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psnet.ahrq.gov/node/47359/psn-pdf
October 10, 2018 - Is there evidence of a July effect among patients
undergoing hysterectomy surgery?
October 10, 2018
Varma S, Mehta A, Hutfless S, et al. Is there evidence of a July effect among patients undergoing
hysterectomy surgery? Am J Obstet Gynecol. 2018;219(2):176.e1-176.e9. doi:10.1016/j.ajog.2018.05.033.
https://psnet.a…
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psnet.ahrq.gov/node/46544/psn-pdf
September 12, 2018 - Interventions to improve follow-up of laboratory test
results pending at discharge: a systematic review.
September 12, 2018
Whitehead NS, Williams L, Meleth S, et al. Interventions to Improve Follow-Up of Laboratory Test Results
Pending at Discharge: A Systematic Review. J Hosp Med. 2018. doi:10.12788/jhm.2944.
ht…
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psnet.ahrq.gov/node/35218/psn-pdf
August 07, 2018 - Building a Memory: Preventing Harm, Reducing Risks and
Improving Patient Safety.
August 7, 2018
Scobie S, Thomson R. London, UK : National Patient Safety Agency; 2005.
https://psnet.ahrq.gov/issue/building-memory-preventing-harm-reducing-risks-and-improving-patient-safety
Created in 2001 to institute changes in he…
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psnet.ahrq.gov/web-mm/under-pressure-delayed-diagnosis-compartment-syndrome-after-lower-leg-fracture
November 25, 2020 - event within the first month after hospital discharge, and many of these are preventable. 16 Case 2 is representative
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psnet.ahrq.gov/node/60552/psn-pdf
June 03, 2020 - Personal protective equipment for preventing highly
infectious diseases due to exposure to contaminated
body fluids in healthcare staff.
June 3, 2020
Verbeek JH, Rajamaki B, Ijaz S, et al. Personal protective equipment for preventing highly infectious
diseases due to exposure to contaminated body fluids in healthc…
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psnet.ahrq.gov/primer/personal-health-literacy
October 31, 2023 - The only nationally representative survey of health literacy, conducted in 2003, tested adults' ability
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psnet.ahrq.gov/node/50768/psn-pdf
December 27, 2019 - In a few places PFACs are required to be
representative of the people who live in the healthcare organization
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psnet.ahrq.gov/node/33599/psn-pdf
August 30, 2023 - The only nationally representative survey of health literacy, conducted in 2003,
tested adults' ability
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psnet.ahrq.gov/node/46060/psn-pdf
October 31, 2017 - Do hospitals support second victims? Collective insights
from patient safety leaders in Maryland.
October 31, 2017
Edrees HH, Morlock L, Wu AW. Do Hospitals Support Second Victims? Collective Insights From Patient
Safety Leaders in Maryland. Jt Comm J Qual Saf. 2017;43(9):471-483. doi:10.1016/j.jcjq.2017.01.008.
h…
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psnet.ahrq.gov/node/35571/psn-pdf
April 06, 2011 - Overestimation of clinical diagnostic performance caused
by low necropsy rates.
April 6, 2011
Shojania KG, Burton EC, McDonald KM, et al. Overestimation of clinical diagnostic performance caused by
low necropsy rates. Qual Saf Health Care. 2005;14(6):408-13.
https://psnet.ahrq.gov/issue/overestimation-clinical-dia…
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psnet.ahrq.gov/node/39987/psn-pdf
September 20, 2011 - Fall prevention in acute care hospitals: a randomized trial.
September 20, 2011
Dykes PC, Carroll DL, Hurley A, et al. Fall prevention in acute care hospitals: a randomized trial. JAMA.
2010;304(17):1912-1918. doi:10.1001/jama.2010.1567.
https://psnet.ahrq.gov/issue/fall-prevention-acute-care-hospitals-randomized-t…
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psnet.ahrq.gov/node/44043/psn-pdf
September 20, 2017 - Incident learning in pursuit of high reliability:
implementing a comprehensive, low-threshold reporting
program in a large, multisite radiation oncology
department.
September 20, 2017
Gabriel PE, Volz E, Bergendahl HW, et al. Incident learning in pursuit of high reliability: implementing a
comprehensive, low-thre…
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psnet.ahrq.gov/node/46559/psn-pdf
December 22, 2018 - Effect of promoting high-quality staff interactions on fall
prevention in nursing homes: a cluster-randomized trial.
December 22, 2018
Colón-Emeric CS, Corazzini K, McConnell ES, et al. Effect of Promoting High-Quality Staff Interactions on
Fall Prevention in Nursing Homes: A Cluster-Randomized Trial. JAMA Intern M…
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psnet.ahrq.gov/node/45760/psn-pdf
February 08, 2017 - Safe practices for copy and paste in the EHR. Systematic
review, recommendations, and novel model for health IT
collaboration.
February 8, 2017
Tsou AY, Lehmann CU, Michel J, et al. Safe Practices for Copy and Paste in the EHR. Systematic Review,
Recommendations, and Novel Model for Health IT Collaboration. Appl C…
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psnet.ahrq.gov/node/44165/psn-pdf
May 27, 2015 - Unplanned return to theater: a quality of care and risk
management index?
May 27, 2015
Pujol N, Merrer J, Lemaire B, et al. Unplanned return to theater: A quality of care and risk management
index? Orthop Traumatol Surg Res. 2015;101(4):399-403. doi:10.1016/j.otsr.2015.03.013.
https://psnet.ahrq.gov/issue/unplanne…
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psnet.ahrq.gov/node/42379/psn-pdf
August 08, 2013 - Prevalence and nature of adverse medical device events
in hospitalized children.
August 8, 2013
Brady PW, Varadarajan K, Peterson LE, et al. Prevalence and nature of adverse medical device events in
hospitalized children. J Hosp Med. 2013;8(7):390-3. doi:10.1002/jhm.2058.
https://psnet.ahrq.gov/issue/prevalence-an…
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psnet.ahrq.gov/node/43678/psn-pdf
April 22, 2015 - 'Connecting the dots': leveraging visual analytics to make
sense of patient safety event reports.
April 22, 2015
Ratwani RM, Fong A. 'Connecting the dots': leveraging visual analytics to make sense of patient safety
event reports. J Am Med Inform Assoc. 2015;22(2):312-7. doi:10.1136/amiajnl-2014-002963.
https://ps…
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psnet.ahrq.gov/node/35802/psn-pdf
January 02, 2017 - Reconciliation failures lead to medication errors.
January 2, 2017
Santell JP. Reconciliation failures lead to medication errors. Jt Comm J Qual Patient Saf. 2006;32(4):225-9.
https://psnet.ahrq.gov/issue/reconciliation-failures-lead-medication-errors
Medication reconciliation represents an active effort of hospita…
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psnet.ahrq.gov/node/34656/psn-pdf
May 27, 2011 - A look into the nature and causes of human errors in the
intensive care unit.
May 27, 2011
Donchin Y, Gopher D, Olin M, et al. A look into the nature and causes of human errors in the intensive care
unit. Crit Care Med. 1995;23(2):294-300.
https://psnet.ahrq.gov/issue/look-nature-and-causes-human-errors-intensive-…
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psnet.ahrq.gov/node/46000/psn-pdf
April 26, 2017 - Diagnostic error in the emergency department: follow up
of patients with minor trauma in the outpatient clinic.
April 26, 2017
Moonen P-J, Mercelina L, Boer W, et al. Diagnostic error in the Emergency Department: follow up of
patients with minor trauma in the outpatient clinic. Scand J Trauma Resusc Emerg Med. 2017…