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psnet.ahrq.gov/node/37430/psn-pdf
February 01, 2011 - Nonpayment for harms resulting from medical care:
catheter-associated urinary tract infections.
February 1, 2011
Wald HL, Kramer AM. Nonpayment for harms resulting from medical care: catheter-associated urinary tract
infections. JAMA. 2007;298(23):2782-4. doi:10.1001/jama.298.23.2782.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/43783/psn-pdf
January 14, 2015 - Improving the quality and safety of care on the medical
ward: a review and synthesis of the evidence base.
January 14, 2015
Pannick S, Beveridge I, Wachter R, et al. Improving the quality and safety of care on the medical ward: A
review and synthesis of the evidence base. Eur J Intern Med. 2014;25(10):874-87.
doi:…
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psnet.ahrq.gov/node/44922/psn-pdf
March 01, 2017 - Mobilising a team for the WHO Surgical Safety Checklist:
a qualitative video study.
March 1, 2017
Korkiakangas T. Mobilising a team for the WHO Surgical Safety Checklist: a qualitative video study. BMJ
Qual Saf. 2017;26(3):177-188. doi:10.1136/bmjqs-2015-004887.
https://psnet.ahrq.gov/issue/mobilising-team-who-sur…
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psnet.ahrq.gov/node/851917/psn-pdf
January 01, 2024 - Incivility in healthcare: the impact of poor
communication.
August 2, 2023
Guppy JH, Widlund H, Munro R, et al. Incivility in healthcare: the impact of poor communication. BMJ Lead.
2024;8(1):83-87. doi:10.1136/leader-2022-000717.
https://psnet.ahrq.gov/issue/incivility-healthcare-impact-poor-communication
Incivi…
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psnet.ahrq.gov/node/38332/psn-pdf
January 14, 2009 - Verifying patient identity and site of surgery: improving
compliance with protocol by audit and feedback.
January 14, 2009
Garnerin P, Arès M, Huchet A, et al. Verifying patient identity and site of surgery: improving compliance
with protocol by audit and feedback. Qual Saf Health Care. 2008;17(6):454-8.
doi:10.11…
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psnet.ahrq.gov/node/46643/psn-pdf
January 10, 2018 - The role of checklists and human factors for improved
patient safety in plastic surgery.
January 10, 2018
Oppikofer C, Schwappach DLB. The Role of Checklists and Human Factors for Improved Patient Safety in
Plastic Surgery. Plast Reconstr Surg. 2017;140(6):812e-817e. doi:10.1097/PRS.0000000000003892.
https://psnet…
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psnet.ahrq.gov/node/846151/psn-pdf
March 15, 2023 - Managing safety in perioperative settings: strategies of
meso-level nurse leaders.
March 15, 2023
Brooks JV, Nelson-Brantley H. Managing safety in perioperative settings: strategies of meso-level nurse
leaders. Health Care Manage Rev. 2023;48(2):175-184. doi:10.1097/hmr.0000000000000364.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/866698/psn-pdf
September 11, 2024 - Can we ensure medication safety with the use of speech
recognition software?
September 11, 2024
Can we ensure medication safety with the use of speech recognition software? ISMP Medication Safety
Alert! Acute Care. August 22, 2024;29(17):1-3.
https://psnet.ahrq.gov/issue/can-we-ensure-medication-safety-use-speech-…
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psnet.ahrq.gov/node/46070/psn-pdf
May 10, 2017 - Frequency, expected effects, obstacles, and facilitators of
disclosure of patient safety incidents: a systematic
review.
May 10, 2017
Ock M, Lim SY, Jo M-W, et al. Frequency, Expected Effects, Obstacles, and Facilitators of Disclosure of
Patient Safety Incidents: A Systematic Review. J Prev Med Public Health. 2017…
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psnet.ahrq.gov/node/47797/psn-pdf
June 14, 2019 - The impact of RVU-based compensation on patient safety
outcomes in outpatient otolaryngology procedures.
June 14, 2019
Stanisce L, Ahmad N, Deckard N, et al. The Impact of RVU-Based Compensation on Patient Safety
Outcomes in Outpatient Otolaryngology Procedures. Otolaryngol Head Neck Surg. 2019;160(6):1003-1008.
d…
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psnet.ahrq.gov/node/46270/psn-pdf
April 16, 2018 - Impact of a restraint management bundle on restraint use
in an intensive care unit.
April 16, 2018
Hall DK, Zimbro KS, Maduro RS, et al. Impact of a Restraint Management Bundle on Restraint Use in an
Intensive Care Unit. J Nurs Care Qual. 2018;33(2):143-148. doi:10.1097/NCQ.0000000000000273.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/47002/psn-pdf
April 25, 2018 - Making Health Care Safer in Ambulatory Care Settings
and Long Term Care Facilities (R18).
April 25, 2018
Rockville, MD: Agency for Healthcare Research and Quality; April 10, 2018. PA-18-750.
https://psnet.ahrq.gov/issue/making-health-care-safer-ambulatory-care-settings-and-long-term-care-
facilities-r18
Research …
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psnet.ahrq.gov/node/46777/psn-pdf
January 24, 2018 - Safety analysis over time: seven major changes to
adverse event investigation.
January 24, 2018
Vincent CA, Carthey J, Macrae C, et al. Safety analysis over time: seven major changes to adverse event
investigation. Implementation Science. 2017;12(1). doi:10.1186/s13012-017-0695-4.
https://psnet.ahrq.gov/issue/safe…
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psnet.ahrq.gov/node/38988/psn-pdf
October 07, 2009 - Resident duty-hour reform associated with increased
morbidity following hip fracture.
October 7, 2009
Browne JA, Cook C, Olson SA, et al. Resident duty-hour reform associated with increased morbidity
following hip fracture. J Bone Joint Surg Am. 2009;91(9):2079-85. doi:10.2106/JBJS.H.01240.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/39264/psn-pdf
February 03, 2010 - Changing cardiac arrest and hospital mortality rates
through a medical emergency team takes time and
constant review.
February 3, 2010
Santamaria J, Tobin A, Holmes J. Changing cardiac arrest and hospital mortality rates through a medical
emergency team takes time and constant review. Crit Care Med. 2010;38(2):445…
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psnet.ahrq.gov/node/849135/psn-pdf
May 17, 2023 - Quality and Safety Considerations in Intensity Modulated
Radiation Therapy: An ASTRO Safety White Paper
Update.
May 17, 2023
Moran JM, Bazan JG, Dawes SL, et al. Quality and Safety Considerations in Intensity Modulated Radiation
Therapy: An ASTRO Safety White Paper Update. Pract Radiat Oncol. 2023;13(3):203-216.
…
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psnet.ahrq.gov/node/41606/psn-pdf
February 01, 2019 - Safe use of opioids in hospitals.
December 23, 2016
Sentinel Event Alert. 2012;49:1-5.
https://psnet.ahrq.gov/issue/safe-use-opioids-hospitals
Opioid pain medications are considered high-risk medications due to the potential for respiratory
depression and other adverse effects. Because these medications are freque…
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psnet.ahrq.gov/node/44877/psn-pdf
April 27, 2016 - Actions Needed to Help Ensure Appropriate Medication
Continuation and Prescribing Practices.
April 27, 2016
Washington, DC: United States Government Accountability Office; January 5, 2016. Publication GAO-16-
158.
https://psnet.ahrq.gov/issue/actions-needed-help-ensure-appropriate-medication-continuation-and-
pre…
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psnet.ahrq.gov/node/35418/psn-pdf
June 14, 2011 - Anatomic pathology databases and patient safety.
June 14, 2011
Raab SS, Grzybicki DM, Zarbo RJ, et al. Anatomic pathology databases and patient safety. Arch Pathol
Lab Med. 2005;129(10):1246-1251.
https://psnet.ahrq.gov/issue/anatomic-pathology-databases-and-patient-safety
This AHRQ-funded project describes the de…
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psnet.ahrq.gov/node/73388/psn-pdf
June 16, 2021 - Reducing surgical specimen errors through
multidisciplinary quality improvement.
June 16, 2021
Holstine JB, Samora JB. Reducing surgical specimen errors through multidisciplinary quality improvement.
Jt Comm J Qual Patient Saf. 2021;47(9):563-571. doi:10.1016/j.jcjq.2021.04.003.
https://psnet.ahrq.gov/issue/reduci…