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psnet.ahrq.gov/node/36021/psn-pdf
September 24, 2016 - Operational failures and interruptions in hospital nursing.
September 24, 2016
Tucker AL, Spear SJ. Operational failures and interruptions in hospital nursing. Health Serv Res. 2006;41(3
Pt 1):643-662.
https://psnet.ahrq.gov/issue/operational-failures-and-interruptions-hospital-nursing
This study discovered that n…
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psnet.ahrq.gov/node/44066/psn-pdf
September 21, 2016 - Raising an alarm, doctors fight to yank hospital ICUs into
the modern era.
September 21, 2016
McFarling UL. STAT. September 7, 2016.
https://psnet.ahrq.gov/issue/raising-alarm-doctors-fight-yank-hospital-icus-modern-era
Intensive care units (ICUs) are complex environments that harbor various challenges to safe car…
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psnet.ahrq.gov/node/74722/psn-pdf
February 02, 2022 - Preventing and mitigating radiology system failures: a
guide to disaster planning.
February 2, 2022
Gibney BT, Roberts JM, D'Ortenzio RM, et al. Preventing and mitigating radiology system failures: a guide
to disaster planning. RadioGraphics. 2021;41(7):2111-2126. doi:10.1148/rg.2021210083.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/37612/psn-pdf
February 15, 2011 - Can we use incident reports to detect hospital adverse
events?
February 15, 2011
Blais R; Bruno D; Bartlett G; Tamblyn R.
https://psnet.ahrq.gov/issue/can-we-use-incident-reports-detect-hospital-adverse-events
Incident reporting systems are ubiquitous, despite a lack of evidence supporting their utility in identif…
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psnet.ahrq.gov/node/33904/psn-pdf
January 25, 2016 - Healthcare Cost and Utilization Project (HCUP).
January 25, 2016
Agency for Healthcare Research and Quality.
https://psnet.ahrq.gov/issue/healthcare-cost-and-utilization-project-hcup
The Healthcare Cost and Utilization Project (HCUP) is a family of databases and related software tools and
products developed throug…
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psnet.ahrq.gov/node/43639/psn-pdf
October 29, 2014 - Ebola case raises concern about everyday hospital
safety.
October 29, 2014
Rodricks D. Baltimore Sun. October 14, 2014.
https://psnet.ahrq.gov/issue/ebola-case-raises-concern-about-everyday-hospital-safety
Although significant progress has been made in improving patient safety over the past decade, many
medical e…
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psnet.ahrq.gov/node/867754/psn-pdf
March 12, 2025 - Decision fatigue in hospital settings: a scoping review.
March 12, 2025
Perry K, Jones S, Stumpff JC, et al. Decision fatigue in hospital settings: a scoping review. J Hosp Med.
2024;Epub Nov 11. doi:10.1002/jhm.13550.
https://psnet.ahrq.gov/issue/decision-fatigue-hospital-settings-scoping-review
Production pressu…
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psnet.ahrq.gov/node/73077/psn-pdf
March 24, 2021 - Well-Being Playbook 2.0. A COVID-19 Resource for
Hospital and Health System Leaders.
March 24, 2021
AHA Physician Alliance. Chicago, IL: American Hospital Association. February 2021.
https://psnet.ahrq.gov/issue/well-being-playbook-20-covid-19-resource-hospital-and-health-system-leaders
Human factors enginee…
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psnet.ahrq.gov/node/41715/psn-pdf
October 03, 2017 - Unaccountable: What Hospitals Won't Tell You and How
Transparency Can Revolutionize Health Care.
October 3, 2017
Makary M. New York, NY: Bloomsbury Press; 2012. ISBN: 9781608198368.
https://psnet.ahrq.gov/issue/unaccountable-what-hospitals-wont-tell-you-and-how-transparency-can-
revolutionize-health-care
This boo…
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psnet.ahrq.gov/node/42914/psn-pdf
June 18, 2014 - 2013 John M. Eisenberg Patient Safety and Quality Award
Recipients Announced.
June 18, 2014
Joint Commission. January 27, 2014.
https://psnet.ahrq.gov/issue/2013-john-m-eisenberg-patient-safety-and-quality-award-recipients-announced
The Eisenberg Award honors individuals and organizations who have made vital accom…
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psnet.ahrq.gov/node/33671/psn-pdf
July 01, 2008 - The Soil, Not the Seed: The Real Problem with Root
Cause Analysis
July 1, 2008
Spath P, Minogue W. The Soil, Not the Seed: The Real Problem with Root Cause Analysis. PSNet
[internet]. 2008.
https://psnet.ahrq.gov/perspective/soil-not-seed-real-problem-root-cause-analysis
Perspective
Throughout most of his life, …
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psnet.ahrq.gov/perspective/peacehealth-governance-journey-support-quality-and-safety
August 01, 2007 - The PeaceHealth Governance Journey in Support of Quality and Safety
John L. Haughom,
MD | August 1, 2007
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Haughom JL. The PeaceHealth Governance Journey in Support of Quality and …
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psnet.ahrq.gov/issue/evaluation-association-between-nursing-home-survey-patient-safety-culture-nhsops-measures-and
April 05, 2017 - Study
Evaluation of the association between Nursing Home Survey on Patient Safety culture (NHSOPS) measures and catheter-associated urinary tract infections: results of a national collaborative.
Citation Text:
Smith SN, Greene MT, Mody L, et al. Evaluation of the association between Nurs…
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psnet.ahrq.gov/node/853072/psn-pdf
September 01, 2014 - Compendium of Strategies to Prevent HAIs in Acute Care
Hospitals 2014.
September 1, 2014
Infect Control Hosp Epidemiol. 2014;35(Suppl 2):s1-s178;35:460-463;797-801.
https://psnet.ahrq.gov/issue/compendium-strategies-prevent-hais-acute-care-hospitals-2014
Preventing healthcare-acquired infections (HAIs) remains a p…
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psnet.ahrq.gov/node/44172/psn-pdf
September 28, 2016 - Preventing high-alert medication errors in hospital
patients.
September 28, 2016
Anderson P, Townsend T. Am Nurse Today. May 2015;10:18-23.
https://psnet.ahrq.gov/issue/preventing-high-alert-medication-errors-hospital-patients
High-alert medications have the potential to cause serious patient harm. This article fo…
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psnet.ahrq.gov/node/34811/psn-pdf
March 28, 2005 - Medication error prevention by clinical pharmacists in two
children's hospitals.
March 28, 2005
Folli HL; Poole RL; Benitz WE; Russo JC
https://psnet.ahrq.gov/issue/medication-error-prevention-clinical-pharmacists-two-childrens-hospitals
This prospective study recorded the rate and potential for harm caused by err…
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psnet.ahrq.gov/node/50744/psn-pdf
December 18, 2019 - EMS crews brought patients to the hospital with
misplaced breathing tubes. None of them survived
December 18, 2019
Arditi L. Peoples Public Radio. December 3, 2019.
https://psnet.ahrq.gov/issue/ems-crews-brought-patients-hospital-misplaced-breathing-tubes-none-them-
survived
Emergency medical services are often p…
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psnet.ahrq.gov/node/73589/psn-pdf
August 11, 2021 - Suicide and suicide attempts on hospital grounds and
clinic areas.
August 11, 2021
Mills PD, Watts BV, Hemphill RR. Suicide and suicide attempts on hospital grounds and clinic areas. J
Patient Saf. 2021;17(5):e423-e428. doi:10.1097/pts.0000000000000356.
https://psnet.ahrq.gov/issue/suicide-and-suicide-attempts-hos…
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psnet.ahrq.gov/node/852801/psn-pdf
August 23, 2023 - Nearly all hospital pharmacists say drug shortages are
negatively impacting care; a third say impacts are
‘critical.’
August 23, 2023
McPhillips D. CNN. August 10, 2023.
https://psnet.ahrq.gov/issue/nearly-all-hospital-pharmacists-say-drug-shortages-are-negatively-impacting-
care-third-say
Drug shortages present…
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psnet.ahrq.gov/node/838312/psn-pdf
October 12, 2022 - Causes of adverse events in home mechanical
ventilation: a nursing perspective.
October 12, 2022
Lipprandt M, Liedtke W, Langanke M, et al. Causes of adverse events in home mechanical ventilation: a
nursing perspective. BMC Nurs. 2022;21(1):264. doi:10.1186/s12912-022-01038-2.
https://psnet.ahrq.gov/issue/causes-a…