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psnet.ahrq.gov/web-mm/seasonal-care-transition-failure
June 01, 2016 - A Seasonal Care Transition Failure
Citation Text:
Young JQ. A Seasonal Care Transition Failure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge
February 23, 2011 - Patient Identification Errors: A Systems Challenge
Citation Text:
Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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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/node/49869/psn-pdf
July 02, 2019 - Failure to Rescue the Mother
July 2, 2019
Vivero A, Klapper EB, Gregory KD, et al. Failure to Rescue the Mother. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/failure-rescue-mother
The Case
A 27-year-old woman, G5 P2 A2, was first admitted to the hospital at 25 weeks of pregnancy for vaginal
bleeding. An …
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psnet.ahrq.gov/issue/effect-increased-inpatient-attending-physician-supervision-medical-errors-patient-safety-and
December 07, 2011 - Study
Emerging Classic
Effect of increased inpatient attending physician supervision on medical errors, patient safety, and resident education: a randomized clinical trial.
Citation Text:
Finn KM, Metlay JP, Chang Y, et al. Effect of Increased Inpatient Attendin…
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psnet.ahrq.gov/issue/preventable-deaths-due-problems-care-english-acute-hospitals-retrospective-case-record-review
July 20, 2022 - Study
Classic
Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review study.
Citation Text:
Hogan H, Healey F, Neale G, et al. Preventable deaths due to problems in care in English acute hospitals: a retrospect…
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psnet.ahrq.gov/issue/challenges-electronic-health-records-and-diabetes-electronic-prescribing-implications-safety
September 23, 2020 - Review
The challenges of electronic health records and diabetes electronic prescribing: implications for safety net care for diverse populations.
Citation Text:
Ratanawongsa N, Chan LLS, Fouts MM, et al. The Challenges of Electronic Health Records and Diabetes Electronic Prescribing: Imp…
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psnet.ahrq.gov/issue/do-medical-inpatients-who-report-poor-service-quality-experience-more-adverse-events-and
July 14, 2021 - Study
Classic
Do medical inpatients who report poor service quality experience more adverse events and medical errors?
Citation Text:
Taylor BB, Marcantonio ER, Pagovich O, et al. Do medical inpatients who report poor service quality experience more adverse ev…
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psnet.ahrq.gov/issue/vital-signs-improving-antibiotic-use-among-hospitalized-patients
February 27, 2019 - Study
Classic
Vital signs: improving antibiotic use among hospitalized patients.
Citation Text:
Fridkin SK, Baggs J, Fagan R, et al. Vital signs: improving antibiotic use among hospitalized patients. MMWR Morb Mortal Wkly Rep. 2014;63(9):194-200.
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psnet.ahrq.gov/issue/medicine-communication-hospital-residential-aged-care-facilities-cross-sectional-survey-aged
December 06, 2023 - Study
Medicine communication from hospital to residential aged care facilities: a cross-sectional survey of aged care facility staff.
Citation Text:
Browning S, Raleigh RA, Hattingh HL. Medicine communication from hospital to residential aged care facilities: a cross-sectional survey of …
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psnet.ahrq.gov/issue/diagnostic-errors-intensive-care-unit-systematic-review-autopsy-studies
March 10, 2021 - Review
Diagnostic errors in the intensive care unit: a systematic review of autopsy studies.
Citation Text:
Winters BD, Custer J, Galvagno SM, et al. Diagnostic errors in the intensive care unit: a systematic review of autopsy studies. BMJ Qual Saf. 2012;21(11):894-902. doi:10.1136/bmj…
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psnet.ahrq.gov/issue/development-evidence-based-framework-factors-contributing-patient-safety-incidents-hospital
June 25, 2014 - Review
Development of an evidence-based framework of factors contributing to patient safety incidents in hospital settings: a systematic review.
Citation Text:
Lawton R, McEachan RRC, Giles SJ, et al. Development of an evidence-based framework of factors contributing to patient safety …
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psnet.ahrq.gov/issue/effect-postdischarge-virtual-ward-readmission-or-death-high-risk-patients-randomized-clinical
October 31, 2011 - Study
Classic
Effect of a postdischarge virtual ward on readmission or death for high-risk patients: a randomized clinical trial.
Citation Text:
Dhalla IA, O'Brien T, Morra D, et al. Effect of a postdischarge virtual ward on readmission or death for high-risk pa…
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psnet.ahrq.gov/node/837194/psn-pdf
January 01, 2023 - National improvements in resident physician-reported
patient safety after limiting first-year resident physicians'
extended duration work shifts: a pooled analysis of
prospective cohort studies.
May 25, 2022
Weaver MD, Landrigan CP, Sullivan JP, et al. National improvements in resident physician-reported patient
…
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psnet.ahrq.gov/issue/spread-remains-challenge-patient-safety-improvement
January 23, 2019 - Newspaper/Magazine Article
'Spread' remains challenge in patient safety improvement.
Citation Text:
'Spread' remains challenge in patient safety improvement. Healthcare benchmarks and quality improvement. 2011;18(5):49-52.
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psnet.ahrq.gov/issue/how-safe-your-hospital-our-new-ratings-find-some-are-riskier-others
May 22, 2023 - Newspaper/Magazine Article
How safe is your hospital? Our new ratings find that some are riskier than others.
Citation Text:
How safe is your hospital? Our new ratings find that too many pose risks. Consumer reports. 2012;77(8):20-8.
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psnet.ahrq.gov/node/39617/psn-pdf
February 18, 2011 - Potential unintended consequences due to Medicare's
"No Pay for Errors Rule"? A randomized controlled trial of
an educational intervention with internal medicine
residents.
February 18, 2011
Mookherjee S, Vidyarthi AR, Ranji SR, et al. Potential Unintended Consequences Due to Medicare’s “No
Pay for Errors Rule”? …
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psnet.ahrq.gov/issue/patient-notification-toolkit
September 07, 2016 - Toolkit
Patient Notification Toolkit.
Citation Text:
Patient Notification Toolkit. Centers for Disease Control and Prevention; CDC.
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psnet.ahrq.gov/issue/patient-safety-6
July 21, 2021 - Multi-use Website
Patient Safety.
Citation Text:
Patient Safety. American Hospital Association; AHA Quality Center.
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psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
February 10, 2021 - SPOTLIGHT CASE
Premature Closure: Was It Just Syncope?
Citation Text:
Maurier D, Barnes DK. Premature Closure: Was It Just Syncope?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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