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psnet.ahrq.gov/web-mm/what-happened-telemetry
January 18, 2012 - Implemented thoughtfully by an interprofessional team with ongoing evaluation, remote telemetry monitoring
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psnet.ahrq.gov/web-mm/one-got-away-elopement-suicidal-patient-emergency-department
September 27, 2023 - We implemented the C-SSRS (Columbia Suicide Severity Rating Scale) at ED triage for a subset of patients
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psnet.ahrq.gov/perspective/conversation-jeffrey-shuren-md-jd
May 28, 2020 - For example, a few years ago we implemented a policy related to the issuance of notifications when we
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psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis
January 29, 2021 - Color coding should be implemented to reduce misconnection errors between different infusion systems,
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psnet.ahrq.gov/perspective/safety-considerations-building-point-care-ultrasound-program
June 01, 2018 - why the full spectrum of education, competency assessment, and ongoing quality control needs to be implemented
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psnet.ahrq.gov/perspective/telehealth-and-patient-safety-during-covid-19-response
May 14, 2020 - Conclusion If implemented appropriately, telehealth can be an incredibly effective approach to ensuring
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psnet.ahrq.gov/web-mm/diffusion-responsibility-leads-danger
November 08, 2013 - Diffusion of Responsibility Leads to Danger
Citation Text:
Balcezak TJ, Deshpande O. Diffusion of Responsibility Leads to Danger. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/web-mm/around-block
March 04, 2020 - Around the Block
Citation Text:
Minichiello T. Around the Block. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/web-mm/returning-home-safely
December 22, 2018 - Returning Home Safely
Citation Text:
Toles M. Returning Home Safely. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-safety-older-adults
April 10, 2024 - To better capture the numbers of cases and deaths, CMS implemented direct mandatory reporting of all
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psnet.ahrq.gov/node/866432/psn-pdf
August 07, 2024 - Improving appropriate use of peripherally inserted central
catheters through a statewide collaborative hospital
initiative: a cost-effectiveness analysis.
August 7, 2024
Heath M, Bernstein SJ, Paje D, et al. Improving appropriate use of peripherally inserted central catheters
through a statewide collaborative hosp…
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psnet.ahrq.gov/node/46720/psn-pdf
January 23, 2019 - Persistent opioid use among pediatric patients after
surgery.
January 23, 2019
Harbaugh CM, Lee JS, Hu HM, et al. Persistent Opioid Use Among Pediatric Patients After Surgery.
Pediatrics. 2018;141(1):e20172439. doi:10.1542/peds.2017-2439.
https://psnet.ahrq.gov/issue/persistent-opioid-use-among-pediatric-patients-…
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psnet.ahrq.gov/node/73084/psn-pdf
March 31, 2021 - Maternal and neonatal health care worker well-being and
patient safety climate amid the COVID-19 pandemic.
March 31, 2021
Haidari E, Main EK, Cui X, et al. Maternal and neonatal health care worker well-being and patient safety
climate amid the COVID-19 pandemic. J Perinatol. 2021;41(5):961-969. doi:10.1038/s41372-0…
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psnet.ahrq.gov/node/60934/psn-pdf
September 23, 2020 - Hospital ward adaptation during the COVID-19 pandemic:
a national survey of academic medical centers.
September 23, 2020
Auerbach AD, O'Leary KJ, Greysen SR, et al. Hospital ward adaptation during the COVID-19 pandemic: a
national survey of academic medical centers. J Hosp Med. 2020;15(8):483-488. doi:10.12788/jhm.…
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psnet.ahrq.gov/node/836786/psn-pdf
January 01, 2023 - Safety implications of remote assessments for suspected
COVID-19: qualitative study in UK primary care.
March 23, 2022
Wieringa S, Neves AL, Rushforth A, et al. Safety implications of remote assessments for suspected
COVID-19: qualitative study in UK primary care. BMJ Qual Saf. 2023;32(12):732-741. doi:10.1136/bmjq…
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psnet.ahrq.gov/node/41942/psn-pdf
July 24, 2017 - Improving situation awareness to reduce unrecognized
clinical deterioration and serious safety events.
July 24, 2017
Brady PW, Muething S, Kotagal U, et al. Improving situation awareness to reduce unrecognized clinical
deterioration and serious safety events. Pediatrics. 2013;131(1):e298-308. doi:10.1542/peds.2012-…
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psnet.ahrq.gov/node/44248/psn-pdf
May 26, 2016 - Wrong-site surgery, retained surgical items, and surgical
fires: a systematic review of surgical never events.
May 26, 2016
Hempel S, Maggard-Gibbons M, Nguyen DK, et al. Wrong-Site Surgery, Retained Surgical Items, and
Surgical Fires : A Systematic Review of Surgical Never Events. JAMA Surg. 2015;150(8):796-805.
…
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psnet.ahrq.gov/node/43007/psn-pdf
December 12, 2014 - 'I think we should just listen and get out': a qualitative
exploration of views and experiences of Patient Safety
Walkrounds.
December 12, 2014
Rotteau L, Shojania KG, Webster F. ‘I think we should just listen and get out’: a qualitative exploration of
views and experiences of Patient Safety Walkrounds: Table 1. B…
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psnet.ahrq.gov/node/38675/psn-pdf
February 15, 2011 - Prescription errors and outcomes related to inconsistent
information transmitted through computerized order
entry: a prospective study.
February 15, 2011
Singh H, Mani S, Espadas D, et al. Prescription errors and outcomes related to inconsistent information
transmitted through computerized order entry: a prospecti…
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psnet.ahrq.gov/node/836967/psn-pdf
April 20, 2022 - Hospital acquired infections in surgical patients: impact
of COVID-19-related infection prevention measures.
April 20, 2022
Tham N, Fazio T, Johnson D, et al. Hospital acquired infections in surgical patients: impact of COVID-19-
related infection prevention measures. World J Surg. 2022;46:1249-1258. doi:10.1007/s0…