-mm/code-status-vs-care-status
September 30, 2020 - SPOTLIGHT CASE
Code Status vs. Care Status
Citation Text:
Krisman RK, Spero H. Code Status vs. Care Status. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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Format:
Google Scholar BibTeX End…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.239_slideshow.ppt
May 01, 2011 - Spotlight Case July 2008
Spotlight Case
Duty to Disclose Someone Else’s Error
*
*
Source and Credits
This presentation is based on the May 2011
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Thomas H. Gallagher, MD University of Washington
…
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psnet.ahrq.gov/node/41895/psn-pdf
December 30, 2014 - Proceedings from the European Handover Research
Collaborative.
December 30, 2014
Philibert I, Barach P, eds. BMJ Qual Saf. 2012;21(suppl 1):i1-i128.
https://psnet.ahrq.gov/issue/proceedings-european-handover-research-collaborative
Articles in this supplement highlight findings of a multi-national effort to improve…
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psnet.ahrq.gov/node/50787/psn-pdf
January 08, 2020 - Q3 Health Innovation Partners.
January 8, 2020
New Jersey Hospital Association, the Ohio Hospital Association and The Hospital and Healthsystem
Association of Pennsylvania.
https://psnet.ahrq.gov/issue/q3-health-innovation-partners
Local efforts that draw from the experience of its leaders serve an important role …
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psnet.ahrq.gov/node/43492/psn-pdf
September 03, 2014 - Rethinking hospital restraints.
September 3, 2014
Parikh R. The Atlantic. August 18, 2014.
https://psnet.ahrq.gov/issue/rethinking-hospital-restraints
The inappropriate use of physical restraints on patients is considered a sentinel event. Although restraints
may be used to protect patients from harm, this magazin…