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psnet.ahrq.gov/node/35403/psn-pdf
February 18, 2011 - consecutive hospital admissions in Ontario, Canada, over a 10-year
period to determine whether mortality rates … Investigators discovered higher rates of in-hospital mortality for patients admitted with ruptured aortic
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psnet.ahrq.gov/node/37701/psn-pdf
February 22, 2011 - inpatient-nurses-and
Incident reporting systems are ubiquitous, but are limited by low clinician reporting rates … use-handheld-computer-application-voluntary-medication-event-reporting-inpatient-nurses-and
https://psnet.ahrq.gov//#incidentreporting
https://psnet.ahrq.gov/issue/rates-and-types-events-reported-established-incident-reporting-systems-two-us-hospitals
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psnet.ahrq.gov/web-mm/dont-push
March 02, 2011 - Don't Push
Citation Text:
Meltzer HY. Don't Push. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Downl…
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psnet.ahrq.gov/node/60376/psn-pdf
July 30, 2020 - COVID-19: Team and Human Factors to Improve Safety
July 30, 2020
Zipperer L. COVID-19: Team and Human Factors to Improve Safety. PSNet [internet]. 2020.
https://psnet.ahrq.gov/primer/covid-19-team-and-human-factors-improve-safety
Background
The rapid transmission of COVID-19 has resulted in an international pandem…
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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/perspective/conversation-erik-hollnagel-phd
February 26, 2025 - In Conversation With… Erik Hollnagel, PhD
June 1, 2019
Citation Text:
In Conversation With… Erik Hollnagel, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/diagnostic-overshadowing-dangers
February 12, 2020 - Diagnostic Overshadowing Dangers
Citation Text:
Raven MC. Diagnostic Overshadowing Dangers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/departure-central-line-ritual
October 13, 2018 - Departure From Central Line Ritual
Citation Text:
Ballard DW, Vinson DR, Mark DG. Departure From Central Line Ritual. 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/web-mm/are-you-mrs-issue-identification-over-telephone
January 01, 2016 - Are You Mrs. A? An Issue of Identification Over Telephone
Citation Text:
Adelman JS. Are You Mrs. A? An Issue of Identification Over Telephone. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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…
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psnet.ahrq.gov/node/49804/psn-pdf
September 01, 2017 - Transfusion Thresholds in Gastrointestinal Bleeding
September 1, 2017
Strate L, Swanson S. Transfusion Thresholds in Gastrointestinal Bleeding. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/transfusion-thresholds-gastrointestinal-bleeding
Case Objectives
Describe risk factors for poor outcome in patients w…
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psnet.ahrq.gov/node/60173/psn-pdf
March 30, 2020 - In Conversation With... Ann Gaffey, RN, MSN, CPHRM and
Bruce Spurlock, MD
March 30, 2020
In Conversation With.. Ann Gaffey, RN, MSN, CPHRM and Bruce Spurlock, MD. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/conversation-ann-gaffey-rn-msn-cphrm-and-bruce-spurlock-md
Editor’s note: Ann D. Gaffey, RN, …
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psnet.ahrq.gov/web-mm/no-bp-during-nibp
March 01, 2011 - No BP During NIBP
Citation Text:
Görges M, Ansermino MJ. No BP During NIBP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/node/33782/psn-pdf
March 01, 2015 - with elevated HSMRs, no differences were seen compared to hospitals
with lower HSMRs in adherence rates … Unfavorable
rates arising from erroneous data or analyses can trigger external inquiries that stigmatize … Comparison of hospital risk-standardized mortality rates
calculated by using in-hospital and 30-day … Variability in the measurement of hospital-wide
mortality rates. N Engl J Med. 2010;363:2530-2539. … What is the empirical evidence that hospitals with higher risk-
adjusted mortality rates provide poor
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psnet.ahrq.gov/node/37510/psn-pdf
March 04, 2011 - rare-adverse-medical-events-va-inpatient-care-reliability-limits-using-patient-
safety
This study assessed the value of AHRQ Patient Safety Indicator (PSI) rates … evaluating-patient-safety-indicators-how-well-do-they-perform-veterans-health-administration
https://psnet.ahrq.gov/issue/tracking-rates-patient-safety-indicators-over-time-lessons-veterans-administration
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psnet.ahrq.gov/node/42087/psn-pdf
March 06, 2013 - attempted to replicate the Keystone study in 223 ICUs in England, yielded a surprising result: infection
rates … significantly in both control and intervention hospitals, likely reflecting secular trends in
infection rates
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psnet.ahrq.gov/node/35889/psn-pdf
March 10, 2011 - study determined that an automated adverse drug event (ADE) surveillance system captured higher
event rates … Not only did the system detect ADEs at higher rates
in the community setting, but the specific events
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psnet.ahrq.gov/node/47283/psn-pdf
January 27, 2019 - No impact
was found on overall opioid prescribing rates. … recent state-level analysis found that states who
implemented a PDMP had lower opioid prescribing rates
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psnet.ahrq.gov/node/39233/psn-pdf
August 02, 2013 - Although RRS usage was associated with decreased cardiac arrest
rates on general wards, overall mortality … rates did not improve, and the review noted significant problems
with the methodological quality of
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psnet.ahrq.gov/node/33928/psn-pdf
June 23, 2015 - This study examines those claims by conducting a literature review of anesthesia-
related mortality rates … Results from aggregate data, as well as mortality rates
determined by peer review, suggest that, contrary
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psnet.ahrq.gov/issue/decreasing-handoff-related-care-failures-childrens-hospitals
April 24, 2018 - August 4, 2021
Temporal trends in rates of patient harm resulting from medical care. … April 26, 2023
Effect of Patient and Family Centered I-PASS on adverse event rates … August 15, 2016
Rates of medical errors and preventable adverse events among hospitalized