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psnet.ahrq.gov/periodic-issue/periodic-issue-467
December 18, 2024 - December 11, 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, repor…
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psnet.ahrq.gov/node/73412/psn-pdf
August 01, 2022 - of a pregnant
patient experiencing a high-risk pregnancy, including outcomes such as maternal and infant … mortality,
preterm birth, low birth weight, and increased substance use during pregnancy.1
IPV is
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psnet.ahrq.gov/issue/association-between-paediatric-intraoperative-anaesthesia-handover-and-adverse-postoperative
July 21, 2021 - Study
Association between paediatric intraoperative anaesthesia handover and adverse postoperative outcomes.
Citation Text:
Kannampallil TG, Lew D, Pfeifer EE, et al. Association between paediatric intraoperative anaesthesia handover and adverse postoperative outcomes. BMJ Qual Saf. 2021…
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psnet.ahrq.gov/issue/nurses-experience-barriers-safe-practice-neonatal-intensive-care-unit-thailand
August 16, 2023 - Study
The nurses' experience of barriers to safe practice in the neonatal intensive care unit in Thailand.
Citation Text:
Jirapaet V, Jirapaet K, Sopajaree C. The nurses' experience of barriers to safe practice in the neonatal intensive care unit in Thailand. J Obstet Gynecol Neonatal …
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psnet.ahrq.gov/issue/are-teaching-hospitals-treated-fairly-hospital-acquired-condition-reduction-program
July 11, 2018 - Study
Are teaching hospitals treated fairly in the Hospital-Acquired Condition Reduction Program?
Citation Text:
Mohajer MA, Joiner KA, Nix DE. Are Teaching Hospitals Treated Fairly in the Hospital-Acquired Condition Reduction Program? Acad Med. 2018;93(12):1827-1832. doi:10.1097/ACM.000…
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psnet.ahrq.gov/issue/impact-team-performance-surgical-safety-checklist-patient-outcomes-operating-room-black-box
March 20, 2024 - Study
Impact of team performance on the surgical safety checklist on patient outcomes: an operating room black box analysis.
Citation Text:
Al Abbas AI, Meier J, Daniel W, et al. Impact of team performance on the surgical safety checklist on patient outcomes: an operating room black box …
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psnet.ahrq.gov/issue/educational-interventions-reduce-prescribing-errors
October 19, 2022 - Study
Educational interventions to reduce prescribing errors.
Citation Text:
Conroy S, North C, Fox T, et al. Educational interventions to reduce prescribing errors. Arch Dis Child. 2008;93(4):313-5. doi:10.1136/adc.2007.127761.
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psnet.ahrq.gov/web-mm/premature-or-overdue
December 23, 2020 - Premature or Overdue?
Citation Text:
Thomas J, Hannah M. Premature or Overdue?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/issue/misgivings
March 17, 2021 - Commentary
Misgivings.
Citation Text:
Farlow B. Misgivings. Hastings Cent Rep. 2009;39(5):19-21.
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psnet.ahrq.gov/web-mm/near-miss-neonate
August 15, 2018 - Near Miss With Neonate
Citation Text:
Malana J, Lyndon A. Near Miss With Neonate. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/issue/patient-safety-initiatives-obstetrics-rapid-review
September 23, 2020 - Review
Patient safety initiatives in obstetrics: a rapid review.
Citation Text:
Antony J, Zarin W, Pham B', et al. Patient safety initiatives in obstetrics: a rapid review. BMJ Open. 2018;8(7):e020170. doi:10.1136/bmjopen-2017-020170.
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psnet.ahrq.gov/issue/language-discordance-and-patient-care-babel
October 30, 2024 - Commentary
Language discordance and patient care-Babel.
Citation Text:
Huson TA. Language discordance and patient care-Babel. JAMA Intern Med. 2024;184(11):1287-1288. doi:10.1001/jamainternmed.2024.4273.
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psnet.ahrq.gov/web-mm/hidden-danger-insidious-postpartum-bleeding-after-emergency-cesarean-delivery
November 25, 2020 - Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery.
Citation Text:
Leiserowitz GS, Hedriana H. Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health an…
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psnet.ahrq.gov/node/49723/psn-pdf
January 01, 2015 - quickly adopted because it offered a
continuous measure of FHR activity and was expected to reduce infant … mortality.(1-4) Both FHR activity
and maternal contractions are recorded by transducers placed on the
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psnet.ahrq.gov/web-mm/aspergillus-mediastinitis-endocarditis-pediatric-patient-complicating-cardiac-surgery-and
November 16, 2022 - Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure.
Citation Text:
Partridge E, Dodson D, Reilly M, et al. Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure.. PSNet [inter…
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psnet.ahrq.gov/issue/rate-causes-and-reporting-medication-errors-jordan-nurses-perspectives
April 15, 2020 - Study
Rate, causes and reporting of medication errors in Jordan: nurses' perspectives.
Citation Text:
MRAYYAN MAJDT, SHISHANI KAWKAB, AL-FAOURI IBRAHIM. Rate, causes and reporting of medication errors in Jordan: nurses? perspectives. J Nurs Manag. 2007;15(6). doi:10.1111/j.1365-2834.20…
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psnet.ahrq.gov/issue/medication-based-trigger-tool-identify-adverse-events-pediatric-anesthesiology
April 22, 2020 - Commentary
A medication-based trigger tool to identify adverse events in pediatric anesthesiology.
Citation Text:
Taghon T, Elsey N, Miler V, et al. A medication-based trigger tool to identify adverse events in pediatric anesthesiology. Jt Comm J Qual Patient Saf. 2014;40(7):326-334.
C…
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psnet.ahrq.gov/node/842923/psn-pdf
February 01, 2023 - Aspergillus Mediastinitis & Endocarditis in a Pediatric
Patient Complicating Cardiac Surgery and Bedside Chest
Closure.
February 1, 2023
Partridge E, Dodson D, Reilly M, et al. Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient
Complicating Cardiac Surgery and Bedside Chest Closure. PSNet [internet]. …
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psnet.ahrq.gov/webmm-case-studies
February 26, 2025 - WebM&M: Case Studies
WebM&M (Morbidity & Mortality Rounds on the Web) features expert analysis of medical errors reported anonymously by our readers. Spotlight Cases include interactive learning modules available for CME/CPE . Commentaries are written by patient safety experts and published monthly. Have you encou…
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psnet.ahrq.gov/node/60000
January 01, 2021 - The High-Risk Pregnancy Program has reduced Arkansas' 60-day infant mortality rate by 0.5 percent due