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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/46299/psn-pdf
September 13, 2017 - Simulation-based assessment of the management of
critical events by board-certified anesthesiologists.
September 13, 2017
Weinger MB, Banerjee A, Burden AR, et al. Simulation-based assessment of the management of critical
events by board-certified anesthesiologists. Anesthesiology. 2017;127(3):475-489.
doi:10.1097…
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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/40946/psn-pdf
January 19, 2012 - Effects of a multicentre teamwork and communication
programme on patient outcomes: results from the Triad
for Optimal Patient Safety (TOPS) project.
January 19, 2012
Auerbach AD, Sehgal NL, Blegen MA, et al. Effects of a multicentre teamwork and communication
programme on patient outcomes: results from the Triad f…
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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/node/38829/psn-pdf
January 03, 2017 - Implementing standardized operating room briefings and
debriefings at a large regional medical center.
January 3, 2017
Berenholtz SM, Schumacher K, Hayanga AJ, et al. Implementing standardized operating room briefings
and debriefings at a large regional medical center. Jt Comm J Qual Patient Saf. 2009;35(8):391-7.
…
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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/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/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/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/46797/psn-pdf
March 14, 2018 - Empowering informal caregivers with health information:
OpenNotes as a safety strategy.
March 14, 2018
Chimowitz H, Gerard M, Fossa A, et al. Empowering Informal Caregivers with Health Information:
OpenNotes as a Safety Strategy. Jt Comm J Qual Saf. 2018;44(3):130-136. doi:10.1016/j.jcjq.2017.09.004.
https://psnet…
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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/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/perspective/key-issues-developing-successful-hospital-safety-program
July 01, 2006 - Key Issues in Developing a Successful Hospital Safety Program
John Whittington, MD | July 1, 2006
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Whittington JC. Key Issues in Developing a Successful Hospital Safety Program. PS…
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psnet.ahrq.gov/perspective/conversation-witheric-coleman-md-mph
December 01, 2007 - In Conversation with...Eric Coleman, MD, MPH
December 1, 2007
Also Read an Essay
Citation Text:
In Conversation with..Eric Coleman, MD, MPH. PSNet [internet]. 2007.In Conversation with...Eric Coleman, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthca…
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psnet.ahrq.gov/node/49640/psn-pdf
November 01, 2011 - The Case for Patient Flow Management
November 1, 2011
Litvak E, Bernheim SA. The Case for Patient Flow Management. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/case-patient-flow-management
The Case
A 52-year-old woman with a history of major depression, posttraumatic stress disorder, and alcohol abuse
wa…
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psnet.ahrq.gov/primer/patient-engagement-and-safety
August 30, 2023 - Patient Engagement and Safety
Citation Text:
Patient Engagement and Safety. 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/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery
September 15, 2024 - Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery
Citation Text:
Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery. 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/sites/default/files/2020-01/final_spotlight_near_miss_transfusion_01082020_tocme.pdf
January 01, 2020 - Spotlight
Spotlight
“This is the wrong patient’s blood!”:
Evaluating a Near-Miss Wrong
Transfusion Event
Source and Credits
• This presentation is based on the January 2020 AHRQ WebM&M
Spotlight Case
• Commentary by: Sarah Barnhard MD
o Medical Director of Transfusion Services at UC-Davis Health
o Editors in …