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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40937/psn-pdf
    November 16, 2011 - AHRQ Projects to Prevent Healthcare-Associated Infections, Fiscal Year 2011. November 16, 2011 Rockville, MD: Agency for Healthcare Research and Quality; October 2011. AHRQ Publication No. 09- P013-4-E. https://psnet.ahrq.gov/issue/ahrq-projects-prevent-healthcare-associated-infections-fiscal-year-2011 This annou…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36798/psn-pdf
    March 09, 2009 - Organizational culture, critical success factors, and the reduction of hospital errors. March 9, 2009 Stock GN, McFadden KL, Gowen CR. Organizational culture, critical success factors, and the reduction of hospital errors. Int J Prod Econ. 2006;106(2). doi:10.1016/j.ijpe.2006.07.005. https://psnet.ahrq.gov/issue/o…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36793/psn-pdf
    August 26, 2011 - Patient safety in Taiwan: a survey on orthopedic surgeons. August 26, 2011 Yang C-T, Chen H-H, Hou S-M. Patient safety in Taiwan: a survey on orthopedic surgeons. J Formos Med Assoc. 2007;106(3):212-6. https://psnet.ahrq.gov/issue/patient-safety-taiwan-survey-orthopedic-surgeons The researchers surveyed Taiwanese…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35891/psn-pdf
    May 03, 2006 - Costs and Benefits of Health Information Technology. May 3, 2006 Shekelle PG, Morton SC, Keeler EB. Rockville, MD: Agency for Healthcare Research and Quality; April 2006. AHRQ Publication No. 06-E006. https://psnet.ahrq.gov/issue/costs-and-benefits-health-information-technology The authors reviewed the literature …
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37743/psn-pdf
    June 06, 2008 - Incidence and prevention of iatrogenic urethral injuries. June 6, 2008 Kashefi C, Messer K, Barden R, et al. Incidence and prevention of iatrogenic urethral injuries. J Urol. 2008;179(6):2254-7; discussion 2257-8. doi:10.1016/j.juro.2008.01.108. https://psnet.ahrq.gov/issue/incidence-and-prevention-iatrogenic-ureth…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50584/psn-pdf
    October 23, 2019 - Unprotected: broken promises in Georgia’s senior care industry. October 23, 2019 Schrade B, Teegardin C. Atlanta Journal-Constitution. Sept-October 2019. https://psnet.ahrq.gov/issue/unprotected-broken-promises-georgias-senior-care-industry Assisted living facilities have challenges that reduce the quality and saf…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41447/psn-pdf
    May 30, 2012 - Massachusetts hospitals launch patient apology program. May 30, 2012 Gallegos A. https://psnet.ahrq.gov/issue/massachusetts-hospitals-launch-patient-apology-program This news article reports on a disclosure and apology program implemented in Massachusetts hospitals to reduce liability lawsuits. https://psnet.ahrq…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34925/psn-pdf
    February 27, 2009 - Medication errors and professional practice of registered nurses. February 27, 2009 Deans C. Medication errors and professional practice of registered nurses. Collegian. 2005;12(1):29-33. https://psnet.ahrq.gov/issue/medication-errors-and-professional-practice-registered-nurses This Australian study identified and…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41636/psn-pdf
    August 29, 2012 - Far more could be done to stop the deadly bacteria C. diff. August 29, 2012 Eisler P. USA Today. August 16, 2012. https://psnet.ahrq.gov/issue/far-more-could-be-done-stop-deadly-bacteria-c-diff This newspaper article reports on how clinicians, hospitals, and health care systems can reduce incidence of hospital-acq…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37654/psn-pdf
    September 24, 2010 - The road to zero preventable birth injuries. September 24, 2010 Mazza F, Kitchens J, Akin M, et al. The road to zero preventable birth injuries. Jt Comm J Qual Patient Saf. 2008;34(4):201-205. https://psnet.ahrq.gov/issue/road-zero-preventable-birth-injuries This article reports how a perinatal safety team, which …
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39255/psn-pdf
    February 02, 2011 - The patient who falls: "It's always a trade-off." February 2, 2011 Tinetti ME, Kumar C. The patient who falls: "It's always a trade-off". JAMA. 2010;303(3):258-66. doi:10.1001/jama.2009.2024. https://psnet.ahrq.gov/issue/patient-who-falls-its-always-trade Through a case study, this article reviews evidence on risk…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36533/psn-pdf
    May 27, 2011 - Effect of computerisation on the quality and safety of chemotherapy prescription. May 27, 2011 Voeffray M, Pannatier A, Stupp R, et al. Effect of computerisation on the quality and safety of chemotherapy prescription. Qual Saf Health Care. 2006;15(6):418-21. https://psnet.ahrq.gov/issue/effect-computerisation-qual…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38709/psn-pdf
    June 17, 2009 - Enteral feeding misconnections: an update. June 17, 2009 Guenter P, Hicks RW, Simmons D. Enteral feeding misconnections: an update. Nutr Clin Pract. 2009;24(3):325-34. doi:10.1177/0884533609335174. https://psnet.ahrq.gov/issue/enteral-feeding-misconnections-update This review surveys information on enteral nutriti…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41562/psn-pdf
    August 01, 2012 - The Final Check: Say it Out Loud. August 1, 2012 https://psnet.ahrq.gov/issue/final-check-say-it-out-loud This Web site provides resources to help reduce incidence of mislabeled blood specimens based on just culture concepts. https://psnet.ahrq.gov/issue/final-check-say-it-out-loud https://psnet.ahrq.gov/web-mm/ri…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60216/psn-pdf
    April 08, 2020 - The Diagnosis of Ectopic Pregnancy. April 8, 2020 Farnborough, UK:  Healthcare Safety Investigation Branch; March 2020. https://psnet.ahrq.gov/issue/diagnosis-ectopic-pregnancy Missed or delayed diagnosis in maternal care can result in serious harm to both the mother and the child. This report analyzes a dela…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38992/psn-pdf
    April 16, 2018 - Safe patient outcomes occur with timely, standardized communication of critical values. April 16, 2018 https://psnet.ahrq.gov/issue/safe-patient-outcomes-occur-timely-standardized-communication-critical- values This article reports on failures surrounding critical test results and describes mechanisms to standardi…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39484/psn-pdf
    April 28, 2010 - Surgical fires, a clear and present danger. April 28, 2010 Yardley IE, Donaldson LJ. Surgical fires, a clear and present danger. Surgeon. 2010;8(2):87-92. doi:10.1016/j.surge.2010.01.005. https://psnet.ahrq.gov/issue/surgical-fires-clear-and-present-danger This article reviews the literature on surgical fires and …
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42596/psn-pdf
    October 23, 2013 - Diagnostic Errors and Strategies to Minimize Them. October 23, 2013 Cutrer WB, Sullivan WM, Fleming AE, et al. Curr Probl Pediatr Adolesc Health Care. 2013;43:225-257.   https://psnet.ahrq.gov/issue/diagnostic-errors-and-strategies-minimize-them Articles in this special issue cover diagnostic errors, includin…
  19. digital.ahrq.gov/principal-investigator/mcculloch-michael
    January 01, 2023 - McCulloch, Michael Improving Pediatric Donor Heart Utilization with Predictive Analytics Description This study aims to optimize the use of donor hearts for infants and children awaiting heart transplantation by developing predictive models to assess in real-time the potential…
  20. digital.ahrq.gov/principal-investigator/porter-michael
    January 01, 2023 - Porter, Michael Improving Pediatric Donor Heart Utilization with Predictive Analytics Description This study aims to optimize the use of donor hearts for infants and children awaiting heart transplantation by developing predictive models to assess in real-time the potential fo…