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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49687/psn-pdf
    August 21, 2013 - Emergency Error August 21, 2013 Symons NRA. Emergency Error. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/emergency-error Case Objectives State that emergency surgery is high risk and has high mortality. Appreciate that emergency laparotomy is a particularly high-risk procedure with a high likelihood of …
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36059/psn-pdf
    June 28, 2006 - Hospitals' bid to heal selves saves thousands. June 28, 2006 https://psnet.ahrq.gov/issue/hospitals-bid-heal-selves-saves-thousands This article article reports on the results of the the 100,000 Lives Campaign. https://psnet.ahrq.gov/issue/hospitals-bid-heal-selves-saves-thousands
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33836/psn-pdf
    June 01, 2017 - The Weekend Effect in Cardiology: Is It Real? If So, Can It Be Fixed? June 1, 2017 Martin VK, Mirnateghi N, Khoshchehreh M. The Weekend Effect in Cardiology: Is It Real? If So, Can It Be Fixed? . PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/weekend-effect-cardiology-it-real-if-so-can-it-be-fixed Per…
  4. psnet.ahrq.gov/web-mm/one-got-away-elopement-suicidal-patient-emergency-department
    September 27, 2023 - The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department. Citation Text: Bourgeois JA, Xiong G, Barnes DK, et al. The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depa…
  5. psnet.ahrq.gov/print/pdf/node/845971
    January 01, 2024 - PSNet Curated Library AHRQ: Agency for Healthcare Research and Quality Value and Patient Safety Curated Library Foundations Safety is the preservation of value. Vandeskog B. J Safety Res. 2024;89:105-115. Safety is at the heart of safety science, and yet “safety” lacks a consensus definition among safety resea…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40674/psn-pdf
    October 16, 2012 - The care transitions intervention: translating from efficacy to effectiveness. October 16, 2012 Voss R, Gardner R, Baier R, et al. The care transitions intervention: translating from efficacy to effectiveness. Arch Intern Med. 2011;171(14):1232-7. doi:10.1001/archinternmed.2011.278. https://psnet.ahrq.gov/issue/ca…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854831/psn-pdf
    January 01, 2024 - Medication safety events after acute myocardial infarction among veterans treated at VA versus non-VA hospitals. October 25, 2023 Weeda ER, Ward R, Gebregziabher M, et al. Medication safety events after acute myocardial infarction among veterans treated at VA versus non-VA hospitals. Med Care. 2024;62(2):72-78. do…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42040/psn-pdf
    September 28, 2016 - The intended and unintended consequences of communication systems on general internal medicine inpatient care delivery: a prospective observational case study of five teaching hospitals. September 28, 2016 Wu RC, Lo V, Morra D, et al. The intended and unintended consequences of communication systems on general in…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45328/psn-pdf
    July 27, 2018 - Vital signs are still vital: instability on discharge and the risk of post-discharge adverse outcomes. July 27, 2018 Nguyen OK, Makam AN, Clark C, et al. Vital Signs Are Still Vital: Instability on Discharge and the Risk of Post-Discharge Adverse Outcomes. J Gen Intern Med. 2017;32(1):42-48. doi:10.1007/s11606-016-…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/61116/psn-pdf
    November 11, 2020 - Using medication containers during pharmacist transitional care visits and impact on medication discrepancies identified and hospital readmission risk. November 11, 2020 Herges JR, Garrison GM, Mara KC, et al. Using medication containers during pharmacist transitional care visits and impact on medication discrepan…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42474/psn-pdf
    September 19, 2015 - A new, evidence-based estimate of patient harms associated with hospital care. September 19, 2015 James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf. 2013;9(3):122-128. doi:10.1097/PTS.0b013e3182948a69. https://psnet.ahrq.gov/issue/new-evidence-based-estimate-pat…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39122/psn-pdf
    January 03, 2017 - Empowering frontline nurses: a structured intervention enables nurses to improve medication administration accuracy. January 3, 2017 Kliger J, Blegen MA, Gootee D, et al. Empowering frontline nurses: a structured intervention enables nurses to improve medication administration accuracy. Jt Comm J Qual Patient Saf.…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/839314/psn-pdf
    November 02, 2022 - Correlation between the number of patient-reported adverse events, adverse drug events, and quality of life in older patients: an observational study. November 2, 2022 Beerlage-Davids CJ, Ponjee GHM, Vanhommerig JW, et al. Correlation between the number of patient- reported adverse events, adverse drug events, and…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74159/psn-pdf
    December 08, 2021 - Disparities after discharge: the association of limited English proficiency and postdischarge patient-reported issues. December 8, 2021 Malevanchik L, Wheeler M, Gagliardi K, et al. Disparities after discharge: the association of limited English proficiency and postdischarge patient-reported issues. . Jt Comm J Qu…
  15. psnet.ahrq.gov/perspective/innovations-promoting-hand-hygiene-compliance
    May 01, 2014 - Innovations in Promoting Hand Hygiene Compliance Alexandre R. Marra, MD and Michael B. Edmond, MD, MPH, MPA | May 1, 2014  Also Read a Conversation View more articles from the same authors. Citation Text: Marra AR, Edmond MB. Innovations in Promoting Hand Hygie…
  16. psnet.ahrq.gov/web-mm/lost-black-hole
    December 01, 2005 - Lost in the Black Hole Citation Text: Wachter R. Lost in the Black Hole. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMe…
  17. psnet.ahrq.gov/perspective/conversation-barbara-drew-rn-phd
    May 01, 2016 - In Conversation With... Barbara Drew, RN, PhD May 1, 2016  Also Read an Essay Citation Text: In Conversation With.. Barbara Drew, RN, PhD. PSNet [internet]. 2016.In Conversation With... Barbara Drew, RN, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34121/psn-pdf
    November 02, 2014 - Safety as You Go from Hospital to Home. November 2, 2014 National Patient Safety Foundation; NPSF https://psnet.ahrq.gov/issue/safety-you-go-hospital-home A review of steps for patients to make their transition home as safe as possible. https://psnet.ahrq.gov/issue/safety-you-go-hospital-home
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36093/psn-pdf
    August 09, 2007 - Hospitals combat errors at the 'hand-off.' August 9, 2007 Landro L. https://psnet.ahrq.gov/issue/hospitals-combat-errors-hand This article reports on communication interventions such as SBAR (Situation-Background-Assessment- Recommendation) that make patient hand-offs more reliable. https://psnet.ahrq.gov/issue/h…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49674/psn-pdf
    December 01, 2012 - Preventing PICC Complications: Whose Line Is It? December 1, 2012 Moureau N. Preventing PICC Complications: Whose Line Is It? PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/preventing-picc-complications-whose-line-it The Case A 55-year-old woman with myasthenia gravis, hypertension, and hypothyroidism prese…

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