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psnet.ahrq.gov/node/60888/psn-pdf
January 01, 2021 - Chronic hospital nurse understaffing meets COVID-19: an
observational study.
September 9, 2020
Lasater KB, Aiken LH, Sloane DM, et al. Chronic hospital nurse understaffing meets COVID-19: an
observational study. BMJ Qual Saf. 2021;8(8):639-647. doi:10.1136/bmjqs-2020-011512.
https://psnet.ahrq.gov/issue/chronic-ho…
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psnet.ahrq.gov/node/72502/psn-pdf
November 25, 2020 - Patient safety in primary care: conceptual meanings to
the health care team and patients.
November 25, 2020
Lai AY. Patient safety in primary care: conceptual meanings to the health care team and patients. J Am
Board Fam Med. 2020;33(5):754-764. doi:10.3122/jabfm.2020.05.200042.
https://psnet.ahrq.gov/issue/patien…
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psnet.ahrq.gov/node/837893/psn-pdf
August 24, 2022 - Exploring nurses' attitudes, skills, and beliefs of
medication safety practices.
August 24, 2022
Arkin L, Schuermann A, Penoyer D, et al. Exploring nurses' attitudes, skills, and beliefs of medication
safety practices. J Nurs Care Qual. 2022;37(4):319-326. doi:10.1097/ncq.0000000000000635.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/60724/psn-pdf
July 29, 2020 - The safety of health care for ethnic minority patients: a
systematic review.
July 29, 2020
Chauhan A, Walton M, Manias E, et al. The safety of health care for ethnic minority patients: a systematic
review. Int J Equity Health. 2020;19(1):118. doi:10.1186/s12939-020-01223-2.
https://psnet.ahrq.gov/issue/safety-heal…
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psnet.ahrq.gov/node/50749/psn-pdf
December 18, 2019 - Medication errors in the care transition of trauma patients
December 18, 2019
Martín Mª ÁP, García MM, Silveira ED, et al. Medication errors in the care transition of trauma patients. Eur
J Clin Pharmacol. 2019;75(12):1739-1746. doi:10.1007/s00228-019-02757-3.
https://psnet.ahrq.gov/issue/medication-errors-care-tra…
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psnet.ahrq.gov/node/837894/psn-pdf
August 24, 2022 - Identifying boundary spanning reporter roles in patient
safety events.
August 24, 2022
Hurley VB, Boxley C, Sloss EA, et al. Identifying boundary spanning reporter roles in patient safety events.
J Patient Saf Risk Manag. 2022;27(4):181-187. doi:10.1177/25160435221103096.
https://psnet.ahrq.gov/issue/identifying-b…
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psnet.ahrq.gov/node/839812/psn-pdf
November 09, 2022 - Measuring psychological safety and local learning to
enable high reliability organisational change.
November 9, 2022
Cartland J, Green M, Kamm D, et al. Measuring psychological safety and local learning to enable high
reliability organisational change. BMJ Open Qual. 2022;11(4):e001757. doi:10.1136/bmjoq-2021-00175…
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psnet.ahrq.gov/node/34677/psn-pdf
February 09, 2011 - Patients' and physicians' attitudes regarding the
disclosure of medical errors.
February 9, 2011
Gallagher TH, Waterman AD, Ebers AG, et al. Patients' and physicians' attitudes regarding the disclosure
of medical errors. JAMA. 2003;289(8):1001-7.
https://psnet.ahrq.gov/issue/patients-and-physicians-attitudes-regar…
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psnet.ahrq.gov/node/843088/psn-pdf
January 25, 2023 - The value of learning from near misses to improve patient
safety: a scoping review.
January 25, 2023
Woodier N, Burnett C, Moppett I. The value of learning from near misses to improve patient safety: a
scoping review. J Patient Saf. 2022;19(1):42-47. doi:10.1097/pts.0000000000001078.
https://psnet.ahrq.gov/issue/v…
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psnet.ahrq.gov/node/837976/psn-pdf
August 31, 2022 - Does seasonal variation in orthopaedic trauma volume
correlate with adverse hospital events and burnout?
August 31, 2022
Waldron J, Denisiuk M, Sharma R, et al. Does seasonal variation in orthopaedic trauma volume correlate
with adverse hospital events and burnout? Injury. 2022;53(6):2053-2059. doi:10.1016/j.injury…
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psnet.ahrq.gov/node/49662/psn-pdf
August 01, 2012 - Wrong Turn through Colon: Misplaced PEG
August 1, 2012
Sorokin R, Conn M. Wrong Turn through Colon: Misplaced PEG. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/wrong-turn-through-colon-misplaced-peg
The Case
An 87-year-old man was admitted for congestive heart failure (CHF) exacerbation. In addition, a pa…
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psnet.ahrq.gov/web-mm/hold-order
December 19, 2018 - Hold That Order
Citation Text:
Grissinger M. Hold That Order. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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Format:
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psnet.ahrq.gov/node/49696/psn-pdf
December 01, 2013 - New Oral Anticoagulants
December 1, 2013
Fang MC. New Oral Anticoagulants. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/new-oral-anticoagulants
Case Objectives
Review properties of newer target-specific oral anticoagulants (TSOACs) such as dabigatran,
rivaroxaban, and apixaban.
State key perioperative c…
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psnet.ahrq.gov/issue/factors-associated-hospital-admission-after-outpatient-surgery-veterans-health-administration
August 17, 2018 - detected by the Veterans Health Administration Surgical Quality Improvement Program and the Patient Safety Indicators … June 5, 2013
Validity of selected patient safety indicators: opportunities and concerns
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psnet.ahrq.gov/issue/opportunities-and-challenges-quality-and-safety-applications-icd-11-international-survey
February 17, 2017 - Related Resources From the Same Author(s)
Deriving ICD-10 codes for patient safety indicators … November 30, 2022
Application of patient safety indicators internationally: a pilot study
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psnet.ahrq.gov/node/60994/psn-pdf
October 07, 2020 - Potentially inappropriate medication combination with
opioids among older dental patients: a retrospective
review of insurance claims data.
October 7, 2020
Zhou J, Calip GS, Rowan S, et al. Potentially inappropriate medication combination with opioids among
older dental patients: a retrospective review of insuranc…
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psnet.ahrq.gov/node/72647/psn-pdf
January 20, 2021 - Association of unexpected newborn deaths with changes
in obstetric and neonatal process of care.
January 20, 2021
Han D, Khadka A, McConnell M, et al. Association of Unexpected Newborn Deaths With Changes in
Obstetric and Neonatal Process of Care. JAMA Netw Open. 2020;3(12):e2024589.
doi:10.1001/jamanetworkopen.20…
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psnet.ahrq.gov/node/43383/psn-pdf
August 13, 2014 - Risk factors for retained surgical items: a meta-analysis
and proposed risk stratification system.
August 13, 2014
Moffatt-Bruce SD, Cook CH, Steinberg SM, et al. Risk factors for retained surgical items: a meta-analysis
and proposed risk stratification system. J Surg Res. 2014;190(2):429-36. doi:10.1016/j.jss.2014…
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psnet.ahrq.gov/node/73976/psn-pdf
October 20, 2021 - A retrospective analysis demonstrates that a failure to
document key comorbid diseases in the anesthesia
preoperative evaluation associates with increased length
of stay and mortality.
October 20, 2021
Hofer IS, Cheng D, Grogan T. A retrospective analysis demonstrates that a failure to document key
comorbid disea…
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psnet.ahrq.gov/node/844988/psn-pdf
February 22, 2023 - Assessment of patient retention of inpatient care
information post-hospitalization.
February 22, 2023
Townshend R, Grondin C, Gupta A, et al. Assessment of patient retention of inpatient care information
post-hospitalization. Jt Comm J Qual Patient Saf. 2023;49(2):70-78. doi:10.1016/j.jcjq.2022.11.002.
https://psn…