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psnet.ahrq.gov/node/38759/psn-pdf
April 05, 2010 - Perceptions of the impact of a large-scale collaborative
improvement programme: experience in the UK Safer
Patients Initiative.
April 5, 2010
Benn J, Burnett S, Parand A, et al. Perceptions of the impact of a large-scale collaborative improvement
programme: experience in the UK Safer Patients Initiative. J Eval Cl…
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psnet.ahrq.gov/node/40010/psn-pdf
December 21, 2014 - The effect of hospital-acquired Clostridium difficile
infection on in-hospital mortality.
December 21, 2014
Oake N, Taljaard M, van Walraven C, et al. The effect of hospital-acquired Clostridium difficile infection on
in-hospital mortality. Arch Intern Med. 2010;170(20):1804-10. doi:10.1001/archinternmed.2010.405.
…
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psnet.ahrq.gov/node/48172/psn-pdf
July 31, 2019 - Prevalence, severity, and nature of preventable patient
harm across medical care settings: systematic review and
meta-analysis.
July 31, 2019
Panagioti M, Khan K, Keers RN, et al. Prevalence, severity, and nature of preventable patient harm across
medical care settings: systematic review and meta-analysis. BMJ. 20…
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psnet.ahrq.gov/node/73214/psn-pdf
May 05, 2021 - Patient and physician perspectives of deprescribing
potentially inappropriate medications in older adults with
a history of falls: a qualitative study.
May 5, 2021
Hahn EE, Munoz-Plaza CE, Lee EA, et al. Patient and physician perspectives of deprescribing potentially
inappropriate medications in older adults with …
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psnet.ahrq.gov/node/838305/psn-pdf
October 12, 2022 - Hospital-acquired conditions reduction program, racial
and ethnic diversity, and Magnet designation in the
United States.
October 12, 2022
Boamah SA, Hamadi HY, Spaulding AC. Hospital-acquired conditions reduction program, racial and ethnic
diversity, and Magnet designation in the United States. J Patient Saf. 202…
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psnet.ahrq.gov/node/61041/psn-pdf
October 21, 2020 - Improving accuracy of handoff by implementing an
electronic health record-generated tool: an improvement
project in an academic neonatal intensive care unit.
October 21, 2020
Koo JK, Moyer L, Castello MA, et al. Improving accuracy of handoff by implementing an electronic health
record-generated tool: an improvemen…
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psnet.ahrq.gov/node/865334/psn-pdf
March 27, 2024 - Describing the evidence linking interprofessional
education interventions to improving the delivery of safe
and effective patient care: a scoping review.
March 27, 2024
Cadet T, Cusimano J, McKearney S, et al. Describing the evidence linking interprofessional education
interventions to improving the delivery of sa…
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psnet.ahrq.gov/node/866432/psn-pdf
August 07, 2024 - Improving appropriate use of peripherally inserted central
catheters through a statewide collaborative hospital
initiative: a cost-effectiveness analysis.
August 7, 2024
Heath M, Bernstein SJ, Paje D, et al. Improving appropriate use of peripherally inserted central catheters
through a statewide collaborative hosp…
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psnet.ahrq.gov/node/61018/psn-pdf
October 14, 2020 - Association of current opioid use with serious adverse
events among older adult survivors of breast cancer.
October 14, 2020
Winn AN, Check DK, Farkas A, et al. Association of current opioid use with serious adverse events among
older adult survivors of breast cancer. JAMA Netw Open. 2020;3(9):e2016858.
doi:10.100…
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psnet.ahrq.gov/node/866584/psn-pdf
August 28, 2024 - Raising the barcode: improving medication safety
behaviours through a behavioural science-informed
feedback intervention. A quality improvement project and
difference-in-difference analysis.
August 28, 2024
Grailey K, Brazier A, Franklin BD, et al. Raising the barcode: improving medication safety behaviours
throu…
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psnet.ahrq.gov/node/48008/psn-pdf
May 22, 2019 - Patients as diagnostic collaborators: sharing visit notes
to promote accuracy and safety.
May 22, 2019
Blease CR, Bell SK. Patients as diagnostic collaborators: sharing visit notes to promote accuracy and
safety. Diagnosis (Berl). 2019;6(3):213-221. doi:10.1515/dx-2018-0106.
https://psnet.ahrq.gov/issue/patients-d…
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psnet.ahrq.gov/node/38877/psn-pdf
April 08, 2011 - Computerized order entry with limited decision support to
prevent prescription errors in a PICU.
April 8, 2011
Kadmon G, Bron-Harlev E, Nahum E, et al. Computerized order entry with limited decision support to
prevent prescription errors in a PICU. Pediatrics. 2009;124(3):935-940. doi:10.1542/peds.2008-2737.
https…
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psnet.ahrq.gov/node/50704/psn-pdf
December 04, 2019 - Hospital-Acquired Condition Reduction Program is not
associated with additional patient safety improvement.
December 4, 2019
Sheetz KH, Dimick JB, Englesbe MJ, et al. Hospital-Acquired Condition Reduction Program Is Not
Associated With Additional Patient Safety Improvement. Health Aff (Millwood). 2019;38(11):1858-1…
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psnet.ahrq.gov/web-mm/under-pressure-delayed-diagnosis-compartment-syndrome-after-lower-leg-fracture
November 25, 2020 - Frequent communication between team members about dynamic clinical conditions reduces the risk of medical
-
psnet.ahrq.gov/node/867428/psn-pdf
December 18, 2024 - Exercise is one of those interventions that reduces fall risks by 23%,
so it is a good one to encourage
-
psnet.ahrq.gov/perspective/health-care-acquired-urinary-tract-infection-problem-and-solutions
November 01, 2008 - A reminder reduces urinary catheterization in hospitalized patients.
-
psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp-0
March 27, 2024 - EHRs do have is order entry, and the literature is pretty clear that order entry improves safety and reduces
-
psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
September 01, 2003 - Improving communication at handover and transfer reduces retained swabs in maternity services.
-
psnet.ahrq.gov/perspective/patient-and-family-roles-safety
June 14, 2023 - reviewed by the guide’s authors shows that including patients and families during care transitions reduces
-
psnet.ahrq.gov/node/49866/psn-pdf
June 01, 2019 - If You Say So: Taking a Syringe at Face Value in the
Operating Room
June 1, 2019
Lyndon A, Lim S. If You Say So: Taking a Syringe at Face Value in the Operating Room. PSNet [internet].
2019.
https://psnet.ahrq.gov/web-mm/if-you-say-so-taking-syringe-face-value-operating-room
The Case
A 43-year-old woman was admi…