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psnet.ahrq.gov/node/39082/psn-pdf
January 04, 2010 - Communication practices on 4 Harvard surgical
services: a surgical safety collaborative.
January 4, 2010
Elbardissi AW, Regenbogen SE, Greenberg CC, et al. Communication practices on 4 Harvard surgical
services: a surgical safety collaborative. Ann Surg. 2009;250(6):861-5.
doi:10.1097/SLA.0b013e3181afe0db.
https:…
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psnet.ahrq.gov/node/41446/psn-pdf
June 13, 2012 - Concept and development of a discharge alert filter for
abnormal laboratory values coupled with computerized
provider order entry: a tool for quality improvement and
hospital risk management.
June 13, 2012
Mathew G, Kho A, Dexter P, et al. Concept and development of a discharge alert filter for abnormal
laborator…
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psnet.ahrq.gov/node/42454/psn-pdf
September 09, 2013 - A perinatal care quality and safety initiative: are there
financial rewards for improved quality?
September 9, 2013
Kozhimannil KB, Sommerness SA, Rauk P, et al. A perinatal care quality and safety initiative: are there
financial rewards for improved quality? Jt Comm J Qual Patient Saf. 2013;39(8):339-48.
https://…
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psnet.ahrq.gov/node/43253/psn-pdf
May 01, 2015 - Interim Report: Review of VHA's Patient Wait Times,
Scheduling Practices, and Alleged Patient Deaths at the
Phoenix Health Care System.
May 1, 2015
Washington, DC: VA Office of the Inspector General; May 28, 2014. Report No. 14-02603-178.
https://psnet.ahrq.gov/issue/interim-report-review-vhas-patient-wait-times-s…
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psnet.ahrq.gov/node/41557/psn-pdf
August 01, 2012 - Signal and noise: applying a laboratory trigger tool to
identify adverse drug events among primary care
patients.
August 1, 2012
Brenner S, Detz A, Lopez A, et al. Signal and noise: applying a laboratory trigger tool to identify adverse
drug events among primary care patients. BMJ Qual Saf. 2012;21(8):670-5. doi:1…
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psnet.ahrq.gov/node/43452/psn-pdf
August 20, 2014 - Electronic health record–related safety concerns: a cross-
sectional survey.
August 20, 2014
Menon S, Singh H, Meyer AND, et al. Electronic health record-related safety concerns: a cross-sectional
survey. J Healthc Risk Manag. 2014;34(1):14-26. doi:10.1002/jhrm.21146.
https://psnet.ahrq.gov/issue/electronic-health…
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psnet.ahrq.gov/issue/ahrq-quality-indicators
December 24, 2008 - Measurement Tool/Indicator
AHRQ Quality Indicators.
Citation Text:
AHRQ Quality Indicators. Agency for Healthcare Research and Quality
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psnet.ahrq.gov/web-mm/medication-overdose
September 01, 2011 - Medication Overdose
Citation Text:
Kaushal R. Medication Overdose. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…
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psnet.ahrq.gov/node/38359/psn-pdf
May 27, 2010 - A surgical safety checklist to reduce morbidity and
mortality in a global population.
May 27, 2010
Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a
global population. N Engl J Med. 2009;360(5):491-9. doi:10.1056/NEJMsa0810119.
https://psnet.ahrq.gov/issue/su…
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psnet.ahrq.gov/node/43589/psn-pdf
November 17, 2014 - Exploring new avenues to assess the sharp end of patient
safety: an analysis of nationally aggregated peer review
data.
November 17, 2014
Meeks DW, Meyer AND, Rose B, et al. Exploring new avenues to assess the sharp end of patient safety:
an analysis of nationally aggregated peer review data. BMJ Qual Saf. 2014;23…
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psnet.ahrq.gov/node/39549/psn-pdf
March 22, 2011 - The impact of traditional and smart pump infusion
technology on nurse medication administration
performance in a simulated inpatient unit.
March 22, 2011
Trbovich PL, Pinkney S, Cafazzo JA, et al. The impact of traditional and smart pump infusion technology on
nurse medication administration performance in a simul…
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psnet.ahrq.gov/node/43817/psn-pdf
November 23, 2016 - Developing and evaluating the success of a family
activated medical emergency team: a quality
improvement report.
November 23, 2016
Brady PW, Zix J, Brilli RJ, et al. Developing and evaluating the success of a family activated medical
emergency team: a quality improvement report. BMJ Qual Saf. 2015;24(3):203-211. …
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psnet.ahrq.gov/node/46805/psn-pdf
September 25, 2018 - Factors associated with hospital admission after
outpatient surgery in the Veterans Health Administration.
September 25, 2018
Mull HJ, Rosen AK, O'Brien WJ, et al. Factors Associated with Hospital Admission after Outpatient Surgery
in the Veterans Health Administration. Health Serv Res. 2018;53(5):3855-3880. doi:10…
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psnet.ahrq.gov/node/47208/psn-pdf
July 19, 2018 - We will not compete on safety: how children's hospitals
have come together to hasten harm reduction.
July 19, 2018
Lyren A, Coffey M, Shepherd M, et al. We Will Not Compete on Safety: How Children's Hospitals Have
Come Together to Hasten Harm Reduction. Jt Comm J Qual Patient Saf. 2018;44(7):377-388.
doi:10.1016/j…
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psnet.ahrq.gov/node/49571/psn-pdf
October 01, 2008 - Coming Up Short
October 1, 2008
Hochberg Z'ev. Coming Up Short. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/coming-short
The Case
A 12-year-old Hispanic female was seen for a well-child check. The child was delivered 2 months
prematurely (likely due to domestic violence) in Puerto Rico. She had an intra…
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psnet.ahrq.gov/node/60362/psn-pdf
April 13, 2018 - Statewide Telehealth Program Enhances Access to Care,
Improves Outcomes for High-Risk Pregnancies in Rural
Area
June 12, 2020
https://psnet.ahrq.gov/innovation/statewide-telehealth-program-enhances-access-care-improves-outcomes-
high-risk
Summary
Formerly known as the Antenatal and Neonatal Guidelines, Education…
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psnet.ahrq.gov/node/42245/psn-pdf
July 22, 2013 - 25-Year summary of US malpractice claims for diagnostic
errors 1986–2010: an analysis from the National
Practitioner Data Bank.
July 22, 2013
Tehrani ASS, Lee HW, Mathews SC, et al. 25-Year summary of US malpractice claims for diagnostic errors
1986-2010: an analysis from the National Practitioner Data Bank. BMJ Q…
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psnet.ahrq.gov/node/42151/psn-pdf
December 21, 2014 - Effect of the 2011 vs 2003 duty hour regulation-compliant
models on sleep duration, trainee education, and
continuity of patient care among internal medicine house
staff: a randomized trial.
December 21, 2014
Desai SV, Feldman LS, Brown L, et al. Effect of the 2011 vs 2003 Duty Hour Regulation–Compliant Models
on…
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psnet.ahrq.gov/node/45183/psn-pdf
July 20, 2016 - Assessing the relationship between patient safety culture
and EHR strategy.
July 20, 2016
Ford E, Silvera GA, Kazley AS, et al. Assessing the relationship between patient safety culture and EHR
strategy. Int J Health Care Qual Assur. 2016;29(6):614-27. doi:10.1108/IJHCQA-10-2015-0125.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/44342/psn-pdf
November 03, 2015 - How effective are patient safety initiatives? A
retrospective patient record review study of changes to
patient safety over time.
November 3, 2015
Baines RJ, Langelaan M, de Bruijne M, et al. How effective are patient safety initiatives? A retrospective
patient record review study of changes to patient safety over…