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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
…
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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
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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…
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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…
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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…
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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…
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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…
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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…
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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-…
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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…
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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…
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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.…
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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…
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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…
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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…
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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…
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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…
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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
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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…
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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…