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psnet.ahrq.gov/node/44372/psn-pdf
June 21, 2016 - Hospital characteristics associated with penalties in the
Centers for Medicare & Medicaid Services Hospital-
Acquired Condition Reduction Program.
June 21, 2016
Rajaram R, Chung JW, Kinnier C, et al. Hospital Characteristics Associated With Penalties in the Centers
for Medicare & Medicaid Services Hospital-Acquire…
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psnet.ahrq.gov/node/38077/psn-pdf
January 31, 2011 - Building physician work hour regulations from first
principles and best evidence.
January 31, 2011
Volpp KG, Landrigan CP. Building physician work hour regulations from first principles and best evidence.
JAMA. 2008;300(10):1197-9. doi:10.1001/jama.300.10.1197.
https://psnet.ahrq.gov/issue/building-physician-work-…
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psnet.ahrq.gov/node/47735/psn-pdf
June 24, 2019 - The Financial and Human Cost of Medical Error... and
How Massachusetts Can Lead the Way on Patient Safety.
June 24, 2019
Boston, MA: Betsy Lehman Center for Patient Safety; June 2019.
https://psnet.ahrq.gov/issue/financial-and-human-cost-medical-error-and-how-massachusetts-can-lead-
way-patient-safety
The Betsy L…
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psnet.ahrq.gov/issue/medical-crisis-checklists-emergency-department-simulation-based-multi-institutional
February 16, 2022 - Study
Medical crisis checklists in the emergency department: a simulation-based multi-institutional randomised controlled trial.
Citation Text:
Dryver E, Lundager Forberg J, Hård af Segerstad C, et al. Medical crisis checklists in the emergency department: a simulation-based multi-instit…
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psnet.ahrq.gov/issue/new-recommendations-duty-hours-acgme-task-force
July 14, 2021 - Commentary
Classic
The new recommendations on duty hours from the ACGME Task Force.
Citation Text:
Nasca TJ, Day SH, Amis S, et al. The new recommendations on duty hours from the ACGME Task Force. N Engl J Med. 2010;363(2):e3. doi:10.1056/NEJMsb1005800.
Copy…
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psnet.ahrq.gov/issue/structured-approach-ehr-surveillance-diagnostic-error-acute-care-exploratory-analysis-two
October 16, 2024 - Study
A structured approach to EHR surveillance of diagnostic error in acute care: an exploratory analysis of two institutionally-defined case cohorts.
Citation Text:
Malik MA, Motta-Calderon D, Piniella N, et al. A structured approach to EHR surveillance of diagnostic error in acute car…
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psnet.ahrq.gov/issue/improving-patient-safety-through-involvement-patients-development-and-evaluation-novel
October 12, 2016 - Book/Report
Improving patient safety through the involvement of patients: development and evaluation of novel interventions to engage patients in preventing patient safety incidents and protecting them against unintended harm.
Citation Text:
Wright J, Lawton R, O’Hara J, et al. Improving…
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psnet.ahrq.gov/issue/description-and-evaluation-adaptations-global-trigger-tool-enhance-value-adverse-event
November 23, 2014 - Study
Description and evaluation of adaptations to the Global Trigger Tool to enhance value to adverse event reduction efforts.
Citation Text:
Kennerly DA, Saldaña M, Kudyakov R, et al. Description and evaluation of adaptations to the global trigger tool to enhance value to adverse eve…
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psnet.ahrq.gov/issue/national-and-institutional-trends-adverse-events-over-time-systematic-review-and-meta
February 03, 2021 - Review
National and institutional trends in adverse events over time: a systematic review and meta-analysis of longitudinal retrospective patient record review studies.
Citation Text:
Connolly W, Li B, Conroy RM, et al. National and institutional trends in adverse events over time: a sys…
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psnet.ahrq.gov/issue/strategies-improving-patient-safety-culture-hospitals-systematic-review
February 14, 2017 - Review
Strategies for improving patient safety culture in hospitals: a systematic review.
Citation Text:
Morello RT, Lowthian JA, Barker AL, et al. Strategies for improving patient safety culture in hospitals: a systematic review. BMJ Qual Saf. 2013;22(1):11-8. doi:10.1136/bmjqs-2011-0…
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psnet.ahrq.gov/issue/situ-simulation-quality-improvement-tool-identify-and-mitigate-latent-safety-threats
February 22, 2023 - Study
In situ simulation as a quality improvement tool to identify and mitigate latent safety threats for emergency department SARS-CoV-2 airway management: a multi-institutional initiative.
Citation Text:
Yang CJ, Saggar V, Seneviratne N, et al. In situ simulation as a quality improveme…
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psnet.ahrq.gov/issue/characterising-nature-primary-care-patient-safety-incident-reports-england-and-wales-national
December 16, 2015 - Book/Report
Characterising the nature of primary care patient safety incident reports in the England and Wales National Reporting and Learning System: a mixed-methods agenda-setting study for general practice.
Citation Text:
Carson-Stevens A, Hibbert P, Williams H, et al. Characterising …
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psnet.ahrq.gov/issue/burden-peri-operative-work-night-perceived-anaesthesiologists-international-survey
May 08, 2024 - Study
The burden of peri-operative work at night as perceived by anaesthesiologists: an international survey.
Citation Text:
Cortegiani A, Ippolito M, Lakbar I, et al. The burden of peri-operative work at night as perceived by anaesthesiologists: an international survey. Eur J Anaesthesi…
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psnet.ahrq.gov/node/33753/psn-pdf
August 22, 2013 - Update on Safety Culture
August 22, 2013
Frankel A, Leonard M. Update on Safety Culture. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/update-safety-culture
Perspective
Safe and reliable care requires a culture of safety: a collaborative environment in which skilled clinicians
treat each other with r…
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psnet.ahrq.gov/sites/default/files/2023-07/spotlight_a_complicated_course.pdf
January 01, 2023 - different levels of care, and discharge timing.23
– This framework can be used to create policies for institution-specific
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psnet.ahrq.gov/web-mm/life-threatening-infant-overdose-sodium-chloride
December 23, 2020 - Life-Threatening Infant Overdose of Sodium Chloride
Citation Text:
Hamline M, McGlynn G, Lee A, et al. Life-Threatening Infant Overdose of Sodium Chloride. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
Copy Citation
Form…
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psnet.ahrq.gov/node/44958/psn-pdf
March 09, 2016 - The Sepsis Early Recognition and Response Initiative
(SERRI).
March 9, 2016
Jones SL, Ashton CM, Kiehne L, et al. The Sepsis Early Recognition and Response Initiative (SERRI). Jt
Comm J Qual Patient Saf. 2016;42(3):122-138.
https://psnet.ahrq.gov/issue/sepsis-early-recognition-and-response-initiative-serri
Early …
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psnet.ahrq.gov/node/39171/psn-pdf
February 10, 2015 - Patient safety at ten: unmistakable progress, troubling
gaps.
February 10, 2015
Wachter R. Patient safety at ten: unmistakable progress, troubling gaps. Health Aff (Millwood).
2010;29(1):165-173. doi:10.1377/hlthaff.2009.0785.
https://psnet.ahrq.gov/issue/patient-safety-ten-unmistakable-progress-troubling-gaps
Th…
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psnet.ahrq.gov/node/836879/psn-pdf
April 27, 2022 - In Conversation With... Michael L. Millenson
April 27, 2022
In Conversation With.. Michael L. Millenson. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/conversation-michael-l-millenson
December 16, 2021
Editor’s note: Michael L. Millenson is the President of Health Quality Advisors LLC, author of the c…
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psnet.ahrq.gov/node/49798/psn-pdf
July 01, 2017 - Pseudo-obstruction But a Real Perforation
July 1, 2017
Paski SC, Dominitz JA. Pseudo-obstruction But a Real Perforation. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/pseudo-obstruction-real-perforation
Case Objectives
Recognize acute colonic pseudo-obstruction and implement a medical management plan.
Ide…