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psnet.ahrq.gov/issue/transfusion-related-errors-and-associated-adverse-reactions-and-blood-product-wastage
September 23, 2020 - Study
Transfusion-related errors and associated adverse reactions and blood product wastage as reported to the National Healthcare Safety Network Hemovigilance Module, 2014-2022.
Citation Text:
Chavez Ortiz JL, Griffin I, Kazakova SV, et al. Transfusion‐related errors and associated adve…
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psnet.ahrq.gov/issue/reporting-clinical-adverse-events-scale-measure-doctor-and-nurse-attitudes-adverse-event
November 12, 2014 - Study
Reporting of Clinical Adverse Events Scale: a measure of doctor and nurse attitudes to adverse event reporting.
Citation Text:
Wilson B, Bekker HL, Fylan F. Reporting of Clinical Adverse Events Scale: a measure of doctor and nurse attitudes to adverse event reporting. Qual Saf He…
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psnet.ahrq.gov/issue/medication-safety-advancing-development-improvement
January 08, 2020 - Grant Announcement
Medication Safety: Advancing the Development of Improvement Strategies and Tools (R18).
Citation Text:
Medication Safety: Advancing the Development of Improvement Strategies and Tools (R18). Rockville, MD: Agency for Healthcare Research and Quality; Septembe…
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psnet.ahrq.gov/issue/uncomfortable-prescribing-decisions-hospitals-impact-teamwork
October 22, 2014 - Study
Uncomfortable prescribing decisions in hospitals: the impact of teamwork.
Citation Text:
Lewis PJ, Tully MP. Uncomfortable prescribing decisions in hospitals: the impact of teamwork. J R Soc Med. 2009;102(11):481-8. doi:10.1258/jrsm.2009.090150.
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psnet.ahrq.gov/issue/survey-cancer-care-providers-attitude-toward-care-older-adults-cancer-during-covid-19
December 16, 2020 - Study
Survey of cancer care providers' attitude toward care for older adults with cancer during the COVID-19 pandemic.
Citation Text:
BrintzenhofeSzoc K. Survey of cancer care providers' attitude toward care for older adults with cancer during the COVID-19 pandemic. J Geriatr Onco. 2021;…
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psnet.ahrq.gov/issue/health-care-associated-infections-among-critically-ill-children-us-2013-2018
May 18, 2022 - Study
Health care-associated infections among critically ill children in the US, 2013-2018.
Citation Text:
Hsu HE, Mathew R, Wang R, et al. Health care-associated infections among critically ill children in the US, 2013-2018. JAMA Pediatr. 2020;174(12):1176-1183. doi:10.1001/jamapediatri…
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psnet.ahrq.gov/node/49692/psn-pdf
September 01, 2013 - A Picture Speaks 1000 Words
September 1, 2013
Hemphill RR. A Picture Speaks 1000 Words. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/picture-speaks-1000-words
The Case
A 62-year-old man with a past medical history of hypertension, hyperlipidemia, and type A aortic dissection
repair presented with chest p…
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psnet.ahrq.gov/node/33643/psn-pdf
December 01, 2006 - In Conversation with...J. Bryan Sexton, PhD, MA
December 1, 2006
In Conversation with..J. Bryan Sexton, PhD, MA. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-withj-bryan-sexton-phd-ma
Editor's Note: J. Bryan Sexton, PhD, MA, is Assistant Professor, Department of Anesthesiology and
Critic…
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psnet.ahrq.gov/issue/eliminating-harm-checklists-reduce-all-cause-preventable-harm
October 19, 2016 - Toolkit
Eliminating Harm Checklists: Reduce All-Cause, Preventable Harm.
Citation Text:
Eliminating Harm Checklists: Reduce All-Cause, Preventable Harm. Chicago, IL: American Hospital Association, Health Research & Educational Trust; 2016.
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psnet.ahrq.gov/web-mm/diagnosing-diagnostic-mistakes
April 30, 2014 - SPOTLIGHT CASE
Diagnosing Diagnostic Mistakes
Citation Text:
McNutt RA, Abrams RI, Hasler S. Diagnosing Diagnostic Mistakes. 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/adverse-events-root-causes-and-latent-factors
June 21, 2017 - Commentary
Adverse events: root causes and latent factors.
Citation Text:
Karl R, Karl MC. Adverse events: root causes and latent factors. Surg Clin North Am. 2012;92(1):89-100. doi:10.1016/j.suc.2011.12.003.
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psnet.ahrq.gov/issue/using-proactive-risk-assessment-hfmea-improve-patient-safety-and-quality-associated
September 19, 2016 - Study
Using proactive risk assessment (HFMEA) to improve patient safety and quality associated with intraocular lens selection and implantation in cataract surgery.
Citation Text:
DeRosier JM, Hansemann BK, Smith-Wheelock MW, et al. Using Proactive Risk Assessment (HFMEA) to Improve Pati…
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psnet.ahrq.gov/node/39893/psn-pdf
November 02, 2010 - Surgical safety and hospital volume across a wide range
of interventions.
November 2, 2010
Eggli Y, Halfon P, Meylan D, et al. Surgical safety and hospital volume across a wide range of
interventions. Med Care. 2010;48(11):962-71. doi:10.1097/MLR.0b013e3181eaf9f6.
https://psnet.ahrq.gov/issue/surgical-safety-and-h…
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psnet.ahrq.gov/node/49623/psn-pdf
March 01, 2011 - Are We Pushing Graduate Nurses Too Fast?
March 1, 2011
Spector ND. Are We Pushing Graduate Nurses Too Fast? . PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/are-we-pushing-graduate-nurses-too-fast
The Case
A middle-aged man was admitted to the surgical intensive care unit (SICU) following a complex surgical…
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psnet.ahrq.gov/issue/complexity-team-training-what-we-have-learned-aviation-and-its-applications-medicine
December 09, 2009 - Commentary
The complexity of team training: what we have learned from aviation and its applications to medicine.
Citation Text:
Hamman WR. The complexity of team training: what we have learned from aviation and its applications to medicine. Qual Saf Health Care. 2004;13 Suppl 1:i72-9. …
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psnet.ahrq.gov/node/46682/psn-pdf
January 24, 2018 - AHRQ Safety Program for Surgery.
January 24, 2018
Rockville, MD: Agency for Healthcare Research and Quality. December 2017. AHRQ Publication No.
16(18)-0004-1-EF.
https://psnet.ahrq.gov/issue/ahrq-safety-program-surgery
Large-scale collaboratives have achieved success in implementing patient safety improvements. T…
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psnet.ahrq.gov/issue/incidence-adverse-events-swedish-hospitals-retrospective-medical-record-review-study
August 05, 2009 - Study
The incidence of adverse events in Swedish hospitals: a retrospective medical record review study.
Citation Text:
Soop M, Fryksmark U, Köster M, et al. The incidence of adverse events in Swedish hospitals: a retrospective medical record review study. Int J Qual Health Care. 2009;…
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psnet.ahrq.gov/issue/agency-information-collection-activities-assessing-impact-national-implementation-teamstepps
July 03, 2013 - Press Release/Announcement
Agency information collection activities: Assessing the Impact of the National Implementation of TeamSTEPPS Master Training Program; comment request.
Citation Text:
Agency information collection activities: Assessing the Impact of the National Implementation …
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psnet.ahrq.gov/node/49776/psn-pdf
November 01, 2016 - Continuity Errors in Resident Clinic
November 1, 2016
Warm EJ. Continuity Errors in Resident Clinic. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/continuity-errors-resident-clinic
The Case
A 32-year-old woman presented to internal medicine clinic for evaluation of headaches and difficulty
concentrating. …
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psnet.ahrq.gov/innovation/standardized-marking-procedure-ent-operations-prevent-wrong-site-surgery-development
February 01, 2013 - EMERGING INNOVATIONS
A standardized marking procedure for ENT operations to prevent wrong-site surgery: development, establishment and subsequent evaluation among patients and medical personnel.
Citation Text:
Rohrmeier C, Abudan Al-Masry N, Keerl R, et al. A standardized marking procedure for ENT…