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psnet.ahrq.gov/node/60356/psn-pdf
May 20, 2020 - How the pandemic is reshaping hospital architecture and
design.
May 20, 2020
Booker C. PBSNewshour Weekend. May 10, 2020.
https://psnet.ahrq.gov/issue/how-pandemic-reshaping-hospital-architecture-and-design
Built environment characteristics can contribute to the spread of infection. This news segment discusses
de…
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psnet.ahrq.gov/node/60565/psn-pdf
June 03, 2020 - The public has been forgiving. But hospitals got some
things wrong.
June 3, 2020
Ofri D. The public has been forgiving. But hospitals got some things wrong. New York Times. 2020; May
21.
https://psnet.ahrq.gov/issue/public-has-been-forgiving-hospitals-got-some-things-wrong
The complexity of the COVID-19 crisis cr…
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psnet.ahrq.gov/node/39751/psn-pdf
August 11, 2010 - Interpreting adverse drug reaction (ADR) reports as
hospital patient safety incidents.
August 11, 2010
Davies EC, Green CF, Mottram DR, et al. Interpreting adverse drug reaction (ADR) reports as hospital
patient safety incidents. Br J Clin Pharmacol. 2010;70(1):102-8. doi:10.1111/j.1365-2125.2010.03671.x.
https://…
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psnet.ahrq.gov/node/50757/psn-pdf
December 18, 2019 - As university hospital hounds debtors, doctors say it's
doing harm.
December 18, 2019
Garcia-Navarro L. Weekend Edition Sunday. National Public Radio. December 1, 2019.
https://psnet.ahrq.gov/issue/university-hospital-hounds-debtors-doctors-say-its-doing-harm
Financial harms occur in health care due to a variety o…
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psnet.ahrq.gov/node/41040/psn-pdf
January 04, 2012 - Implementing an electronic medical record with
computerized prescriber order entry at a critical access
hospital.
January 4, 2012
Horning R. Implementing an electronic medical record with computerized prescriber order entry at a critical
access hospital. Am J Health Syst Pharm. 2011;68(23):2288-92. doi:10.2146/ajh…
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psnet.ahrq.gov/node/42203/psn-pdf
April 17, 2013 - What do hospital staff in the UK think are the causes of
penicillin medication errors?
April 17, 2013
Wilcock M, Harding G, Moore L, et al. What do hospital staff in the UK think are the causes of penicillin
medication errors? Int J Clin Pharm. 2012;35(1). doi:10.1007/s11096-012-9708-1.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/42477/psn-pdf
August 07, 2013 - Review into the Quality of Care and Treatment Provided
by 14 Hospital Trusts in England: Overview Report.
August 7, 2013
Keogh B. London, UK: National Health Service; July 2013.
https://psnet.ahrq.gov/issue/review-quality-care-and-treatment-provided-14-hospital-trusts-england-
overview-report
Outlining findings f…
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psnet.ahrq.gov/node/43621/psn-pdf
October 22, 2014 - Multidisciplinary in-hospital teams improve patient
outcomes: a review.
October 22, 2014
Epstein NE. Multidisciplinary in-hospital teams improve patient outcomes: A review. Surg Neurol Int.
2014;5(Suppl 7):S295-303. doi:10.4103/2152-7806.139612.
https://psnet.ahrq.gov/issue/multidisciplinary-hospital-teams-improve…
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psnet.ahrq.gov/node/846459/psn-pdf
March 22, 2023 - Few hospitals are willing to bear the cost of providing
psychiatric care for kids.
March 22, 2023
Schorsch K, Karp S. WBEZ Chicago. March 9, 2023.
https://psnet.ahrq.gov/issue/few-hospitals-are-willing-bear-cost-providing-psychiatric-care-kids
Pediatric mental health is a patient safety concern. This news story ou…
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psnet.ahrq.gov/node/38561/psn-pdf
April 15, 2009 - Health-Care–Associated Infections in Hospitals:
Continuing Leadership Needed from HHS to Prioritize
Prevention Practices and Improve Data on These
Infections.
April 15, 2009
Subcommittee on Health Care, Committee on Finance, US Senate, Government Accountability Office,
GAO-09-516T (March 18, 2009)
https://psnet.…
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psnet.ahrq.gov/node/40537/psn-pdf
June 15, 2011 - Rural nurses' safeguarding work: reembodying patient
safety.
June 15, 2011
MacKinnon K. Rural nurses' safeguarding work: reembodying patient safety. ANS Adv Nurs Sci.
2011;34(2):119-129. doi:10.1097/ANS.0b013e3182186b86.
https://psnet.ahrq.gov/issue/rural-nurses-safeguarding-work-reembodying-patient-safety
Rural …
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psnet.ahrq.gov/node/46605/psn-pdf
January 24, 2018 - The impact of interruptions on medication errors in
hospitals: an observational study of nurses.
January 24, 2018
Johnson M, Sanchez P, Langdon R, et al. The impact of interruptions on medication errors in hospitals: an
observational study of nurses. J Nurs Manag. 2017;25(7):498-507. doi:10.1111/jonm.12486.
https:…
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psnet.ahrq.gov/node/44241/psn-pdf
November 09, 2015 - The overlooked danger of delirium in hospitals.
November 9, 2015
Boodman SG. The Atlantic. June 7, 2015.
https://psnet.ahrq.gov/issue/overlooked-danger-delirium-hospitals
Delirium is a common unintended consequence of hospitalization, most often following a surgical
procedure. This magazine article discusses chara…
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psnet.ahrq.gov/node/845655/psn-pdf
March 08, 2023 - Crisis in the Lakeshore Hospital ER.
March 8, 2023
Derfel A. Montreal Gazette. February 24- March 1, 2023
https://psnet.ahrq.gov/issue/crisis-lakeshore-hospital-er
Emergency room failures are often rooted in system weaknesses. This series examines six patient deaths
associated with emergency care that, w…
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psnet.ahrq.gov/node/41302/psn-pdf
April 18, 2012 - A review of patient safety measures based on routinely
collected hospital data.
April 18, 2012
Tsang C, Palmer WL, Bottle A, et al. A review of patient safety measures based on routinely collected
hospital data. Am J Med Qual. 2012;27(2):154-69. doi:10.1177/1062860611414697.
https://psnet.ahrq.gov/issue/review-pat…
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psnet.ahrq.gov/node/48054/psn-pdf
June 26, 2019 - Lessons learned from a death outside a hospital's
doorstep.
June 26, 2019
Palmer J. Patient Saf Qual Healthc. May/June 2019.
https://psnet.ahrq.gov/issue/lessons-learned-death-outside-hospitals-doorstep
Organizations must learn from adverse events to prevent similar incidents. Reporting on lessons to be
learned f…
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psnet.ahrq.gov/node/33571/psn-pdf
March 15, 2025 - Reporting Patient Safety Events
March 15, 2025
Reporting Patient Safety Events. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/reporting-patient-safety-events
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in th…
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psnet.ahrq.gov/node/37613/psn-pdf
March 12, 2008 - Implementing patient safety interventions in your
hospital: what to try and what to avoid.
March 12, 2008
Ranji SR, Shojania KG. Implementing patient safety interventions in your hospital: what to try and what to
avoid. Med Clin North Am. 2008;92(2):275-93, vii-viii. doi:10.1016/j.mcna.2007.10.007.
https://psnet.a…
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psnet.ahrq.gov/node/38733/psn-pdf
July 13, 2009 - Full implementation of computerized physician order
entry and medication-related quality outcomes: a study of
3364 hospitals.
July 13, 2009
Yu FB, Menachemi N, Berner ES, et al. Full implementation of computerized physician order entry and
medication-related quality outcomes: a study of 3364 hospitals. Am J Med Qu…
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psnet.ahrq.gov/node/38902/psn-pdf
November 13, 2009 - Out-of-hospital medication errors: a 6-year analysis of the
national poison data system.
November 13, 2009
Shah K, Barker KA. Out-of-hospital medication errors: a 6-year analysis of the national poison data system.
Pharmacoepidemiol Drug Saf. 2009;18(11):1080-5. doi:10.1002/pds.1823.
https://psnet.ahrq.gov/issue/o…