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psnet.ahrq.gov/node/35670/psn-pdf
June 28, 2010 - Quality improvement implementation and hospital
performance on patient safety indicators.
June 28, 2010
Weiner BJ, Alexander JA, Baker LC, et al. Quality improvement implementation and hospital performance
on patient safety indicators. Med Care Res Rev. 2006;63(1):29-57.
https://psnet.ahrq.gov/issue/quality-improv…
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psnet.ahrq.gov/node/38843/psn-pdf
June 28, 2011 - Application of patient safety indicators internationally: a
pilot study among seven countries.
June 28, 2011
Drösler SE, Klazinga NS, Romano PS, et al. Application of patient safety indicators internationally: a pilot
study among seven countries. Int J Qual Health Care. 2009;21(4):272-8. doi:10.1093/intqhc/mzp018.
…
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psnet.ahrq.gov/node/45393/psn-pdf
November 16, 2016 - Agency for Healthcare Research and Quality (AHRQ)
Patient Safety Indicator for Postoperative Respiratory
Failure (PSI 11) does not identify accurately patients who
received unsafe care.
November 16, 2016
Nguyen MC, Moffatt-Bruce SD, Strosberg DS, et al. Agency for Healthcare Research and Quality (AHRQ)
Patient Sa…
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psnet.ahrq.gov/node/42520/psn-pdf
August 21, 2013 - Validity of Agency for Healthcare Research and Quality
Patient Safety Indicators at an academic medical center.
August 21, 2013
Ramanathan R, Leavell P, Stockslager G, et al. Validity of Agency for Healthcare Research and Quality
Patient Safety Indicators at an academic medical center. Am Surg. 2013;79(6):578-582.
…
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psnet.ahrq.gov/node/38926/psn-pdf
November 13, 2009 - "Canary measures" among the AHRQ Patient Safety
Indicators.
November 13, 2009
Yu H, Greenberg MD, Haviland AM, et al. "Canary measures" among the AHRQ patient safety indicators.
Am J Med Qual. 2009;24(6):465-73. doi:10.1177/1062860609341585.
https://psnet.ahrq.gov/issue/canary-measures-among-ahrq-patient-safety-in…
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psnet.ahrq.gov/node/39217/psn-pdf
January 20, 2010 - Positive predictive value of the AHRQ accidental puncture
or laceration patient safety indicator.
January 20, 2010
Utter GH, Zrelak PA, Baron R, et al. Positive predictive value of the AHRQ accidental puncture or
laceration patient safety indicator. Ann Surg. 2009;250(6):1041-5. doi:10.1097/SLA.0b013e3181afe095.
h…
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psnet.ahrq.gov/node/35296/psn-pdf
July 14, 2009 - Evaluating the Patient Safety Indicators: how well do they
perform on Veterans Health Administration data?
July 14, 2009
Rosen AK, Rivard PE, Zhao S, et al. Evaluating the patient safety indicators: how well do they perform on
Veterans Health Administration data? Med Care. 2005;43(9):873-884.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/40131/psn-pdf
April 03, 2017 - Designing an abstraction instrument: lessons from efforts
to validate the AHRQ Patient Safety Indicators.
April 3, 2017
Utter GH, Borzecki A, Rosen AK, et al. Designing an abstraction instrument: lessons from efforts to validate
the AHRQ patient safety indicators. Jt Comm J Qual Patient Saf. 2011;37(1):20-8.
https…
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psnet.ahrq.gov/node/34918/psn-pdf
December 17, 2009 - Racial, ethnic, and socioeconomic disparities in estimates
of AHRQ patient safety indicators.
December 17, 2009
Coffey RM, Andrews RM, Moy E. Racial, ethnic, and socioeconomic disparities in estimates of AHRQ
patient safety indicators. Med Care. 2005;43(3 Suppl):I48-I57.
https://psnet.ahrq.gov/issue/racial-ethnic-…
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psnet.ahrq.gov/node/45779/psn-pdf
January 10, 2018 - The link between clinically validated patient safety
indicators and clinical outcomes.
January 10, 2018
Gray DM, Hefner JL, Nguyen MC, et al. The Link Between Clinically Validated Patient Safety Indicators and
Clinical Outcomes. Am J Med Qual. 2017;32(6):583-590. doi:10.1177/1062860616683014.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/40944/psn-pdf
March 06, 2012 - Using the Agency for Healthcare Research and Quality
Patient Safety Indicators for targeting nursing quality
improvement.
March 6, 2012
Zrelak PA, Utter GH, Sadeghi B, et al. Using the Agency for Healthcare Research and Quality patient
safety indicators for targeting nursing quality improvement. J Nurs Care Qual. …
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psnet.ahrq.gov/node/38757/psn-pdf
January 03, 2017 - Clinical validation of the AHRQ postoperative venous
thromboembolism patient safety indicator.
January 3, 2017
Henderson KE, Recktenwald AJ, Reichley RM, et al. Clinical validation of the AHRQ postoperative venous
thromboembolism patient safety indicator. Jt Comm J Qual Patient Saf. 2009;35(7):370-376.
https://psn…
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psnet.ahrq.gov/node/39107/psn-pdf
May 25, 2010 - Testing the association between Patient Safety Indicators
and hospital structural characteristics in VA and
nonfederal hospitals.
May 25, 2010
Rivard PE, Elixhauser A, Christiansen CL, et al. Testing the Association Between Patient Safety Indicators
and Hospital Structural Characteristics in VA and Nonfederal Hosp…
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psnet.ahrq.gov/node/41545/psn-pdf
December 29, 2014 - Using the patient safety indicators to detect potential
safety events among US veterans with psychotic
disorders: clinical and research implications.
December 29, 2014
Smith EG, Zhao S, Rosen AK. Using the patient safety indicators to detect potential safety events among
US veterans with psychotic disorders: clini…
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psnet.ahrq.gov/node/41764/psn-pdf
January 18, 2013 - Examining the impact of the AHRQ Patient Safety
Indicators (PSIs) on the Veterans Health Administration:
the case of readmissions.
January 18, 2013
Rosen AK, Loveland S, Shin MH, et al. Examining the impact of the AHRQ Patient Safety Indicators (PSIs)
on the Veterans Health Administration: the case of readmissions…
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psnet.ahrq.gov/node/45333/psn-pdf
September 21, 2016 - Association of inpatient hospital experience with patient
safety indicators: a cross-sectional, Canadian study.
September 21, 2016
Kemp KA, Santana MJ, Southern DA, et al. Association of inpatient hospital experience with patient safety
indicators: a cross-sectional, Canadian study. BMJ Open. 2016;6(7):e011242. doi…
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psnet.ahrq.gov/node/37096/psn-pdf
June 24, 2010 - Impact of diagnosis-timing indicators on measures of
safety, comorbidity, and case mix groupings from
administrative data sources.
June 24, 2010
Naessens JM, Campbell CR, Berg B, et al. Impact of diagnosis-timing indicators on measures of safety,
comorbidity, and case mix groupings from administrative data sources…
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psnet.ahrq.gov/node/72911/psn-pdf
March 15, 2021 - The Impact of Communication on Medication Errors
March 15, 2021
Branch J, Hiner D, Jackson V. The Impact of Communication on Medication Errors. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/impact-communication-medication-errors
The Case
A 93-year-old man with a history of chronic systolic heart failure…
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psnet.ahrq.gov/web-mm/pill-organizing-plight
June 19, 2018 - SPOTLIGHT CASE
A Pill Organizing Plight
Citation Text:
McGalliard B, Shane R, Rosen S. A Pill Organizing Plight. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
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psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event
July 01, 2017 - SPOTLIGHT CASE
“This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event
Citation Text:
Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Dep…