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psnet.ahrq.gov/node/853429/psn-pdf
September 13, 2023 - Multifaceted intervention to improve patient safety
incident reporting in intensive care units.
September 13, 2023
Griffeth EM, Gajic O, Schueler N, et al. Multifaceted intervention to improve patient safety incident reporting
in intensive care units. J Patient Saf. 2023;19(7):422-428. doi:10.1097/pts.0000000000001…
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psnet.ahrq.gov/node/37871/psn-pdf
January 06, 2017 - A controlled trial of a rapid response system in an
academic medical center.
January 6, 2017
Rothschild JM, Woolf S, Finn KM, et al. A controlled trial of a rapid response system in an academic
medical center. Jt Comm J Qual Patient Saf. 2008;34(7):417-25, 365.
https://psnet.ahrq.gov/issue/controlled-trial-rapid-r…
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psnet.ahrq.gov/node/39197/psn-pdf
January 06, 2010 - Resident fatigue: is there a patient safety issue?
January 6, 2010
Mitchell CD, Mooty CR, Dunn EL, et al. Resident fatigue: is there a patient safety issue? Am J Surg.
2009;198(6):811-6. doi:10.1016/j.amjsurg.2009.04.028.
https://psnet.ahrq.gov/issue/resident-fatigue-there-patient-safety-issue
Regulations limiting…
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psnet.ahrq.gov/node/50804/psn-pdf
January 15, 2020 - The use of patient digital facial images to confirm patient
identity in a children's hospital's anesthesia information
management system.
January 15, 2020
Thomas JJ, Yaster M, Guffey P. The Use of Patient Digital Facial Images to Confirm Patient Identity in a
Children's Hospital's Anesthesia Information Management…
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psnet.ahrq.gov/node/43798/psn-pdf
January 07, 2015 - Pharmacist-managed inpatient discharge medication
reconciliation: a combined onsite and telepharmacy
model.
January 7, 2015
Keeys C, Kalejaiye B, Skinner M, et al. Pharmacist-managed inpatient discharge medication reconciliation:
a combined onsite and telepharmacy model. Am J Health Syst Pharm. 2014;71(24):2159-66…
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psnet.ahrq.gov/node/866636/psn-pdf
January 01, 2025 - Hospital commitments to address diagnostic errors: an
assessment of 95 US hospitals.
September 4, 2024
Campione Russo A, Tilly J?L, Kaufman L, et al. Hospital commitments to address diagnostic errors: an
assessment of 95 US hospitals. J Hosp Med. 2025;20(2):120-134. doi:10.1002/jhm.13485.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/37153/psn-pdf
October 06, 2011 - The effect of a rapid response team on major clinical
outcome measures in a community hospital.
October 6, 2011
Dacey MJ, Mirza ER, Wilcox V, et al. The effect of a rapid response team on major clinical outcome
measures in a community hospital. Crit Care Med. 2007;35(9):2076-82.
https://psnet.ahrq.gov/issue/effect…
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psnet.ahrq.gov/node/33668/psn-pdf
May 01, 2008 - To be fair,
CMS is beginning to think about implementing incentives like that.
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psnet.ahrq.gov/primer/duty-hours-and-patient-safety
June 15, 2024 - Duty Hours and Patient Safety
Citation Text:
Duty Hours and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
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psnet.ahrq.gov/web-mm/copy-and-paste
December 10, 2014 - Copy and Paste
Citation Text:
Hersh WR. Copy and Paste. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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Format:
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…
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psnet.ahrq.gov/node/49850/psn-pdf
January 01, 2019 - Critical Order Set Change and Critical Limb Ischemia
January 1, 2019
Clay B. Critical Order Set Change and Critical Limb Ischemia. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/critical-order-set-change-and-critical-limb-ischemia
The Case
A 72-year-old woman with a history of severe peripheral vascular dis…
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psnet.ahrq.gov/node/846922/psn-pdf
March 29, 2023 - Enhancing Support for Patients’ Social Needs to Reduce
Hospital Readmissions and Improve Health Outcomes
March 29, 2023
https://psnet.ahrq.gov/innovation/enhancing-support-patients-social-needs-reduce-hospital-readmissions-
and-improve-health
Summary
With increasing recognition that health is linked to the condit…
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psnet.ahrq.gov/node/49542/psn-pdf
August 21, 2007 - Copy and Paste
August 21, 2007
Hersh WR. Copy and Paste. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/copy-and-paste
The Case
A 77-year-old woman was admitted to a teaching hospital with diarrhea and dehydration after completing
her fifth cycle of chemotherapy for ovarian cancer. Her only relevant past m…
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psnet.ahrq.gov/innovation/hospital-homesm-care-reduces-costs-readmissions-and-complications-and-enhances
November 15, 2023 - for patients in their homes), and leadership buy-in (e.g., does the site have success developing and implementing … organizations that are not willing to embrace and accommodate this type of disruption will have difficulty implementing
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psnet.ahrq.gov/innovation/enhancing-support-patients-social-needs-reduce-hospital-readmissions-and-improve-health
February 26, 2025 - Enhancing Support for Patients’ Social Needs to Reduce Hospital Readmissions and Improve Health Outcomes
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March 29, 2023
Innovation
Co…
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psnet.ahrq.gov/web-mm/add-case-and-missing-checklist
September 01, 2012 - Add-on Case and the Missing Checklist
Citation Text:
Catchpole K. Add-on Case and the Missing Checklist. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/periodic-issue/periodic-issue-471
December 31, 2024 - January 22, 2025 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, report…
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psnet.ahrq.gov/node/37997/psn-pdf
June 16, 2011 - Revealing and resolving patient safety defects: the impact
of leadership WalkRounds on frontline caregiver
assessments of patient safety.
June 16, 2011
Frankel A, Grillo SP, Pittman M, et al. Revealing and resolving patient safety defects: the impact of
leadership WalkRounds on frontline caregiver assessments of p…
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psnet.ahrq.gov/node/867640/psn-pdf
February 26, 2025 - Patient safety of virtual primary care: a qualitative study
examining risks and mitigation strategies.
February 26, 2025
Lounsbury O, Li E, Lunova T, et al. Patient safety of virtual primary care: a qualitative study examining risks
and mitigation strategies. Health Policy Tech. 2025;14(1):100966. doi:10.1016/j.hlp…
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psnet.ahrq.gov/node/44189/psn-pdf
September 09, 2015 - Variation in printed handoff documents: results and
recommendations from a multicenter needs assessment.
September 9, 2015
Rosenbluth G, Bale JF, Starmer AJ, et al. Variation in printed handoff documents: Results and
recommendations from a multicenter needs assessment. J Hosp Med. 2015;10(8):517-24.
doi:10.1002/jh…