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psnet.ahrq.gov/web-mm/patient-mix
December 01, 2007 - Patient Mix-Up
Citation Text:
Shojania KG. Patient Mix-Up. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/node/50843/psn-pdf
January 29, 2020 - Incomplete Orders for Hypertonic Saline to Treat
Hyponatremia
January 29, 2020
Wiegley N, Morfín JA. Incomplete Orders for Hypertonic Saline to Treat Hyponatremia. PSNet [internet].
2020.
https://psnet.ahrq.gov/web-mm/incomplete-orders-hypertonic-saline-treat-hyponatremia
The Case
A 54-year-old man was brought t…
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psnet.ahrq.gov/web-mm/chemotherapy-administration-safety-standards
March 30, 2016 - Chemotherapy Administration Safety Standards
Citation Text:
Bergsbaken J. Chemotherapy Administration Safety Standards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/issue/preventing-infections-during-cancer-treatment
September 07, 2016 - Government Resource
Preventing Infections During Cancer Treatment.
Citation Text:
Preventing Infections During Cancer Treatment. Centers for Disease Control and Prevention; CDC.
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psnet.ahrq.gov/issue/aorn-guidance-statement-safe-medication-practices-perioperative-settings-across-life-span
September 22, 2021 - Organizational Policy/Guidelines
AORN Guidance Statement: Safe Medication Practices in Perioperative Settings Across the Life Span.
Citation Text:
AORN guidance statement: safe medication practices in perioperative settings across the life span. AORN J. 2006;84(2):276-283.
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psnet.ahrq.gov/issue/iatrogenic-disease
March 19, 2008 - Special or Theme Issue
Iatrogenic Disease.
Citation Text:
Iatrogenic Disease. Hermansen MC, ed. Clin Perinatol. 2008;35(1):1-292
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psnet.ahrq.gov/node/848037/psn-pdf
April 26, 2023 - A cluster randomized trial of two implementation
strategies to deliver audit and feedback in the EQUIPPED
medication safety program.
April 26, 2023
Vaughan CP, Burningham Z, Kelleher JL, et al. A cluster?randomized trial of two implementation strategies
to deliver audit and feedback in the EQUIPPED medication safe…
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psnet.ahrq.gov/node/39084/psn-pdf
March 05, 2010 - The impact of Rapid Response System on delayed
emergency team activation patient characteristics and
outcomes—a follow-up study.
March 5, 2010
Calzavacca P, Licari E, Tee A, et al. The impact of Rapid Response System on delayed emergency team
activation patient characteristics and outcomes--a follow-up study. Resu…
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psnet.ahrq.gov/node/46344/psn-pdf
October 13, 2018 - Prescription opioid use, misuse, and use disorders in U.S.
adults: 2015 National Survey on Drug Use and Health.
October 13, 2018
Han B, Compton WM, Blanco C, et al. Prescription opioid use, misuse, and use disorders in U.S. adults:
2015 National Survey on Drug Use and Health. Ann Intern Med. 2017;167(5):293-301. do…
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psnet.ahrq.gov/node/47559/psn-pdf
November 14, 2018 - Changes in prevalence of health care-associated
infections in U.S. hospitals.
November 14, 2018
Magill SS, O'Leary E, Janelle SJ, et al. Changes in Prevalence of Health Care-Associated Infections in U.S.
Hospitals. N Engl J Med. 2018;379(18):1732-1744. doi:10.1056/NEJMoa1801550.
https://psnet.ahrq.gov/issue/change…
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psnet.ahrq.gov/node/47071/psn-pdf
January 23, 2019 - Medication for opioid use disorder after nonfatal opioid
overdose and association with mortality: a cohort study.
January 23, 2019
Larochelle MR, Bernson D, Land T, et al. Medication for Opioid Use Disorder After Nonfatal Opioid
Overdose and Association With Mortality: A Cohort Study. Ann Intern Med. 2018;169(3):13…
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psnet.ahrq.gov/node/47694/psn-pdf
February 06, 2019 - Association of pharmaceutical industry marketing of
opioid products with mortality from opioid-related
overdoses.
February 6, 2019
Hadland SE, Rivera-Aguirre A, Marshall BDL, et al. Association of Pharmaceutical Industry Marketing of
Opioid Products With Mortality From Opioid-Related Overdoses. JAMA Netw Open. 201…
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psnet.ahrq.gov/node/43857/psn-pdf
August 02, 2015 - A checklist-based intervention to improve surgical
outcomes in Michigan: evaluation of the Keystone
Surgery program.
August 2, 2015
Reames BN, Krell RW, Campbell D, et al. A checklist-based intervention to improve surgical outcomes in
Michigan: evaluation of the Keystone Surgery program. JAMA Surg. 2015;150(3):208…
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psnet.ahrq.gov/node/38612/psn-pdf
May 06, 2009 - Assessing controlled substance prescribing errors in a
pediatric teaching hospital: an analysis of the safety of
analgesic prescription practice in the transition from the
hospital to home.
May 6, 2009
Lee BH, Lehmann CU, Jackson E, et al. Assessing controlled substance prescribing errors in a pediatric
teaching …
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psnet.ahrq.gov/node/46913/psn-pdf
May 09, 2018 - Factors associated with the use of cognitive aids in
operating room crises: a cross-sectional study of US
hospitals and ambulatory surgical centers.
May 9, 2018
Alidina S, Goldhaber-Fiebert SN, Hannenberg A, et al. Factors associated with the use of cognitive aids in
operating room crises: a cross-sectional study …
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psnet.ahrq.gov/node/46424/psn-pdf
March 20, 2018 - Electronic triggers to identify delays in follow-up of
mammography: harnessing the power of big data in
health care.
March 20, 2018
Murphy DR, Meyer AND, Vaghani V, et al. Electronic Triggers to Identify Delays in Follow-Up of
Mammography: Harnessing the Power of Big Data in Health Care. J Am Coll Radiol. 2018;15(…
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psnet.ahrq.gov/node/46405/psn-pdf
October 13, 2018 - Children's hospitals' solutions for patient safety
collaborative impact on hospital-acquired harm.
October 13, 2018
Lyren A, Brilli RJ, Zieker K, et al. Children's Hospitals' Solutions for Patient Safety Collaborative Impact on
Hospital-Acquired Harm. Pediatrics. 2017;140(3). doi:10.1542/peds.2016-3494.
https://ps…
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psnet.ahrq.gov/node/41748/psn-pdf
April 05, 2013 - Factors contributing to all-cause 30-day readmissions: a
structured case series across 18 hospitals.
April 5, 2013
Feigenbaum P, Neuwirth E, Trowbridge L, et al. Factors contributing to all-cause 30-day readmissions: a
structured case series across 18 hospitals. Med Care. 2012;50(7):599-605.
doi:10.1097/MLR.0b013e…
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psnet.ahrq.gov/node/40216/psn-pdf
February 16, 2011 - Impact of a statewide intensive care unit quality
improvement initiative on hospital mortality and length of
stay: retrospective comparative analysis.
February 16, 2011
Lipitz-Snyderman A, Steinwachs D, Needham DM, et al. Impact of a statewide intensive care unit quality
improvement initiative on hospital mortalit…
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psnet.ahrq.gov/node/43264/psn-pdf
June 18, 2014 - CDC central-line bloodstream infection prevention efforts
produced net benefits of at least $640 million during
1990–2008.
June 18, 2014
Scott D, Sinkowitz-Cochran R, Wise ME, et al. CDC central-line bloodstream infection prevention efforts
produced net benefits of at least $640 Million during 1990-2008. Health Af…