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psnet.ahrq.gov/issue/attitudes-toward-safety-and-teamwork-maternity-unit-embedded-team-training
November 20, 2013 - Study
Attitudes toward safety and teamwork in a maternity unit with embedded team training.
Citation Text:
Siassakos D, Fox R, Hunt L, et al. Attitudes toward safety and teamwork in a maternity unit with embedded team training. Am J Med Qual. 2011;26(2):132-7. doi:10.1177/1062860610373…
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psnet.ahrq.gov/issue/national-incidence-medication-error-surgical-patients-and-after-accreditation-council
September 23, 2020 - Study
National incidence of medication error in surgical patients before and after Accreditation Council for Graduate Medical Education duty-hour reform.
Citation Text:
Vadera S, Griffith SD, Rosenbaum BP, et al. National Incidence of Medication Error in Surgical Patients Before and Afte…
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psnet.ahrq.gov/issue/cost-quality-academic-health-centers-annual-costs-its-quality-and-patient-safety
October 14, 2020 - Study
The cost of quality: an academic health center's annual costs for its quality and patient safety infrastructure.
Citation Text:
Blanchfield BB, Demehin AA, Cummings CT, et al. The cost of quality: an academic health center's annual costs for its quality and patient safety infrastru…
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psnet.ahrq.gov/issue/rate-sepsis-hospitalizations-after-misdiagnosis-adult-emergency-department-patients-look
December 08, 2021 - Study
Rate of sepsis hospitalizations after misdiagnosis in adult emergency department patients: a look-forward analysis with administrative claims data using Symptom-Disease Pair Analysis of Diagnostic Error methodology in an integrated health system.
Citation Text:
Horberg MA, Nassery …
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psnet.ahrq.gov/issue/process-failures-increase-risk-infection-through-respiratory-droplets-study-patient-safety
March 24, 2021 - Study
Process failures that increase the risk of infection through respiratory droplets: a study of patient safety events reported by hospitals across Pennsylvania.
Citation Text:
Harper A, Kukielka E, Jones RM. Process failures that increase the risk of infection through respiratory dro…
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psnet.ahrq.gov/web-mm/overdose-gabapentin-and-oxycodone-patient-end-stage-renal-disease-case-appropriate
June 24, 2020 - In addition, custom renal dose warnings can be labor-intensive to build and maintain in an EHR system
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psnet.ahrq.gov/perspective/conversation-jack-needleman-phd
September 01, 2012 - We need to build payment systems that create incentives to maintain safe staffing levels.
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psnet.ahrq.gov/perspective/preparing-health-reform-federal-government-and-nursing-workforce
September 01, 2012 - We need to build payment systems that create incentives to maintain safe staffing levels.
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psnet.ahrq.gov/issue/sustaining-reductions-central-line-associated-bloodstream-infections-michigan-intensive-care
June 16, 2011 - Study
Sustaining reductions in central line-associated bloodstream infections in Michigan intensive care units: a 10-year analysis.
Citation Text:
Pronovost P, Watson S, Goeschel CA, et al. Sustaining Reductions in Central Line-Associated Bloodstream Infections in Michigan Intensive Care…
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psnet.ahrq.gov/issue/anticoagulant-medication-errors-nursing-homes-characteristics-causes-outcomes-and-association
December 15, 2011 - Study
Anticoagulant medication errors in nursing homes: characteristics, causes, outcomes, and association with patient harm.
Citation Text:
Desai RJ, Williams CE, Greene SB, et al. Anticoagulant medication errors in nursing homes: characteristics, causes, outcomes, and association with…
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psnet.ahrq.gov/issue/comprehensive-obstetric-patient-safety-program-reduces-liability-claims-and-payments
June 22, 2017 - Study
A comprehensive obstetric patient safety program reduces liability claims and payments.
Citation Text:
Pettker CM, Thung SF, Lipkind HS, et al. A comprehensive obstetric patient safety program reduces liability claims and payments. Am J Obstet Gynecol. 2014;211(4):319-25. doi:10.10…
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psnet.ahrq.gov/issue/nurses-shift-length-and-overtime-working-12-european-countries-association-perceived-quality
August 20, 2018 - Study
Nurses' shift length and overtime working in 12 European countries: the association with perceived quality of care and patient safety.
Citation Text:
Griffiths P, Dall'Ora C, Simon M, et al. Nurses' shift length and overtime working in 12 European countries: the association with pe…
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psnet.ahrq.gov/web-mm/inflicting-confusion
August 04, 2021 - Inflicting Confusion
Citation Text:
Scott FI, Lichtenstein GR. Inflicting Confusion. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/perspective/conversation-alison-holmes-md-mph
March 01, 2014 - prescribing diversity—that we don't have very homogenous prescribing practice—so that we can try to maintain
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psnet.ahrq.gov/perspective/how-does-infection-prevention-fit-safety-program
March 01, 2014 - prescribing diversity—that we don't have very homogenous prescribing practice—so that we can try to maintain
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psnet.ahrq.gov/perspective/resilient-healthcare-and-safety-i-and-safety-ii-frameworks
December 14, 2022 - delivery grows more complex, resilient healthcare methods can be applied to support patient safety and maintain
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psnet.ahrq.gov/perspective/conversation-libby-hoy-and-stephen-hoy
March 10, 2021 - important; 2) having the confidence and knowledge necessary to take action; 3) actually taking action to maintain
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psnet.ahrq.gov/innovation/statewide-telehealth-program-enhances-access-care-improves-outcomes-high-risk
November 13, 2024 - cultivating trust and understanding of telemedicine through onsite visits to rural clinics, phone calls to maintain
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psnet.ahrq.gov/node/837659/psn-pdf
July 08, 2022 - Medication Safety Events Related to Diagnostic Imaging
July 8, 2022
Sanchez L, Porras H, Lammers C. Medication Safety Events Related to Diagnostic Imaging. PSNet
[internet]. 2022.
https://psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
The Cases
Case #1: A 42-year-old woman admitted with…