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psnet.ahrq.gov/web-mm/volume-too-low-and-out
July 01, 2017 - SPOTLIGHT CASE
Volume Too Low: In and Out
Citation Text:
Miller MR. Volume Too Low: In and Out . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/web-mm/order-interrupted-text-multitasking-mishap
August 21, 2015 - SPOTLIGHT CASE
Order Interrupted by Text: Multitasking Mishap
Citation Text:
Halamka J. Order Interrupted by Text: Multitasking Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/web-mm/diagnostic-failure-growing-deficit
June 01, 2005 - Diagnostic Failure: The Growing Deficit
Citation Text:
Chang R, Flanders S. Diagnostic Failure: The Growing Deficit. 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/33715/psn-pdf
July 01, 2011 - Becoming a Patient Safety Organization
July 1, 2011
Jaffe R. Becoming a Patient Safety Organization. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/becoming-patient-safety-organization
Perspective
While I was the first employee of the California Hospital Patient Safety Organization (CHPSO), its story
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.203_slideshow.ppt
August 01, 2009 - Spotlight Case July 2008
Spotlight Case
Nurse Staffing Ratios:
The Crucible of Money, Policy, Research, and Patient Care
*
Source and Credits
This presentation is based on the August 2009 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME/CEU credit is available
Commentary by: …
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psnet.ahrq.gov/node/49830/psn-pdf
May 01, 2018 - Suicide Risk in the Hospital
May 1, 2018
Mills PD. Suicide Risk in the Hospital. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/suicide-risk-hospital
The Case
A 37-year-old woman with a past medical history of depression, anxiety, and posttraumatic stress disorder
presented to the emergency department (ED)…
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psnet.ahrq.gov/perspective/soil-not-seed-real-problem-root-cause-analysis
March 01, 2007 - The Soil, Not the Seed: The Real Problem with Root Cause Analysis
Patrice Spath, BA, RHIT, and William Minogue, MD | July 1, 2008
View more articles from the same authors.
Citation Text:
Spath P, Minogue W. The Soil, Not the Seed: The Real Problem with Root Cause …
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psnet.ahrq.gov/issue/how-one-hospital-improved-patient-safety-10-minutes-day
April 11, 2018 - Newspaper/Magazine Article
How one hospital improved patient safety in 10 minutes a day.
Citation Text:
How one hospital improved patient safety in 10 minutes a day. van der Heijde R, Deichmann D. Harv Bus Rev. October 30, 2018.
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psnet.ahrq.gov/issue/concealed-renal-insufficiency-and-adverse-drug-reactions-elderly-hospitalized-patients
March 27, 2024 - Study
Concealed renal insufficiency and adverse drug reactions in elderly hospitalized patients.
Citation Text:
Corsonello A, Pedone C, Corica F, et al. Concealed renal insufficiency and adverse drug reactions in elderly hospitalized patients. Arch Intern Med. 2005;165(7):790-5.
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psnet.ahrq.gov/issue/risk-adverse-drug-events-patient-destination-after-hospital-discharge
March 04, 2020 - Study
Risk of adverse drug events by patient destination after hospital discharge.
Citation Text:
Triller DM, Clause SL, Hamilton RA. Risk of adverse drug events by patient destination after hospital discharge. Am J Health Syst Pharm. 2005;62(18):1883-9.
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psnet.ahrq.gov/issue/computerized-physician-order-entry-us-hospitals-results-2002-survey
April 29, 2018 - Study
Computerized physician order entry in US hospitals: results of a 2002 survey.
Citation Text:
Ash JS, Gorman PN, Seshadri V, et al. Computerized physician order entry in U.S. hospitals: results of a 2002 survey. J Am Med Inform Assoc. 2004;11(2):95-9.
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…
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psnet.ahrq.gov/issue/nhs-hospitals-employ-safety-experts-tackle-thousands-avoidable-mistakes
June 07, 2023 - Newspaper/Magazine Article
NHS hospitals to employ safety experts to tackle thousands of avoidable mistakes.
Citation Text:
Lintern S. NHS hospitals to employ safety experts to tackle thousands of avoidable mistakes. Independent. December 25, 2019;
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Goo…
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psnet.ahrq.gov/issue/man-falls-surgical-table-st-josephs-hospital-sued
May 13, 2020 - Newspaper/Magazine Article
Man falls off surgical table; St. Joseph's Hospital sued.
Citation Text:
Man falls off surgical table; St. Joseph's Hospital sued. Smith ML; Wolfe WA.
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psnet.ahrq.gov/issue/acute-stroke-chameleons-university-hospital-risk-factors-circumstances-and-outcomes
March 05, 2025 - Study
Acute stroke chameleons in a university hospital: risk factors, circumstances, and outcomes.
Citation Text:
Richoz B, Hugli O, Dami F, et al. Acute stroke chameleons in a university hospital: Risk factors, circumstances, and outcomes. Neurology. 2015;85(6):505-11. doi:10.1212/WNL.0…
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psnet.ahrq.gov/issue/flu-shot-mix-oklahoma-facility-leaves-10-hospitalized
July 22, 2020 - Newspaper/Magazine Article
Flu shot mix-up at Oklahoma facility leaves 10 hospitalized
Citation Text:
Flu shot mix-up at Oklahoma facility leaves 10 hospitalized The Associated Press. NBC News. November 8, 2019.
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psnet.ahrq.gov/issue/hospital-not-just-factory-complex-adaptive-system-implications-perioperative-care
May 11, 2019 - Commentary
A hospital is not just a factory, but a complex adaptive system—implications for perioperative care.
Citation Text:
Mahajan A, Islam SD, Schwartz MJ, et al. A Hospital Is Not Just a Factory, but a Complex Adaptive System-Implications for Perioperative Care. Anesth Analg. 2017;…
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psnet.ahrq.gov/issue/diagnostic-safety-needs-assessment-and-informed-curriculum-academic-childrens-hospital
June 28, 2023 - Study
Diagnostic safety: needs assessment and informed curriculum at an academic children's hospital.
Citation Text:
Congdon M, Rasooly IR, Toto RL, et al. Diagnostic safety: needs assessment and informed curriculum at an academic children's hospital. Pediatr Qual Saf. 2024;9(6):e773. do…
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psnet.ahrq.gov/issue/incidence-and-cost-unexpected-hospital-use-after-scheduled-outpatient-endoscopy
October 31, 2012 - Study
The incidence and cost of unexpected hospital use after scheduled outpatient endoscopy.
Citation Text:
Leffler DA, Kheraj R, Garud S, et al. The incidence and cost of unexpected hospital use after scheduled outpatient endoscopy. Arch Intern Med. 2010;170(19):1752-7. doi:10.1001/arc…
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psnet.ahrq.gov/node/39166/psn-pdf
December 09, 2009 - Effectiveness of a pharmacist–nurse intervention on
resolving medication discrepancies for patients
transitioning from hospital to home health care.
December 9, 2009
Setter SM, Corbett CF, Neumiller JJ, et al. Effectiveness of a pharmacist-nurse intervention on resolving
medication discrepancies for patients trans…
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psnet.ahrq.gov/node/44728/psn-pdf
December 02, 2015 - Doctors debate safety of their white coats.
December 2, 2015
Butler DL, Major Y, Bearman G, et al. Transmission of nosocomial pathogens by white coats: an in-vitro
model. The Journal of hospital infection. 2010;75(2):137-8. doi:10.1016/j.jhin.2009.11.024.
https://psnet.ahrq.gov/issue/doctors-debate-safety-their-whi…