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psnet.ahrq.gov/web-mm/slippery-slide-life
January 21, 2017 - Slippery Slide Into Life
Citation Text:
Halamek LP. Slippery Slide Into Life. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/issue/medication-misadventures-resulting-emergency-department-visits-hmo-medical-center
March 16, 2022 - Study
Classic
Medication misadventures resulting in emergency department visits at an HMO medical center.
Citation Text:
Medication misadventures resulting in emergency department visits at an HMO medical center. Schneitman-McIntire O, Farnen TA, Gordon N, et al…
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psnet.ahrq.gov/issue/medication-reconciliation-failures-children-and-young-adults-chronic-disease-during-intensive
June 22, 2022 - Study
Medication reconciliation failures in children and young adults with chronic disease during intensive and intermediate care.
Citation Text:
DeCourcey DD, Silverman M, Chang E, et al. Medication reconciliation failures in children and young adults with chronic disease during intensi…
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psnet.ahrq.gov/node/60542/psn-pdf
May 27, 2020 - Life-Threatening Infant Overdose of Sodium Chloride
May 27, 2020
Hamline M, McGlynn G, Lee A, et al. Life-Threatening Infant Overdose of Sodium Chloride. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/life-threatening-infant-overdose-sodium-chloride
The Case
An infant with trisomy 21 underwent repair of a…
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psnet.ahrq.gov/issue/impact-pharmacists-led-medicines-reconciliation-healthcare-outcomes-secondary-care-systematic
August 07, 2024 - Review
Emerging Classic
The impact of pharmacists-led medicines reconciliation on healthcare outcomes in secondary care: a systematic review and meta-analysis of randomized controlled trials.
Citation Text:
Cheema E, Alhomoud FK, Kinsara ASA-D, et al. The impact…
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psnet.ahrq.gov/periodic-issue/periodic-issue-466
December 18, 2024 - December 4, 2024 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, report…
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psnet.ahrq.gov/issue/preventing-critical-failure-can-routinely-collected-data-be-repurposed-predict-avoidable
July 02, 2014 - Study
Preventing critical failure. Can routinely collected data be repurposed to predict avoidable patient harm? A quantitative descriptive study.
Citation Text:
Nowotny BM, Davies-Tuck M, Scott B, et al. Preventing critical failure. Can routinely collected data be repurposed to predict…
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psnet.ahrq.gov/issue/application-failure-mode-effect-analysis-improve-care-septic-patients-admitted-through
February 01, 2013 - Study
Application of failure mode effect analysis to improve the care of septic patients admitted through the emergency department.
Citation Text:
Alamry A, Owais SMA, Marini AM, et al. Application of Failure Mode Effect Analysis to Improve the Care of Septic Patients Admitted Through th…
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psnet.ahrq.gov/issue/risk-and-pharmacoeconomic-analyses-injectable-medication-process-paediatric-and-neonatal
December 17, 2014 - Study
Risk and pharmacoeconomic analyses of the injectable medication process in the paediatric and neonatal intensive care units.
Citation Text:
De Giorgi I, Fonzo-Christe C, Cingria L, et al. Risk and pharmacoeconomic analyses of the injectable medication process in the paediatric an…
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psnet.ahrq.gov/issue/hospital-staff-nurses-shift-length-associated-safety-and-quality-care
April 23, 2012 - Study
Hospital staff nurses' shift length associated with safety and quality of care.
Citation Text:
Stimpfel AW, Aiken LH. Hospital staff nurses' shift length associated with safety and quality of care. J Nurs Care Qual. 2013;28(2):122-129. doi:10.1097/NCQ.0b013e3182725f09.
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psnet.ahrq.gov/issue/effects-resident-work-hours-sleep-duration-and-work-experience-randomized-order-safety-trial
March 10, 2021 - Study
Effects on resident work hours, sleep duration and work experience in a Randomized Order Safety Trial Evaluating Resident-physician Schedules (ROSTERS).
Citation Text:
Barger LK, Sullivan JP, Blackwell T, et al. Effects on resident work hours, sleep duration, and work experience in…
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psnet.ahrq.gov/node/49773/psn-pdf
July 01, 2016 - Near Miss With Neonate
October 1, 2016
Malana J, Lyndon A. Near Miss With Neonate. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/near-miss-neonate
The Case
A 37-year-old pregnant woman was admitted to the hospital for scheduled induction of labor for postterm
dates. Early the next morning, intravenous oxy…
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psnet.ahrq.gov/primer/maternal-safety
January 10, 2024 - Maternal Safety
Citation Text:
Shauer M, Nichols A, Lyndon A. Maternal Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/issue/babys-death-spotlights-safety-risks-linked-computerized-systems
December 05, 2018 - Newspaper/Magazine Article
Baby's death spotlights safety risks linked to computerized systems.
Citation Text:
Graham J; Dizikes C.
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psnet.ahrq.gov/issue/distinguishing-high-performing-low-performing-hospitals-severe-maternal-morbidity-focus
June 01, 2022 - Study
Distinguishing high-performing from low-performing hospitals for severe maternal morbidity: a focus on quality and equity.
Citation Text:
Howell EA, Sofaer S, Balbierz A, et al. Distinguishing high-performing from low-performing hospitals for severe maternal morbidity: a focus on q…
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psnet.ahrq.gov/periodic-issue/periodic-issue-315
October 27, 2021 - October 27, 2021 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, report…
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psnet.ahrq.gov/issue/potentially-inappropriate-medication-use-among-elderly-home-care-patients-europe
September 19, 2016 - Study
Potentially inappropriate medication use among elderly home care patients in Europe.
Citation Text:
Fialová D, Topinková E, Gambassi G, et al. Potentially inappropriate medication use among elderly home care patients in Europe. JAMA. 2005;293(11):1348-58.
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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/issue/woman-works-end-black-maternal-health-crisis-after-daughter-dies-after-giving-birth
May 27, 2020 - Newspaper/Magazine Article
Woman works to end Black maternal health crisis after daughter dies after giving birth.
Citation Text:
Woman works to end Black maternal health crisis after daughter dies after giving birth. Kindelan K. ABC News. April 14, 2022.
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psnet.ahrq.gov/issue/va-pauses-16b-oracle-cerner-ehr-deployments-indefinitely-address-error-ridden-early-rollout
September 14, 2022 - Newspaper/Magazine Article
VA pauses $16B Oracle Cerner EHR deployments indefinitely to address error-ridden early rollout.
Citation Text:
VA pauses $16B Oracle Cerner EHR deployments indefinitely to address error-ridden early rollout. Muoio D. Fierce Healthcare. April 21, 2023.
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