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psnet.ahrq.gov/issue/patient-centered-care-improvement-guide
June 10, 2020 - Book/Report
Patient-Centered Care Improvement Guide.
Citation Text:
Patient-Centered Care Improvement Guide. Frampton S, Guastello S, Brady C, et al. Derby, CT: Planetree; Camden, ME: Picker Institute; 2008.
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psnet.ahrq.gov/issue/hospital-bosses-ignored-months-doctors-warnings-about-lucy-letby
September 01, 2010 - Newspaper/Magazine Article
Hospital bosses ignored months of doctors' warnings about Lucy Letby.
Citation Text:
Hospital bosses ignored months of doctors' warnings about Lucy Letby. Moritz J, Coffey J, Buchanan M. BBC News. August 19, 2023.
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psnet.ahrq.gov/issue/physicians-multiple-patient-complaints-ending-our-silence
June 01, 2004 - Commentary
Physicians with multiple patient complaints: ending our silence.
Citation Text:
Gallagher TH, Levinson W. Physicians with multiple patient complaints: ending our silence. BMJ Qual Saf. 2013;22(7):521-4. doi:10.1136/bmjqs-2013-001880.
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psnet.ahrq.gov/issue/day-passes-vulnerable-patients-psychiatric-hospitals-can-have-dangerous-even-fatal
October 29, 2014 - Newspaper/Magazine Article
Day passes for vulnerable patients of psychiatric hospitals can have dangerous, even fatal consequences.
Citation Text:
Day passes for vulnerable patients of psychiatric hospitals can have dangerous, even fatal consequences. Woodruff E. Baltimore Sun. June 9, 2…
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psnet.ahrq.gov/issue/ems-crews-brought-patients-hospital-misplaced-breathing-tubes-none-them-survived
November 20, 2019 - Newspaper/Magazine Article
EMS crews brought patients to the hospital with misplaced breathing tubes. None of them survived
Citation Text:
EMS crews brought patients to the hospital with misplaced breathing tubes. None of them survived Arditi L. Peoples Public Radio. December 3, 2019.
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psnet.ahrq.gov/issue/patient-safety-investigation-report-services-university-hospital-galway-uhg-and-reflected
June 14, 2017 - Book/Report
Patient Safety Investigation report into services at University Hospital Galway (UHG) and as reflected in the care provided to Savita Halappanavar.
Citation Text:
Patient Safety Investigation report into services at University Hospital Galway (UHG) and as reflected in the ca…
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psnet.ahrq.gov/issue/next-generation-doctors-may-be-learning-bad-habits-teaching-hospitals-many-safety-violations
June 28, 2023 - Newspaper/Magazine Article
The next generation of doctors may be learning bad habits at teaching hospitals with many safety violations.
Citation Text:
The next generation of doctors may be learning bad habits at teaching hospitals with many safety violations. Blau M. STAT. April 20, 2018…
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psnet.ahrq.gov/issue/when-medical-error-becomes-personal-activism-becomes-painful
August 21, 2019 - Newspaper/Magazine Article
When medical error becomes personal, activism becomes painful.
Citation Text:
When medical error becomes personal, activism becomes painful. Millenson M. Forbes. September 16, 2022.
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psnet.ahrq.gov/node/49770/psn-pdf
September 01, 2016 - Wrong-Time Error With High-Alert Medication
September 1, 2016
Yang A, Nelson LS. Wrong-Time Error With High-Alert Medication. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/wrong-time-error-high-alert-medication
The Case
A 60-year-old man was admitted to the hospital for a total knee arthroplasty. During th…
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psnet.ahrq.gov/node/35644/psn-pdf
January 18, 2006 - Comparison and interpretation of urinalysis performed by
a nephrologist versus a hospital-based clinical laboratory.
January 18, 2006
Tsai JJ, Yeun JY, Kumar VA, et al. Comparison and interpretation of urinalysis performed by a nephrologist
versus a hospital-based clinical laboratory. Am J Kidney Dis. 2005;46(5):82…
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psnet.ahrq.gov/node/43827/psn-pdf
January 14, 2015 - The surprising way to stay safe in the hospital.
January 14, 2015
https://psnet.ahrq.gov/issue/surprising-way-stay-safe-hospital
This news article summarizes the results of a survey exploring how patients' perceptions of respect from
hospital staff corresponds with the potential for medical error. Recommended strat…
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psnet.ahrq.gov/node/39436/psn-pdf
October 25, 2013 - HealthGrades Seventh Annual Patient Safety in American
Hospitals Study.
October 25, 2013
Golden, CO: HealthGrades, Inc.; March 2010.
https://psnet.ahrq.gov/issue/healthgrades-seventh-annual-patient-safety-american-hospitals-study
This report, the latest in an annual series, uses the Agency for Healthcare Research …
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psnet.ahrq.gov/node/46958/psn-pdf
March 28, 2018 - Disposal of paper records containing personal
information in hospitals.
March 28, 2018
Ramjist JK, Coburn N, Urbach DR, et al. Disposal of Paper Records Containing Personal Information in
Hospitals. JAMA. 2018;319(11):1162-1163. doi:10.1001/jama.2017.21533.
https://psnet.ahrq.gov/issue/disposal-paper-records-conta…
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psnet.ahrq.gov/node/40373/psn-pdf
December 21, 2014 - Increases in mortality, length of stay, and cost associated
with hospital-acquired infections in trauma patients.
December 21, 2014
Glance LG, Stone PW, Mukamel DB, et al. Increases in mortality, length of stay, and cost associated with
hospital-acquired infections in trauma patients. Arch Surg. 2011;146(7):794-801…
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psnet.ahrq.gov/node/35385/psn-pdf
January 02, 2017 - El Camino Hospital: using health information technology
to promote patient safety.
January 2, 2017
Bukunt S, Hunter C, Perkins S, et al. El Camino Hospital: Using Health Information Technology to Promote
Patient Safety. Jt Comm J Qual Patient Saf. 2016;31(10):561-565. doi:10.1016/s1553-7250(05)31073-7.
https://psn…
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psnet.ahrq.gov/node/40217/psn-pdf
April 04, 2011 - The objective impact of clinical peer review on hospital
quality and safety.
April 4, 2011
Edwards MT. The objective impact of clinical peer review on hospital quality and safety. Am J Med Qual.
2011;26(2):110-9. doi:10.1177/1062860610380732.
https://psnet.ahrq.gov/issue/objective-impact-clinical-peer-review-hospi…
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psnet.ahrq.gov/node/48182/psn-pdf
August 21, 2019 - Organizational learning in hospitals: a realist review.
August 21, 2019
Lyman B, Jacobs JD, Hammond EL, et al. Organizational learning in hospitals: A realist review. J Adv Nurs.
2019;75(11):2352-2377. doi:10.1111/jan.14091.
https://psnet.ahrq.gov/issue/organizational-learning-hospitals-realist-review
Organization…
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psnet.ahrq.gov/node/42760/psn-pdf
May 29, 2014 - Senior charge nurses' leadership behaviours in relation to
hospital ward safety: a mixed method study.
May 29, 2014
Agnew C, Flin R. Senior charge nurses' leadership behaviours in relation to hospital ward safety: a mixed
method study. Int J Nurs Stud. 2014;51(5):768-80. doi:10.1016/j.ijnurstu.2013.10.001.
https:/…
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psnet.ahrq.gov/node/43541/psn-pdf
August 28, 2017 - A step toward high reliability: implementation of a daily
safety brief in a children's hospital.
August 28, 2017
Saysana M, McCaskey M, Cox E, et al. A Step Toward High Reliability: Implementation of a Daily Safety
Brief in a Children's Hospital. J Patient Saf. 2017;13(3):149-152. doi:10.1097/PTS.0000000000000131.
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psnet.ahrq.gov/node/36835/psn-pdf
July 08, 2008 - Predicting future staffing needs at teaching hospitals: use
of an analytical program with multiple variables.
July 8, 2008
Mitchell CC, Ashley SW, Zinner MJ, et al. Predicting future staffing needs at teaching hospitals: use of an
analytical program with multiple variables. Arch Surg. 2007;142(4):329-34.
https://p…