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psnet.ahrq.gov/node/60237/psn-pdf
April 15, 2020 - Coronavirus strains hospitals, cancer patients face
treatment delays, uncertainty.
April 15, 2020
Stone W. Health Shots. National Public Radio. April 2, 2020.
https://psnet.ahrq.gov/issue/coronavirus-strains-hospitals-cancer-patients-face-treatment-delays-
uncertainty
Lack of access to services is emerging as a p…
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psnet.ahrq.gov/node/48134/psn-pdf
August 14, 2019 - Root cause analysis for hospital-acquired pressure injury.
August 14, 2019
Black JM. Root cause analysis for hospital-acquired pressure injury. J Wound Ostomy Continence Nurs.
2019;46(4):298-304. doi:10.1097/WON.0000000000000546.
https://psnet.ahrq.gov/issue/root-cause-analysis-hospital-acquired-pressure-injury
Pr…
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psnet.ahrq.gov/node/863763/psn-pdf
March 06, 2024 - After his wife died, he joined nurses to push for new
staffing rules in hospitals.
March 6, 2024
Wells K. Health Shots. KFF News and Michigan Public. February 22, 2024.
https://psnet.ahrq.gov/issue/after-his-wife-died-he-joined-nurses-push-new-staffing-rules-hospitals
Mandatory staffing ratios are a controversial …
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psnet.ahrq.gov/node/46522/psn-pdf
October 29, 2017 - Public reporting of surgical outcomes: surgeons,
hospitals, or both?
October 29, 2017
Jha AK. Public Reporting of Surgical Outcomes: Surgeons, Hospitals, or Both? JAMA. 2017;318(15):1429-
1430. doi:10.1001/jama.2017.13815.
https://psnet.ahrq.gov/issue/public-reporting-surgical-outcomes-surgeons-hospitals-or-both
…
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psnet.ahrq.gov/node/44872/psn-pdf
February 12, 2016 - Reducing preventable harm in hospitals.
February 12, 2016
Bornstein D. New York Times. January 26, and February 2, 2016.
https://psnet.ahrq.gov/issue/reducing-preventable-harm-hospitals
Discussing the importance of designing safeguards to prevent system failures that can result in patient
harm, this two-part newsp…
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psnet.ahrq.gov/node/34591/psn-pdf
January 04, 2017 - John M. Eisenberg Patient Safety Awards. Safety,
effectiveness, and efficiency: a Web-based virtual
anticoagulation clinic.
January 4, 2017
Kelly JJ, Sweigard KW, Shields K, et al. John M. Eisenberg Patient Safety Awards. Safety, effectiveness,
and efficiency: a Web-based virtual anticoagulation clinic. Jt Comm J …
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psnet.ahrq.gov/node/849614/psn-pdf
May 31, 2023 - Hospitals in two states denied an abortion to a
miscarrying patient. Investigators say they broke federal
law.
May 31, 2023
Surana K. Pro Publica. May 19, 2023.
https://psnet.ahrq.gov/issue/hospitals-two-states-denied-abortion-miscarrying-patient-investigators-say-
they-broke-federal
The unintended clinical cons…
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psnet.ahrq.gov/node/42915/psn-pdf
January 01, 2016 - Reducing Avoidable Readmissions Effectively campaign:
a statewide collaborative.
February 5, 2014
McCoy KA, Bear-Pfaffendorf K, Foreman JK, et al. Reducing Avoidable Hospital Readmissions Effectively:
A Statewide Campaign. Joint Comm J Qual Patient Saf. 2016;40(5):198-204, AP2. doi:10.1016/s1553-
7250(14)40026-6.
…
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psnet.ahrq.gov/node/47850/psn-pdf
March 27, 2019 - Medicines-related harm in the elderly post-hospital
discharge.
March 27, 2019
Cheong V-L, Tomlinson J, Khan S, et al. Prescriber. 2019;30:29-34.
https://psnet.ahrq.gov/issue/medicines-related-harm-elderly-post-hospital-discharge
Geriatric patients are particularly vulnerable to medication-related harm. This articl…
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psnet.ahrq.gov/node/846756/psn-pdf
March 29, 2023 - Frequency of medication administration timing error in
hospitals: a systematic review.
March 29, 2023
Pullam T, Russell CL, White-Lewis S. Frequency of medication administration timing error in hospitals: a
systematic review. J Nurs Care Qual. 2023;38(2):126-133. doi:10.1097/ncq.0000000000000668.
https://psnet.ahr…
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psnet.ahrq.gov/node/44901/psn-pdf
March 30, 2016 - Medication safety pharmacy technician in a large, tertiary
care, community hospital.
March 30, 2016
Brown KN, Bergsbaken J, Reichard JS. Medication safety pharmacy technician in a large, tertiary care,
community hospital. Am J Health Syst Pharm. 2016;73(4):188-191. doi:10.2146/ajhp150098.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/issue/100k-lives-falling-short
November 11, 2015 - Newspaper/Magazine Article
100K Lives falling short.
Citation Text:
100K Lives falling short. Robeznieks A.
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…
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psnet.ahrq.gov/node/44026/psn-pdf
November 03, 2015 - Effect of a postdischarge virtual ward on readmission or
death for high-risk patients: a randomized clinical trial.
November 3, 2015
Dhalla IA, O'Brien T, Morra D, et al. Effect of a postdischarge virtual ward on readmission or death for high-
risk patients: a randomized clinical trial. JAMA. 2014;312(13):1305-12. …
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psnet.ahrq.gov/node/46296/psn-pdf
September 24, 2017 - Perception of safety of surgical practice among operating
room personnel from survey data is associated with all-
cause 30-day postoperative death rate in South Carolina.
September 24, 2017
Molina G, Berry WR, Lipsitz S, et al. Perception of Safety of Surgical Practice Among Operating Room
Personnel From Survey Da…
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psnet.ahrq.gov/issue/patient-safety-0
February 28, 2015 - Government Resource
Patient Safety.
Citation Text:
Patient Safety. Minnesota Department of Health
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November …
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psnet.ahrq.gov/issue/i-pass-handoff-program-use-campaign-effect-transformational-change
April 24, 2018 - Study
I-PASS handoff program: use of a campaign to effect transformational change.
Citation Text:
Rosenbluth G, Destino LA, Starmer AJ, et al. I-PASS Handoff Program: Use of a Campaign to Effect Transformational Change. Ped Qual Saf. 2018;3(4):e088. doi:10.1097/pq9.0000000000000088.
Co…
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psnet.ahrq.gov/issue/use-artificial-intelligence-optimize-medication-alerts-generated-clinical-decision-support
May 26, 2021 - Review
The use of artificial intelligence to optimize medication alerts generated by clinical decision support systems: a scoping review.
Citation Text:
Graafsma J, Murphy RM, van de Garde EMW, et al. The use of artificial intelligence to optimize medication alerts generated by clinical …
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psnet.ahrq.gov/issue/associations-between-double-checking-and-medication-administration-errors-direct
January 18, 2023 - Study
Associations between double-checking and medication administration errors: a direct observational study of paediatric inpatients.
Citation Text:
Westbrook JI, Li L, Raban MZ, et al. Associations between double-checking and medication administration errors: a direct observational st…
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psnet.ahrq.gov/issue/hand-hygiene-among-physicians-performance-beliefs-and-perceptions
January 14, 2011 - Study
Classic
Hand hygiene among physicians: performance, beliefs, and perceptions.
Citation Text:
Pittet D, Simon A, Hugonnet S, et al. Hand hygiene among physicians: performance, beliefs, and perceptions. Ann Intern Med. 2004;141(1):1-8.
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psnet.ahrq.gov/issue/use-fmea-analysis-reduce-risk-errors-prescribing-and-administering-drugs-paediatric-wards
March 08, 2023 - Study
Use of FMEA analysis to reduce risk of errors in prescribing and administering drugs in paediatric wards: a quality improvement report.
Citation Text:
Lago P, Bizzarri G, Scalzotto F, et al. Use of FMEA analysis to reduce risk of errors in prescribing and administering drugs in p…