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psnet.ahrq.gov/node/40449/psn-pdf
December 21, 2014 - Reduction in hospital mortality over time in a hospital
without a pediatric medical emergency team: limitations
of before-and-after study designs.
December 21, 2014
Joffe AR, Anton NR, Burkholder SC. Reduction in hospital mortality over time in a hospital without a
pediatric medical emergency team: limitations of …
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psnet.ahrq.gov/node/46645/psn-pdf
January 23, 2019 - Emergency department contribution to the prescription
opioid epidemic.
January 23, 2019
Axeen S, Seabury SA, Menchine M. Emergency Department Contribution to the Prescription Opioid
Epidemic. Ann Emerg Med. 2018;71(6):659-667.e3. doi:10.1016/j.annemergmed.2017.12.007.
https://psnet.ahrq.gov/issue/emergency-departm…
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psnet.ahrq.gov/node/42342/psn-pdf
December 31, 2014 - The safety of electronic prescribing: manifestations,
mechanisms, and rates of system-related errors
associated with two commercial systems in hospitals.
December 31, 2014
Westbrook JI, Baysari M, Li L, et al. The safety of electronic prescribing: manifestations, mechanisms, and
rates of system-related errors asso…
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psnet.ahrq.gov/node/47921/psn-pdf
June 18, 2019 - Using incident reports to assess communication failures
and patient outcomes.
June 18, 2019
Umberfield E, Ghaferi AA, Krein SL, et al. Using Incident Reports to Assess Communication Failures and
Patient Outcomes. Jt Comm J Qual Patient Saf. 2019;45(6):406-413. doi:10.1016/j.jcjq.2019.02.006.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/44831/psn-pdf
January 27, 2016 - IHI Skilled Nursing Facility Trigger Tool for Measuring
Adverse Events.
January 27, 2016
Adler L, Moore J, Federico F. Cambridge, MA: Institute for Healthcare Improvement; November 2015.
https://psnet.ahrq.gov/issue/ihi-skilled-nursing-facility-trigger-tool-measuring-adverse-events
Prior research has shown that sa…
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psnet.ahrq.gov/issue/vha-national-patient-safety-improvement-handbook
April 12, 2019 - Organizational Policy/Guidelines
VHA National Patient Safety Improvement Handbook.
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January 17, 2012
A handbook developed by the …
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psnet.ahrq.gov/node/45231/psn-pdf
February 14, 2017 - 6-PACK programme to decrease fall injuries in acute
hospitals: cluster randomised controlled trial.
February 14, 2017
Barker AL, Morello RT, Wolfe R, et al. 6-PACK programme to decrease fall injuries in acute hospitals:
cluster randomised controlled trial. BMJ. 2016;352:h6781. doi:10.1136/bmj.h6781.
https://psnet.…
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psnet.ahrq.gov/node/45543/psn-pdf
February 17, 2017 - Deriving ICD-10 codes for patient safety indicators for
large-scale surveillance using administrative hospital
data.
February 17, 2017
Southern DA, Burnand B, Droesler SE, et al. Deriving ICD-10 Codes for Patient Safety Indicators for Large-
scale Surveillance Using Administrative Hospital Data. Med Care. 2017;55(…
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psnet.ahrq.gov/perspective/conversation-eric-thomas-about-zero-harm-striving-reduce-preventable-harms-point
September 24, 2024 - and the importance or promoting safety in team meetings throughout the hospital system. 2 They also implemented
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psnet.ahrq.gov/perspective/conversation-withmark-chassin-md-mpp-mph
April 01, 2009 - explicitly set safety goals that exceed accreditation requirements, and many hospitals have voluntarily implemented
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psnet.ahrq.gov/node/60174/psn-pdf
March 30, 2020 - Making Healthcare Safer III Report
March 30, 2020
Gaffey AD, Spurlock B, Fitall E, et al. Making Healthcare Safer III Report. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/making-healthcare-safer-iii-report
What is the Making Healthcare Safer Report?
The Making Healthcare Safer Report represents an ef…
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psnet.ahrq.gov/innovation/battle-buddies-rapid-deployment-psychological-resilience-intervention-health-care
September 09, 2020 - EMERGING INNOVATIONS
Battle Buddies: rapid deployment of a psychological resilience intervention for health care workers during the COVID-19 pandemic
Citation Text:
Albott CS, Wozniak JR, McGlinch BP, et al. Battle Buddies: rapid deployment of a psychological resilience intervention for health car…
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psnet.ahrq.gov/node/45553/psn-pdf
October 13, 2018 - Computerized prescriber order entry–related patient
safety reports: analysis of 2522 medication errors.
October 13, 2018
Amato MG, Salazar A, Hickman T-TT, et al. Computerized prescriber order entry-related patient safety
reports: analysis of 2522 medication errors. J Am Med Inform Assoc. 2017;24(2):316-322.
doi:1…
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psnet.ahrq.gov/node/47875/psn-pdf
July 19, 2019 - Observer-based tools for non-technical skills assessment
in simulated and real clinical environments in healthcare:
a systematic review.
July 19, 2019
Higham H, Greig PR, Rutherford J, et al. Observer-based tools for non-technical skills assessment in
simulated and real clinical environments in healthcare: a syste…
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psnet.ahrq.gov/node/42923/psn-pdf
September 26, 2017 - Assessing the state of safe medication practices using
the ISMP Medication Safety Self Assessment for
Hospitals: 2000 and 2011.
September 26, 2017
Vaida AJ, Lamis RL, Smetzer JL, et al. Assessing the State of Safe Medication Practices Using the ISMP
Medication Safety Self Assessment ® for Hospitals: 2000 and 2011.…
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psnet.ahrq.gov/node/39082/psn-pdf
January 04, 2010 - Communication practices on 4 Harvard surgical
services: a surgical safety collaborative.
January 4, 2010
Elbardissi AW, Regenbogen SE, Greenberg CC, et al. Communication practices on 4 Harvard surgical
services: a surgical safety collaborative. Ann Surg. 2009;250(6):861-5.
doi:10.1097/SLA.0b013e3181afe0db.
https:…
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psnet.ahrq.gov/node/39921/psn-pdf
September 01, 2016 - Unintended effects of a computerized physician order
entry nearly hard-stop alert to prevent a drug interaction:
a randomized controlled trial.
September 1, 2016
Strom BL, Schinnar R, Aberra F, et al. Unintended effects of a computerized physician order entry nearly
hard-stop alert to prevent a drug interaction: a…
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psnet.ahrq.gov/node/44958/psn-pdf
March 09, 2016 - The Sepsis Early Recognition and Response Initiative
(SERRI).
March 9, 2016
Jones SL, Ashton CM, Kiehne L, et al. The Sepsis Early Recognition and Response Initiative (SERRI). Jt
Comm J Qual Patient Saf. 2016;42(3):122-138.
https://psnet.ahrq.gov/issue/sepsis-early-recognition-and-response-initiative-serri
Early …
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psnet.ahrq.gov/node/40073/psn-pdf
July 01, 2011 - Residents' perspectives on ACGME regulation of
supervision and duty hours—a national survey.
December 8, 2010
Drolet BC, Spalluto LB, Fischer SA. Residents' perspectives on ACGME regulation of supervision and duty
hours--a national survey. N Engl J Med. 2010;363(23):e34. doi:10.1056/NEJMp1011413.
https://psnet.ahr…
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psnet.ahrq.gov/node/47946/psn-pdf
May 22, 2019 - Vital signs: pregnancy-related deaths, United States,
2011-2015, and strategies for prevention, 13 states, 2013-
2017.
May 22, 2019
Petersen EE, Davis NL, Goodman D, et al. Vital Signs: Pregnancy-Related Deaths, United States, 2011-
2015, and Strategies for Prevention, 13 States, 2013-2017. MMWR Morb Mortal Wkly R…