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psnet.ahrq.gov/issue/managing-costs-clinical-negligence-trusts
March 28, 2018 - Book/Report
Managing the Costs of Clinical Negligence in Trusts.
Citation Text:
Managing the Costs of Clinical Negligence in Trusts. Comptroller and Auditor General, Department of Health; London, UK: National Audit Office; 2017. ISBN: 9781786041395.
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psnet.ahrq.gov/issue/unaccountable-what-hospitals-wont-tell-you-and-how-transparency-can-revolutionize-health-care
July 07, 2021 - Book/Report
Unaccountable: What Hospitals Won't Tell You and How Transparency Can Revolutionize Health Care.
Citation Text:
Unaccountable: What Hospitals Won't Tell You and How Transparency Can Revolutionize Health Care. Makary M. New York, NY: Bloomsbury Press; 2012. ISBN: 9781608198368…
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psnet.ahrq.gov/node/49492/psn-pdf
November 01, 2005 - Reconciling Doses
November 1, 2005
Federico F. Reconciling Doses. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/reconciling-doses
Case Objectives
List the steps involved in medication reconciliation.
Describe the role of each of the stakeholders in medication reconciliation.
Discuss how medication reconc…
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psnet.ahrq.gov/node/49592/psn-pdf
October 01, 2009 - Danger in Disruption
October 1, 2009
Fontaine DK. Danger in Disruption. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/danger-disruption
The Case
A 23-month-old toddler was severely dehydrated after vomiting due to gastric outlet obstruction. She had
metabolic alkalosis (pH = 7.58), and her last peripheral…
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psnet.ahrq.gov/node/49788/psn-pdf
March 01, 2017 - Correct Treatment Plan for Incorrect Diagnosis: A
Pharmacist Intervention
March 1, 2017
Nelson SD. Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention. PSNet [internet].
2017.
https://psnet.ahrq.gov/web-mm/correct-treatment-plan-incorrect-diagnosis-pharmacist-intervention
The Case
A 48-year…
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psnet.ahrq.gov/node/46068/psn-pdf
July 09, 2018 - A national survey assessing the number of records
allowed open in electronic health records at hospitals and
ambulatory sites.
July 9, 2018
Adelman JS, Berger MA, Rai A, et al. A national survey assessing the number of records allowed open in
electronic health records at hospitals and ambulatory sites. J Am Med In…
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psnet.ahrq.gov/node/41458/psn-pdf
June 19, 2012 - What stops hospital clinical staff from following
protocols? An analysis of the incidence and factors
behind the failure of bedside clinical staff to activate the
rapid response system in a multi-campus Australian
metropolitan healthcare service.
June 19, 2012
Shearer B, Marshall S, Buist MD, et al. What stops ho…
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psnet.ahrq.gov/node/33829/psn-pdf
March 01, 2017 - Our Maturing Understanding of Safety Culture: How to
Change It and How It Changes Safety
March 1, 2017
Singer SJ. Our Maturing Understanding of Safety Culture: How to Change It and How It Changes Safety.
PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/our-maturing-understanding-safety-culture-how-change…
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psnet.ahrq.gov/primer/measurement-patient-safety
September 15, 2024 - Measurement of Patient Safety
Citation Text:
Measurement of Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…
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psnet.ahrq.gov/node/48058/psn-pdf
June 19, 2019 - Organisational learning in hospitals: a concept analysis.
June 19, 2019
Lyman B, Hammond EL, Cox JR. Organisational learning in hospitals: A concept analysis. J Nurs Manag.
2019;27(3):633-646. doi:10.1111/jonm.12722.
https://psnet.ahrq.gov/issue/organisational-learning-hospitals-concept-analysis
Organizations are …
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psnet.ahrq.gov/node/858166/psn-pdf
December 13, 2023 - Pay practices and safety organizing: evidence from
hospital nursing units.
December 13, 2023
Conroy SA, Vogus TJ. Pay practices and safety organizing: evidence from hospital nursing units. Health
Care Manage Rev. 2023;49(1):68-73. doi:10.1097/hmr.0000000000000392.
https://psnet.ahrq.gov/issue/pay-practices-and-saf…
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psnet.ahrq.gov/node/44065/psn-pdf
July 16, 2015 - Nurses' use of computerized clinical guidelines to
improve patient safety in hospitals.
July 16, 2015
Hovde B, Jensen KH, Alexander GL, et al. Nurses' Use of Computerized Clinical Guidelines to Improve
Patient Safety in Hospitals. West J Nurs Res. 2015;37(7):877-98. doi:10.1177/0193945915577430.
https://psnet.ahrq…
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psnet.ahrq.gov/node/43945/psn-pdf
September 09, 2015 - Hospital and procedure incidence of pediatric retained
surgical items.
September 9, 2015
Wang B, Tashiro J, Perez EA, et al. Hospital and procedure incidence of pediatric retained surgical items. J
Surg Res. 2015;198(2):400-5. doi:10.1016/j.jss.2015.03.054.
https://psnet.ahrq.gov/issue/hospital-and-procedure-incid…
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psnet.ahrq.gov/node/46449/psn-pdf
September 27, 2017 - VA hospitals flooded with complaints about care.
September 27, 2017
Estes A. Boston Globe. September 16, 2017.
https://psnet.ahrq.gov/issue/va-hospitals-flooded-complaints-about-care
Psychological safety can empower staff to communicate concerns that affect patient safety. This
newspaper article reports on Veteran…
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psnet.ahrq.gov/node/43568/psn-pdf
April 25, 2016 - Medication safety in the operating room: a survey of
preparation methods and drug concentration
consistencies in children's hospitals in the United States.
April 25, 2016
Shaw RE, Litman RS. Medication Safety in the Operating Room: A Survey of Preparation Methods and
Drug Concentration Consistencies in Children's …
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psnet.ahrq.gov/node/44712/psn-pdf
December 09, 2015 - The effect of contact precautions on frequency of hospital
adverse events.
December 9, 2015
Croft LD, Liquori M, Ladd J, et al. The Effect of Contact Precautions on Frequency of Hospital Adverse
Events. Infect Control Hosp Epidemiol. 2015;36(11):1268-74. doi:10.1017/ice.2015.192.
https://psnet.ahrq.gov/issue/effec…
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psnet.ahrq.gov/node/47998/psn-pdf
May 08, 2019 - An organization-specific and modifiable inpatient safety
composite measure.
May 8, 2019
Smith PK, Amster A. An Organization-Specific and Modifiable Inpatient Safety Composite Measure. Jt
Comm J Qual Patient Saf. 2019;45(4):304-314. doi:10.1016/j.jcjq.2018.11.005.
https://psnet.ahrq.gov/issue/organization-specific-…
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psnet.ahrq.gov/node/74115/psn-pdf
November 24, 2021 - How low can they go? Rural hospitals weigh keeping
obstetric units when births decline.
November 24, 2021
Huff C. Kaiser Health News. November 12, 2021.
https://psnet.ahrq.gov/issue/how-low-can-they-go-rural-hospitals-weigh-keeping-obstetric-units-when-
births-decline
This article discusses the challenge of provi…
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psnet.ahrq.gov/node/46148/psn-pdf
May 31, 2017 - Implementation of a structured hospital-wide morbidity
and mortality rounds model.
May 31, 2017
Kwok ESH, Calder LA, Barlow-Krelina E, et al. Implementation of a structured hospital-wide morbidity and
mortality rounds model. BMJ Qual Saf. 2017;26(6):439-448. doi:10.1136/bmjqs-2016-005459.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/44352/psn-pdf
August 12, 2015 - Hospital checklists are meant to save lives—so why do
they often fail?
August 12, 2015
Anthes E. Hospital checklists are meant to save lives - so why do they often fail? Nature.
2015;523(7562):516-8. doi:10.1038/523516a.
https://psnet.ahrq.gov/issue/hospital-checklists-are-meant-save-lives-so-why-do-they-often-fai…