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psnet.ahrq.gov/node/74835/psn-pdf
February 16, 2022 - Discrepancy between emergency department admission
diagnosis and hospital discharge diagnosis and its
impact on length of stay, up-triage to the intensive care
unit, and mortality.
February 16, 2022
Bastakoti M, Muhailan M, Nassar A, et al. Discrepancy between emergency department admission
diagnosis and hospital…
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psnet.ahrq.gov/innovation/cleveland-clinic-pairs-advanced-practice-registered-nurses-and-paramedics-provide-home
October 30, 2024 - The Cleveland Clinic Pairs Advanced Practice Registered Nurses and Paramedics To Provide Home Visits to Recently Discharged Patients at Highest Risk for Hospital Readmission
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psnet.ahrq.gov/node/35773/psn-pdf
March 15, 2006 - The association between hospital characteristics and
rates of preventable complications and adverse events.
March 15, 2006
Thornlow DK; Stukenborg GJ.
https://psnet.ahrq.gov/issue/association-between-hospital-characteristics-and-rates-preventable-
complications-and-adverse
Using the Agency for Healthcare Research…
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psnet.ahrq.gov/node/35382/psn-pdf
October 05, 2005 - Rx for a better prescription. Hospital bans doctors from
using confusing medical abbreviations.
October 5, 2005
Hall J. Fredericksburg Times. September 25, 2005
https://psnet.ahrq.gov/issue/rx-better-prescription-hospital-bans-doctors-using-confusing-medical-
abbreviations
This article presents one hospital’s pro…
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psnet.ahrq.gov/node/37137/psn-pdf
October 04, 2011 - Rural hospital patient safety systems implementation in
two states.
October 4, 2011
Longo DR, Hewett JE, Ge B, et al. Rural Hospital Patient Safety Systems Implementation in Two States.
The Journal of Rural Health. 2007;23(3). doi:10.1111/j.1748-0361.2007.00090.x.
https://psnet.ahrq.gov/issue/rural-hospital-patien…
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psnet.ahrq.gov/primer/leadership-role-improving-safety
September 15, 2024 - Leadership Role in Improving Safety
Citation Text:
Leadership Role in Improving Safety. 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/print/pdf/node/848754
January 01, 2025 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Implementation of Patient Safety Projects
Curated Library
Foundations
Leading change: why transformation efforts fail.
Kotter JP. Harvard Bus Rev 1995;73(2);59-67.
Kotter, a professor at Harvard Business School, outlines the eight stages …
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psnet.ahrq.gov/node/40924/psn-pdf
February 23, 2015 - Interdisciplinary teamwork in hospitals: a review and
practical recommendations for improvement.
February 23, 2015
O'Leary KJ, Sehgal NL, Terrell G, et al. Interdisciplinary teamwork in hospitals: a review and practical
recommendations for improvement. J Hosp Med. 2012;7(1):48-54. doi:10.1002/jhm.970.
https://psne…
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psnet.ahrq.gov/node/35279/psn-pdf
June 30, 2009 - Results of a survey on medical error reporting systems in
Korean hospitals.
June 30, 2009
KIM J, Bates DW. Results of a survey on medical error reporting systems in Korean hospitals. Int J Med
Inform. 2005;75(2). doi:10.1016/j.ijmedinf.2005.06.005.
https://psnet.ahrq.gov/issue/results-survey-medical-error-reportin…
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psnet.ahrq.gov/node/49730/psn-pdf
April 01, 2015 - Transition to Nowhere
April 1, 2015
Farrell TW. Transition to Nowhere. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/transition-nowhere
The Case
A 75-year-old man with a history of prostate cancer, poorly controlled myotonic dystrophy, hypertension,
and chronic kidney disease was admitted to the hospital …
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psnet.ahrq.gov/issue/medicare-part-d-beneficiaries-serious-risk-opioid-misuse-or-overdose-closer-look
August 09, 2017 - Book/Report
Medicare Part D Beneficiaries at Serious Risk of Opioid Misuse or Overdose: A Closer Look.
Citation Text:
Medicare Part D Beneficiaries at Serious Risk of Opioid Misuse or Overdose: A Closer Look. HHS OIG Data Brief. Washington DC; Office of the Inspector General: May 4, 2020…
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psnet.ahrq.gov/issue/hardwiring-safety-computer-system-one-hospitals-actions-provide-technology-support-u-500
February 24, 2016 - Newspaper/Magazine Article
Hardwiring safety into the computer system: one hospital's actions to provide technology support for U-500 insulin.
Citation Text:
Hardwiring safety into the computer system: one hospital's actions to provide technology support for U-500 insulin. ISMP Medicatio…
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psnet.ahrq.gov/issue/hospital-experiences-responding-covid-19-pandemic-results-national-pulse-survey-march-23-27
December 23, 2020 - Book/Report
Classic
Hospital Experiences Responding to the COVID-19 Pandemic: Results of a National Pulse Survey March 23-27, 2020.
Citation Text:
Hospital Experiences Responding to the COVID-19 Pandemic: Results of a National Pulse Survey March 23-27, 2020. Was…
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psnet.ahrq.gov/issue/adverse-events-toolkit-clinical-guidance-identifying-harm
July 26, 2023 - Tools/Toolkit
Adverse Events Toolkit: Clinical Guidance for Identifying Harm
Citation Text:
Adverse Events Toolkit: Clinical Guidance for Identifying Harm Maxwell A. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; July 2023. Report n…
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psnet.ahrq.gov/issue/how-reliable-your-hospital-qualitative-framework-analysing-reliability-levels
October 19, 2022 - Commentary
How reliable is your hospital? A qualitative framework for analysing reliability levels.
Citation Text:
Ikkersheim DE, Berg M. How reliable is your hospital? A qualitative framework for analysing reliability levels. BMJ Qual Saf. 2011;20(9):785-790.
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psnet.ahrq.gov/issue/overlooked-condition
October 03, 2018 - Newspaper/Magazine Article
An overlooked condition.
Citation Text:
Nicholas L. An overlooked condition. For diabetics, the hospital can be a dangerous place. Modern healthcare. 2005;35(46):24.
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psnet.ahrq.gov/issue/fda-guidance-document-hospital-bed-system-dimensional-and-assessment-guidance-reduce
July 01, 2009 - Organizational Policy/Guidelines
FDA Guidance Document: Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment.
Citation Text:
FDA Guidance Document: Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment. Rockville MD: Center for Devices a…
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psnet.ahrq.gov/issue/diagnostic-safety-toolkit
December 05, 2024 - Toolkit
Diagnostic Safety Toolkit.
Citation Text:
Child Health Patient Safety Organization. Diagnostic Safety Toolkit. Washington DC: Children's Hospital Association. May 2020.
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psnet.ahrq.gov/issue/nowhere-safe-record-number-patients-contracted-covid-hospital-january
November 18, 2020 - Newspaper/Magazine Article
Nowhere is safe: record number of patients contracted Covid in the hospital in January.
Citation Text:
Nowhere is safe: record number of patients contracted Covid in the hospital in January. Levy R, Vestal AJ. Politico. February 19, 2022.
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psnet.ahrq.gov/node/43814/psn-pdf
June 21, 2015 - Improving hand hygiene at eight hospitals in the United
States by targeting specific causes of noncompliance.
June 21, 2015
Chassin MR, Mayer C, Nether K. Improving hand hygiene at eight hospitals in the United States by
targeting specific causes of noncompliance. Jt Comm J Qual Patient Saf. 2015;41(1):4-12.
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