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psnet.ahrq.gov/issue/heart-failure-decline-historic-transplant-program
July 22, 2020 - Special or Theme Issue
Heart Failure: The Decline of a Historic Transplant Program.
Citation Text:
Heart Failure: The Decline of a Historic Transplant Program. Hixenbaugh M, Ornstein C. Houston Chronicle and Propublica. May 2018-May 2019.
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psnet.ahrq.gov/issue/do-panels-vary-when-assessing-intrapartum-adverse-events-reproducibility-assessments-hospital
July 07, 2021 - Study
Do panels vary when assessing intrapartum adverse events? The reproducibility of assessments by hospital risk management groups.
Citation Text:
Do panels vary when assessing intrapartum adverse events? The reproducibility of assessments by hospital risk management groups. Kerna…
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psnet.ahrq.gov/issue/errors-omission-missed-nursing-care
September 27, 2017 - Review
Errors of omission: missed nursing care.
Citation Text:
Kalisch BJ, Xie B. Errors of Omission: Missed Nursing Care. West J Nurs Res. 2014;36(7):875-890. doi:10.1177/0193945914531859.
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psnet.ahrq.gov/issue/coronavirus-commission-safety-and-quality-nursing-homes
May 26, 2021 - Book/Report
Coronavirus Commission for Safety and Quality in Nursing Homes.
Citation Text:
Coronavirus Commission for Safety and Quality in Nursing Homes. Centers for Medicare and Medicaid Services. McLean, VA: MITRE Corporation; September 2020.
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psnet.ahrq.gov/node/35207/psn-pdf
December 19, 2009 - Patient safety concerns arising from test results that
return after hospital discharge.
December 19, 2009
Roy CL, Poon EG, Karson A, et al. Patient safety concerns arising from test results that return after hospital
discharge. Ann Intern Med. 2005;143(2):121-128.
https://psnet.ahrq.gov/issue/patient-safety-concer…
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psnet.ahrq.gov/node/46965/psn-pdf
March 28, 2018 - The other opioid crisis: hospital shortages lead to patient
pain, medical errors.
March 28, 2018
Bartolone P. Kaiser Health News. March 16, 2018.
https://psnet.ahrq.gov/issue/other-opioid-crisis-hospital-shortages-lead-patient-pain-medical-errors
Drug shortages may require clinicians, pharmacists, and hospitals to…
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psnet.ahrq.gov/node/47897/psn-pdf
January 01, 2021 - What influences sustainment and nonsustainment of
facilitation activities in implementation? Analysis of
organizational factors in hospitals implementing
TeamSTEPPS.
June 5, 2019
Baloh J, Zhu X, Ward MM. What influences sustainment and nonsustainment of facilitation activities in
implementation? Analysis of organ…
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psnet.ahrq.gov/node/34803/psn-pdf
January 05, 2017 - Systematic root cause analysis of adverse drug events in
a tertiary referral hospital.
January 5, 2017
Rex JH, Turnbull JE, Allen SJ, et al. Systematic Root Cause Analysis of Adverse Drug Events in a Tertiary
Referral Hospital. Jt Comm J Qual Improv. 2016;26(10). doi:10.1016/s1070-3241(00)26048-3.
https://psnet.ah…
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psnet.ahrq.gov/node/74233/psn-pdf
January 12, 2022 - Don't go to the hospital alone: ensuring safe, highly
reliable patient visitation.
January 12, 2022
Gandhi TK. Don't go to the hospital alone: ensuring safe, highly reliable patient visitation. Jt Comm J Qual
Patient Saf. 2022;48(1):61-64. doi:10.1016/j.jcjq.2021.10.006.
https://psnet.ahrq.gov/issue/dont-go-hospit…
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psnet.ahrq.gov/node/43127/psn-pdf
April 23, 2014 - An interprofessional qualitative study of barriers and
potential solutions for the safe use of insulin in the
hospital setting.
April 23, 2014
Rousseau M-P, Beauchesne M-F, Naud A-S, et al. An interprofessional qualitative study of barriers and
potential solutions for the safe use of insulin in the hospital settin…
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psnet.ahrq.gov/node/865661/psn-pdf
April 24, 2024 - Pay-for-performance and patient safety in acute care: a
systematic review.
April 24, 2024
Slawomirski L, Hensher M, Campbell JL, et al. Pay-for-performance and patient safety in acute care: a
systematic review. Health Policy. 2024;143:105051. doi:10.1016/j.healthpol.2024.105051.
https://psnet.ahrq.gov/issue/pay-pe…
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psnet.ahrq.gov/node/836809/psn-pdf
March 30, 2022 - Pharmacist transition-of-care services improve patient
satisfaction and decrease hospital readmissions.
March 30, 2022
March KL, Peters MJ, Finch CK, et al. J Pharm Pract. 2022;35(1):86-93.
https://psnet.ahrq.gov/issue/pharmacist-transition-care-services-improve-patient-satisfaction-and-decrease-
hospital
Tr…
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psnet.ahrq.gov/web-mm/safety-and-quality-long-term-care
January 01, 2016 - SPOTLIGHT CASE
The Safety and Quality of Long Term Care
Citation Text:
Vogelsmeier AA. The Safety and Quality of Long Term Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/node/40095/psn-pdf
December 22, 2010 - Assessing and improving safety culture throughout an
academic medical centre: a prospective cohort study.
December 22, 2010
Paine LA, Rosenstein BJ, Sexton B, et al. Assessing and improving safety culture throughout an academic
medical centre: a prospective cohort study. Qual Saf Health Care. 2010;19(6):547-54.
do…
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psnet.ahrq.gov/issue/teams-quicken-response-medical-emergencies
November 11, 2015 - Newspaper/Magazine Article
Teams quicken response in medical emergencies.
Citation Text:
Teams quicken response in medical emergencies. Srikameswaran A.
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psnet.ahrq.gov/issue/guide-hcas-safe-patient-transfers
March 03, 2019 - Newspaper/Magazine Article
A guide for HCAs on safe patient transfers.
Citation Text:
A guide for HCAs on safe patient transfers. Lees L.
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psnet.ahrq.gov/issue/not-what-doctor-ordered
November 23, 2016 - Newspaper/Magazine Article
Not what the doctor ordered.
Citation Text:
Not what the doctor ordered. Trebilcock B.
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psnet.ahrq.gov/issue/crisis-do-not-revive-requests-dont-always-work
December 16, 2015 - Newspaper/Magazine Article
In a crisis, do-not-revive requests don't always work.
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January 3, 2007
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psnet.ahrq.gov/issue/extra-dose-safety
June 16, 2019 - Newspaper/Magazine Article
An extra dose of safety.
Citation Text:
An extra dose of safety. Installation of a bar-coding system drives an entire workflow redesign at a non-profit hospital and healthcare network. Health management technology. 2007;28(4):30-2, 34.
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psnet.ahrq.gov/node/39329/psn-pdf
September 30, 2015 - Safe Patients, Smart Hospitals: How One Doctor's
Checklist Can Help Us Change Health Care from the
Inside Out.
September 30, 2015
Pronovost P, Vohr E. New York, NY: Hudson Street Press; 2010. ISBN: 9781594630644.
https://psnet.ahrq.gov/issue/safe-patients-smart-hospitals-how-one-doctors-checklist-can-help-us-chang…