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  1. Contact the PSO Program | PSO

    pso.ahrq.gov/contact
    February 01, 2025 - SHARE: More topics in this section Contact PSO Subscribe to Email Updates Contact the PSO Program AHRQ PSO Program Contact the AHRQ PSO Program for more information about the Patient Safety Act and Rule, PSO listing process,…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47266/psn-pdf
    August 08, 2018 - Outpatient opioid prescriptions for children and opioid- related adverse events. August 8, 2018 Chung CP, Callahan T, Cooper WO, et al. Outpatient Opioid Prescriptions for Children and Opioid-Related Adverse Events. Pediatrics. 2018;142(2):e20172156. doi:10.1542/peds.2017-2156. https://psnet.ahrq.gov/issue/outpati…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47991/psn-pdf
    July 12, 2019 - What quality and safety of care for patients admitted to clinically inappropriate wards: a systematic review. July 12, 2019 La Regina M, Guarneri F, Romano E, et al. What Quality and Safety of Care for Patients Admitted to Clinically Inappropriate Wards: a Systematic Review. J Gen Intern Med. 2019;34(7):1314-1321. …

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46491/psn-pdf
    August 20, 2018 - A qualitative study of speaking out about patient safety concerns in intensive care units. August 20, 2018 Tarrant C, Leslie M, Bion J, et al. A qualitative study of speaking out about patient safety concerns in intensive care units. Soc Sci Med. 2017;193:8-15. doi:10.1016/j.socscimed.2017.09.036. https://psnet.ah…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38164/psn-pdf
    July 02, 2009 - A Compendium of Strategies to Prevent Healthcare- Associated Infections in Acute Care Hospitals. July 2, 2009 Yokoe DS, Mermel LA, Anderson DJ, et al. Infect Control Hosp Epidemiol. 2008;29:901-994.   https://psnet.ahrq.gov/issue/compendium-strategies-prevent-healthcare-associated-infections-acute-care- hospi…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46245/psn-pdf
    June 28, 2017 - Associations between patient factors and adverse events in the home care setting: a secondary data analysis of two Canadian adverse event studies. June 28, 2017 Sears NA, Blais R, Spinks M, et al. Associations between patient factors and adverse events in the home care setting: a secondary data analysis of two can…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/845361/psn-pdf
    March 29, 2023 - A standardized marking procedure for ENT operations to prevent wrong-site surgery: development, establishment and subsequent evaluation among patients and medical personnel. March 29, 2023 Rohrmeier C, Abudan Al-Masry N, Keerl R, et al. A standardized marking procedure for ENT operations to prevent wrong-site sur…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43652/psn-pdf
    August 04, 2015 - Do clinicians know which of their patients have central venous catheters?: A multicenter observational study. August 4, 2015 Chopra V, Govindan S, Kuhn L, et al. Do clinicians know which of their patients have central venous catheters?: a multicenter observational study. Ann Intern Med. 2014;161(8):562-7. doi:10.73…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44709/psn-pdf
    November 18, 2016 - Lost information during the handover of critically injured trauma patients: a mixed-methods study. November 18, 2016 Zakrison TL, Rosenbloom B, McFarlan A, et al. Lost information during the handover of critically injured trauma patients: a mixed-methods study. BMJ Qual Saf. 2016;25(12):929-936. doi:10.1136/bmjqs-2…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46232/psn-pdf
    February 10, 2018 - Implications of electronic health record downtime: an analysis of patient safety event reports. February 10, 2018 Larsen E, Fong A, Wernz C, et al. Implications of electronic health record downtime: an analysis of patient safety event reports. J Am Med Inform Assoc. 2018;25(2):187-191. doi:10.1093/jamia/ocx057. ht…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40412/psn-pdf
    March 23, 2012 - Veterans Affairs initiative to prevent methicillin-resistant Staphylococcus aureus infections. March 23, 2012 Jain R, Kralovic SM, Evans ME, et al. Veterans Affairs initiative to prevent methicillin-resistant Staphylococcus aureus infections. N Engl J Med. 2011;364(15):1419-30. doi:10.1056/NEJMoa1007474. https://p…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37838/psn-pdf
    June 11, 2008 - Mitigation of patient harm from testing errors in family medicine offices: a report from the American Academy of Family Physicians National Research Network. June 11, 2008 Graham DG, Harris DM, Elder NC, et al. Mitigation of patient harm from testing errors in family medicine offices: a report from the American Ac…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41964/psn-pdf
    April 17, 2013 - Use of HIT for adverse event reporting in nursing homes: barriers and facilitators. April 17, 2013 Wagner LM, Castle NG, Handler S. Use of HIT for adverse event reporting in nursing homes: barriers and facilitators. Geriatr Nurs. 2013;34(2):112-5. doi:10.1016/j.gerinurse.2012.10.003. https://psnet.ahrq.gov/issue/u…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40146/psn-pdf
    March 02, 2011 - Primary care–relevant interventions to prevent falling in older adults: a systematic evidence review for the U.S. Preventive Services Task Force. March 2, 2011 Michael YL, Whitlock EP, Lin JS, et al. Primary care-relevant interventions to prevent falling in older adults: a systematic evidence review for the U.S. P…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47610/psn-pdf
    March 13, 2019 - Patient safety outcomes under flexible and standard resident duty-hour rules. March 13, 2019 Silber JH, Bellini LM, Shea JA, et al; iCOMPARE Research Group. N Engl J Med. 2019;380:905-914. https://psnet.ahrq.gov/issue/patient-safety-outcomes-under-flexible-and-standard-resident-duty-hour-rules Duty hour reform for…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38710/psn-pdf
    September 14, 2009 - Patient readmissions, emergency visits, and adverse events after software-assisted discharge from hospital: cluster randomized trial. September 14, 2009 Graumlich JF, Novotny NL, Nace S, et al. Patient readmissions, emergency visits, and adverse events after software-assisted discharge from hospital: cluster rando…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40656/psn-pdf
    October 16, 2012 - Defining health information technology–related errors: new developments since To Err Is Human. October 16, 2012 Sittig DF, Singh H. Defining health information technology-related errors: new developments since to err is human. Arch Intern Med. 2011;171(14):1281-4. doi:10.1001/archinternmed.2011.327. https://psnet.…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40904/psn-pdf
    January 04, 2012 - Effect of illness severity and comorbidity on patient safety and adverse events. January 4, 2012 Naessens JM, Campbell CR, Shah ND, et al. Effect of illness severity and comorbidity on patient safety and adverse events. Am J Med Qual. 2012;27(1):48-57. doi:10.1177/1062860611413456. https://psnet.ahrq.gov/issue/eff…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39031/psn-pdf
    March 23, 2011 - Care homes' use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people. March 23, 2011 Barber ND, Alldred DP, Raynor DK, et al. Care homes' use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people. Qual …

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39215/psn-pdf
    January 03, 2017 - Adverse drug events among hospitalized Medicare patients: epidemiology and national estimates from a new approach to surveillance. January 3, 2017 Classen D, Jaser L, Budnitz DS. Adverse drug events among hospitalized Medicare patients: epidemiology and national estimates from a new approach to surveillance. Jt Co…
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