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psnet.ahrq.gov/node/45376/psn-pdf
November 09, 2016 - The new CMS hospital quality star ratings: the stars are
not aligned.
November 9, 2016
Bilimoria KY, Barnard C. The New CMS Hospital Quality Star Ratings: The Stars Are Not Aligned. JAMA.
2016;316(17):1761-1762. doi:10.1001/jama.2016.13679.
https://psnet.ahrq.gov/issue/new-cms-hospital-quality-star-ratings-stars-a…
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psnet.ahrq.gov/node/866399/psn-pdf
July 31, 2024 - Typology of solutions addressing diagnostic disparities:
gaps and opportunities.
July 31, 2024
Dukhanin V, Wiegand AA, Sheikh T, et al. Typology of solutions addressing diagnostic disparities: gaps
and opportunities. Diagnosis (Berl). 2024;11(4):389-399. doi:10.1515/dx-2024-0026.
https://psnet.ahrq.gov/issue/typol…
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psnet.ahrq.gov/node/36529/psn-pdf
August 09, 2011 - 5 Million Lives Campaign.
August 9, 2011
Institute for Healthcare Improvement; IHI
https://psnet.ahrq.gov/issue/5-million-lives-campaign
The Institute for Healthcare Improvement's 100,000 Lives Campaign successfully engaged more than
3,000 US hospitals in a coordinated effort to reduce preventable inpatient deaths…
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psnet.ahrq.gov/node/43080/psn-pdf
March 26, 2014 - Hospital-based transfusion error tracking from 2005 to
2010: identifying the key errors threatening patient
transfusion safety.
March 26, 2014
Maskens C, Downie H, Wendt A, et al. Hospital-based transfusion error tracking from 2005 to 2010:
identifying the key errors threatening patient transfusion safety. Transfu…
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psnet.ahrq.gov/node/38070/psn-pdf
March 10, 2011 - Can surveillance systems identify and avert adverse drug
events? A prospective evaluation of a commercial
application.
March 10, 2011
Jha AK, Laguette J, Seger AC, et al. Can surveillance systems identify and avert adverse drug events? A
prospective evaluation of a commercial application. J Am Med Inform Assoc. 20…
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psnet.ahrq.gov/node/44187/psn-pdf
November 10, 2015 - A safe practice standard for barcode technology.
November 10, 2015
Leung AA, Denham CR, Gandhi TK, et al. A safe practice standard for barcode technology. J Patient Saf.
2015;11(2):89-99. doi:10.1097/PTS.0000000000000049.
https://psnet.ahrq.gov/issue/safe-practice-standard-barcode-technology
Barcode technology has…
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psnet.ahrq.gov/node/44172/psn-pdf
September 28, 2016 - Preventing high-alert medication errors in hospital
patients.
September 28, 2016
Anderson P, Townsend T. Am Nurse Today. May 2015;10:18-23.
https://psnet.ahrq.gov/issue/preventing-high-alert-medication-errors-hospital-patients
High-alert medications have the potential to cause serious patient harm. This article fo…
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psnet.ahrq.gov/node/46100/psn-pdf
July 11, 2017 - The tension between promoting mobility and preventing
falls in the hospital.
July 11, 2017
Growdon ME, Shorr RI, Inouye SK. The Tension Between Promoting Mobility and Preventing Falls in the
Hospital. JAMA Intern Med. 2017;177(6):759-760. doi:10.1001/jamainternmed.2017.0840.
https://psnet.ahrq.gov/issue/tension-be…
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psnet.ahrq.gov/node/47798/psn-pdf
February 20, 2019 - Simulation safety first: an imperative.
February 20, 2019
Raemer D, Hannenberg A, Mullen A. Simulation Safety First: An Imperative. Simul Healthc.
2018;13(6):373-375. doi:10.1097/SIH.0000000000000341.
https://psnet.ahrq.gov/issue/simulation-safety-first-imperative
Although simulation training heightens the learnin…
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psnet.ahrq.gov/node/44072/psn-pdf
August 02, 2015 - The rise of the medical scribe industry: implications for
the advancement of electronic health records.
August 2, 2015
Gellert GA, Ramirez R, Webster L. The rise of the medical scribe industry: implications for the
advancement of electronic health records. JAMA. 2015;313(13):1315-1316. doi:10.1001/jama.2014.17128.
…
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psnet.ahrq.gov/node/46597/psn-pdf
November 01, 2017 - A novel process audit for standardized perioperative
handoff protocols.
November 1, 2017
Pallekonda V, Scholl AT, McKelvey GM, et al. A Novel Process Audit for Standardized Perioperative
Handoff Protocols. Jt Comm J Qual Patient Saf. 2017;43(11):611-618. doi:10.1016/j.jcjq.2017.04.011.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/50453/psn-pdf
October 09, 2019 - Effect of a sedation weaning protocol on safety and
medication use among hospitalized children post critical
illness
October 9, 2019
Solodiuk JC, Greco CD, O'Donnell KA, et al. Effect of a Sedation Weaning Protocol on Safety and
Medication Use among Hospitalized Children Post Critical Illness. J Pediatr Nurs. 2019…
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psnet.ahrq.gov/node/43692/psn-pdf
April 22, 2015 - Surgeon-specific mortality data disguise wider failings in
delivery of safe surgical services.
April 22, 2015
Westaby S, De Silva R, Petrou M, et al. Surgeon-specific mortality data disguise wider failings in delivery of
safe surgical services. Eur J Cardiothorac Surg. 2015;47(2):341-5. doi:10.1093/ejcts/ezu380.
h…
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psnet.ahrq.gov/node/860391/psn-pdf
January 10, 2024 - Neonatal near-miss audits: a systematic review and a call
to action.
January 10, 2024
Medeiros PB, Bailey C, Pollock D, et al. Neonatal near-miss audits: a systematic review and a call to
action. BMC Pediatr. 2023;23(1):573. doi:10.1186/s12887-023-04383-6.
https://psnet.ahrq.gov/issue/neonatal-near-miss-audits-sys…
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psnet.ahrq.gov/node/72778/psn-pdf
February 24, 2021 - Distractions in the cardiac catheterisation laboratory:
impact for cardiologists and patient safety.
February 24, 2021
Mahadevan K, Cowan E, Kalsi N, et al. Distractions in the cardiac catheterisation laboratory: impact for
cardiologists and patient safety. Open Heart. 2020;7(2). doi:10.1136/openhrt-2020-001260.
h…
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psnet.ahrq.gov/node/866190/psn-pdf
June 26, 2024 - What is diagnostic safety? A review of safety science
paradigms and rethinking paths to improving diagnosis.
June 26, 2024
Choi JJ. What is diagnostic safety? A review of safety science paradigms and rethinking paths to improving
diagnosis. Diagnosis (Berl). 2024;11(4):369-373. doi:10.1515/dx-2024-0008.
https://ps…
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psnet.ahrq.gov/node/40622/psn-pdf
September 25, 2011 - Alternatives to potentially inappropriate medications for
use in e-prescribing software: triggers and treatment
algorithms.
September 25, 2011
Hume AL, Quilliam BJ, Goldman R, et al. Alternatives to potentially inappropriate medications for use in e-
prescribing software: triggers and treatment algorithms. BMJ Qua…
-
psnet.ahrq.gov/node/46390/psn-pdf
October 29, 2017 - Using data to enhance performance and improve quality
and safety in surgery.
October 29, 2017
Goldenberg MG, Jung JJ, Grantcharov T. Using Data to Enhance Performance and Improve Quality and
Safety in Surgery. JAMA Surg. 2017;152(10):972-973. doi:10.1001/jamasurg.2017.2888.
https://psnet.ahrq.gov/issue/using-data-…
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psnet.ahrq.gov/node/47237/psn-pdf
January 01, 2020 - First-year analysis of the Operating Room Black Box
study.
July 25, 2018
Jung JJ, Jüni P, Lebovic G, et al. First-year Analysis of the Operating Room Black Box Study. Ann Surg.
2020;271(1):122-127. doi:10.1097/SLA.0000000000002863.
https://psnet.ahrq.gov/issue/first-year-analysis-operating-room-black-box-study
An…
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psnet.ahrq.gov/node/50744/psn-pdf
December 18, 2019 - EMS crews brought patients to the hospital with
misplaced breathing tubes. None of them survived
December 18, 2019
Arditi L. Peoples Public Radio. December 3, 2019.
https://psnet.ahrq.gov/issue/ems-crews-brought-patients-hospital-misplaced-breathing-tubes-none-them-
survived
Emergency medical services are often p…