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psnet.ahrq.gov/node/49477/psn-pdf
April 01, 2005 - Hold the tPA
April 1, 2005
Fagan SC. Hold the tPA. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/hold-tpa
The Case
A 74-year-old woman with a history of atrial fibrillation on warfarin therapy came to the emergency
department (ED) 1 hour after the sudden onset of aphasia and right-sided weakness. A non-co…
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psnet.ahrq.gov/node/45305/psn-pdf
February 14, 2017 - Sustaining reductions in central line-associated
bloodstream infections in Michigan intensive care units: a
10-year analysis.
February 14, 2017
Pronovost P, Watson S, Goeschel CA, et al. Sustaining Reductions in Central Line-Associated
Bloodstream Infections in Michigan Intensive Care Units: A 10-Year Analysis. Am…
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psnet.ahrq.gov/node/43279/psn-pdf
October 20, 2014 - A comprehensive obstetric patient safety program
reduces liability claims and payments.
October 20, 2014
Pettker CM, Thung SF, Lipkind HS, et al. A comprehensive obstetric patient safety program reduces liability
claims and payments. Am J Obstet Gynecol. 2014;211(4):319-25. doi:10.1016/j.ajog.2014.04.038.
https://…
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psnet.ahrq.gov/node/37544/psn-pdf
June 16, 2011 - Differences in safety climate among hospital anesthesia
departments and the effect of a realistic simulation-based
training program.
June 16, 2011
Cooper JB, Blum RH, Carroll JS, et al. Differences in safety climate among hospital anesthesia
departments and the effect of a realistic simulation-based training progr…
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psnet.ahrq.gov/node/45385/psn-pdf
January 03, 2017 - Viewing prevention of catheter-associated urinary tract
infection as a system: using systems engineering and
human factors engineering in a quality improvement
project in an academic medical center.
January 3, 2017
Rhee C, Phelps E, Meyer B, et al. Viewing Prevention of Catheter-Associated Urinary Tract Infection …
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psnet.ahrq.gov/node/47835/psn-pdf
April 24, 2019 - Facilitation of surgical innovation: is it possible to speed
the introduction of new technology while simultaneously
improving patient safety?
April 24, 2019
Marcus RK, Lillemoe HA, Caudle AS, et al. Facilitation of Surgical Innovation: Is It Possible to Speed the
Introduction of New Technology While Simultaneousl…
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psnet.ahrq.gov/node/44197/psn-pdf
November 03, 2015 - Effect of the World Health Organization checklist on
patient outcomes: a stepped wedge cluster randomized
controlled trial.
November 3, 2015
Haugen AS, Søfteland E, Almeland SK, et al. Effect of the World Health Organization checklist on patient
outcomes: a stepped wedge cluster randomized controlled trial. Ann Su…
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psnet.ahrq.gov/node/45901/psn-pdf
April 12, 2017 - Development and applications of the Veterans Health
Administration's Stratification Tool for Opioid Risk
Mitigation (STORM) to improve opioid safety and prevent
overdose and suicide.
April 12, 2017
Oliva EM, Bowe T, Tavakoli S, et al. Development and applications of the Veterans Health Administration's
Stratifica…
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psnet.ahrq.gov/node/43917/psn-pdf
November 03, 2015 - Underlying reasons associated with hospital readmission
following surgery in the United States.
November 3, 2015
Merkow RP, Ju MH, Chung JW, et al. Underlying reasons associated with hospital readmission following
surgery in the United States. JAMA. 2015;313(5):483-495. doi:10.1001/jama.2014.18614.
https://psnet.a…
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psnet.ahrq.gov/node/46340/psn-pdf
September 27, 2017 - A systematic review of the effectiveness of interruptive
medication prescribing alerts in hospital CPOE systems
to change prescriber behavior and improve patient safety.
September 27, 2017
Page N, Baysari MT, Westbrook JI. A systematic review of the effectiveness of interruptive medication
prescribing alerts in ho…
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psnet.ahrq.gov/node/39104/psn-pdf
February 16, 2011 - Is there a relationship between high-quality performance
in major teaching hospitals and residents' knowledge of
quality and patient safety?
February 16, 2011
Pingleton SK, Horak BJ, Davis DA, et al. Is there a relationship between high-quality performance in major
teaching hospitals and residents' knowledge of qu…
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psnet.ahrq.gov/innovation/there-app-mobile-technology-improves-complication-reporting-and-resident-perception
November 28, 2012 - EMERGING INNOVATIONS
There is an app for that: mobile technology improves complication reporting and resident perception of their role in patient safety
Citation Text:
Johnson CR, Noorzad A, Pujari A, et al. There is an app for that: mobile technology improves complication reporting and resident p…
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psnet.ahrq.gov/perspective/our-maturing-understanding-safety-culture-how-change-it-and-how-it-changes-safety
March 01, 2017 - Our Maturing Understanding of Safety Culture: How to Change It and How It Changes Safety
Sara J. Singer, MBA, PhD | March 1, 2017
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Singer SJ. Our Maturing Understanding of Safety C…
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psnet.ahrq.gov/web-mm/hold-tpa
July 29, 2020 - Hold the tPA
Citation Text:
Fagan SC. Hold the tPA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Dow…
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psnet.ahrq.gov/innovation/geisingers-outpatient-addiction-medicine-specialty-program-uses-data-driven-decision
October 30, 2024 - Geisinger’s Outpatient Addiction Medicine Specialty Program Uses Data-Driven Decision Making and MAT to Reduce Mortality Rates
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February 9, 2021
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psnet.ahrq.gov/primer/individual-clinician-performance-issues
March 15, 2025 - Individual Clinician Performance Issues
Citation Text:
Individual Clinician Performance Issues. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/33796/psn-pdf
January 01, 2016 - In Conversation With… Mark L. Graber, MD
January 1, 2016
In Conversation With… Mark L. Graber, MD. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-mark-l-graber-md
Editor's note: Dr. Graber is a Senior Fellow at RTI International and Professor Emeritus of Medicine at
the State University o…
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psnet.ahrq.gov/node/40965/psn-pdf
December 15, 2011 - Medication errors during patient transitions into nursing
homes: characteristics and association with patient harm.
December 15, 2011
Desai R, Williams CE, Greene SB, et al. Medication errors during patient transitions into nursing homes:
characteristics and association with patient harm. Am J Geriatr Pharmacother.…
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psnet.ahrq.gov/node/46481/psn-pdf
August 20, 2018 - An electronic trigger based on care escalation to identify
preventable adverse events in hospitalised patients.
August 20, 2018
Bhise V, Sittig DF, Vaghani V, et al. An electronic trigger based on care escalation to identify preventable
adverse events in hospitalised patients. BMJ Qual Saf. 2018;27(3):241-246. doi:…
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psnet.ahrq.gov/issue/lessons-event-reports
January 16, 2025 - Multi-use Website
Lessons from Event Reports.
Citation Text:
Lessons from Event Reports. Patient Safety Authority.
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