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psnet.ahrq.gov/issue/delayed-rapid-response-team-activation-associated-increased-hospital-mortality-morbidity-and
March 16, 2022 - Study
Delayed rapid response team activation is associated with increased hospital mortality, morbidity, and length of stay in a tertiary care institution.
Citation Text:
Barwise A, Thongprayoon C, Gajic O, et al. Delayed Rapid Response Team Activation Is Associated With Increased Hospit…
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psnet.ahrq.gov/issue/impact-medication-reconciliation-improving-transitions-care
June 19, 2019 - Review
Emerging Classic
Impact of medication reconciliation for improving transitions of care.
Citation Text:
Redmond P, Grimes TC, McDonnell R, et al. Impact of medication reconciliation for improving transitions of care. Cochrane Database Syst Rev. 2018;8(8):C…
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psnet.ahrq.gov/issue/two-year-longitudinal-assessment-physicians-perceptions-after-replacement-longstanding
December 31, 2014 - Study
Two-year longitudinal assessment of physicians' perceptions after replacement of a longstanding homegrown electronic health record: does a J-curve of satisfaction really exist?
Citation Text:
Hanauer DA, Branford GL, Greenberg G, et al. Two-year longitudinal assessment of physician…
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psnet.ahrq.gov/issue/learning-lawsuits-using-malpractice-claims-data-develop-care-transitions-planning-tools
January 21, 2019 - Study
Learning from lawsuits: using malpractice claims data to develop care transitions planning tools.
Citation Text:
Arbaje AI, Werner NE, Kasda EM, et al. Learning From Lawsuits: Using Malpractice Claims Data to Develop Care Transitions Planning Tools. J Patient Saf. 2020;16(1):52-57.…
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psnet.ahrq.gov/issue/time-take-hearing-loss-seriously
September 23, 2020 - Commentary
Time to take hearing loss seriously.
Citation Text:
Blustein J, Wallhagen MI, Weinstein BE, et al. Time to take hearing loss seriously. Jt Comm J Qual Patient Saf. 2019;46(1):53-58. doi:10.1016/j.jcjq.2019.10.003.
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psnet.ahrq.gov/issue/use-audit-feedback-implementation-strategy-promote-medication-error-reporting-nurses
March 24, 2021 - Study
Use of an audit with feedback implementation strategy to promote medication error reporting by nurses.
Citation Text:
Hutchinson A, Brotto V, Chapman A, et al. Use of an audit with feedback implementation strategy to promote medication error reporting by nurses. J Clin Nurs. 2020;2…
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psnet.ahrq.gov/issue/shared-understanding-resilient-practices-context-inpatient-suicide-prevention-narrative
December 23, 2020 - Study
Shared understanding of resilient practices in the context of inpatient suicide prevention: a narrative synthesis.
Citation Text:
Berg SH, Rørtveit K, Walby FA, et al. Shared understanding of resilient practices in the context of inpatient suicide prevention: a narrative synthesis.…
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psnet.ahrq.gov/node/866395/psn-pdf
July 23, 2024 - Rescue Improvement Conference Innovation Summary
July 23, 2024
https://psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary
Summary
The Rescue Improvement Conference (RIC)1 was designed at the University of Michigan to address failure
to rescue with a particular focus on communication and com…
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psnet.ahrq.gov/node/35222/psn-pdf
August 03, 2005 - Hospitals study when to apologize to patients.
August 3, 2005
Kowalczyk L.
https://psnet.ahrq.gov/issue/hospitals-study-when-apologize-patients
This article reports on a proposed disclosure policy among Harvard Medical School teaching hospitals. The
policy would outline a process for discussing error with patients…
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psnet.ahrq.gov/node/35098/psn-pdf
June 15, 2005 - Hospital takes a page from Toyota.
June 15, 2005
Connolly C.
https://psnet.ahrq.gov/issue/hospital-takes-page-toyota
This article reports on one hospital's adoption of Japanese business philosophy to improve its cancer
center. The approach, adapted from Toyota Motor Corporation, is focused on high quality, efficie…
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psnet.ahrq.gov/node/38845/psn-pdf
August 05, 2009 - Hospitals tally their avoidable mistakes.
August 5, 2009
Rein L. Washington Post. July 21, 2009:E1.
https://psnet.ahrq.gov/issue/hospitals-tally-their-avoidable-mistakes
This news article reports on Washington, DC–area initiatives to track preventable patient injury and
discusses strategies to hold hospitals accou…
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psnet.ahrq.gov/node/33961/psn-pdf
May 04, 2015 - Statement of The Hospital & Healthsystem Association of
Pennsylvania.
May 4, 2015
Combes J; Hospital & Healthsystem Association of Pennsylvania
https://psnet.ahrq.gov/issue/statement-hospital-healthsystem-association-pennsylvania
This statement introduces the Pennsylvania Patient Safety Reporting System (PA-PSRS),…
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psnet.ahrq.gov/node/37991/psn-pdf
August 16, 2008 - Hospitals shine light on mistakes by publicly saying:
"we're sorry."
August 16, 2008
O'Reilly KB.
https://psnet.ahrq.gov/issue/hospitals-shine-light-mistakes-publicly-saying-were-sorry
This article reports on hospital officials' public admissions of error and discusses the potential impact of
these disclosures on…
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psnet.ahrq.gov/node/36230/psn-pdf
June 13, 2011 - Hospitals put emphasis on collection of medication data.
June 13, 2011
Krizner K. Managed Healthcare Executive. August 1, 2006.
https://psnet.ahrq.gov/issue/hospitals-put-emphasis-collection-medication-data
This article describes several hospital-based medication reconciliation efforts.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/42373/psn-pdf
June 19, 2013 - Hospitals lagging in PSO contracts.
June 19, 2013
Clarke C. HealthLeaders Media. June 6, 2013.
https://psnet.ahrq.gov/issue/hospitals-lagging-pso-contracts
This news piece examines why few hospitals participate in the AHRQ Patient Safety Organizations
program.
https://psnet.ahrq.gov/issue/hospitals-lagging-pso-co…
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psnet.ahrq.gov/node/35847/psn-pdf
April 12, 2006 - Hospital-acquired Infections in Pennsylvania.
April 12, 2006
PHC4 Research Briefs. 2006(9):1-4.
https://psnet.ahrq.gov/issue/hospital-acquired-infections-pennsylvania-0
This report presents findings from data collected in Pennsylvania related to hospital-acquired infection and
how it affects length of stay, death …
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psnet.ahrq.gov/node/37490/psn-pdf
January 23, 2008 - Battling hospital-acquired infections.
January 23, 2008
Gross T; Shannon R. NPR. January 9, 2008.
https://psnet.ahrq.gov/issue/battling-hospital-acquired-infections
This interview with Richard Shannon, MD, addresses the safety consequences of hospital-acquired
infections and discusses prevention tactics for health…
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psnet.ahrq.gov/node/41310/psn-pdf
September 12, 2016 - Hospitals scramble on the front lines of drug shortages.
September 12, 2016
Sun LH. Washington Post. April 10, 2012.
https://psnet.ahrq.gov/issue/hospitals-scramble-front-lines-drug-shortages
This newspaper article discusses strategies hospitals are using to address drug shortages.
https://psnet.ahrq.gov/issue/ho…
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psnet.ahrq.gov/node/35589/psn-pdf
June 17, 2010 - Health for life. Keys to safer hospitals.
June 17, 2010
Berwick DM. Health for life. 6 keys to safer hospitals. Newsweek. 2005;146(24):76-8.
https://psnet.ahrq.gov/issue/health-life-keys-safer-hospitals
Institute for Healthcare Improvement President Don Berwick summarizes the six improvement measures of
the 100K L…
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psnet.ahrq.gov/node/35691/psn-pdf
February 08, 2006 - Recommendations for Safe Use of Insulin in Hospitals.
February 8, 2006
Bethesda MD: American Society of Health-system Pharmacists, Hospital and Health-System Association of
Pennsylvania; 2004.
https://psnet.ahrq.gov/issue/recommendations-safe-use-insulin-hospitals
This report contains recommendations from a panel …