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psnet.ahrq.gov/issue/unexpectedly-long-hospital-stays-indicator-risk-unsafe-care-exploratory-study
January 07, 2015 - Study
Unexpectedly long hospital stays as an indicator of risk of unsafe care: an exploratory study.
Citation Text:
Borghans I, Hekkert KD, Ouden L den, et al. Unexpectedly long hospital stays as an indicator of risk of unsafe care: an exploratory study. BMJ Open. 2014;4(6):e004773. doi:…
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psnet.ahrq.gov/issue/hospital-staff-should-use-more-one-method-detect-adverse-events-and-potential-adverse-events
November 12, 2014 - Study
Hospital staff should use more than one method to detect adverse events and potential adverse events: incident reporting, pharmacist surveillance and local real-time record review may all have a place.
Citation Text:
Olsen S, Neale G, Schwab K, et al. Hospital staff should use mo…
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psnet.ahrq.gov/issue/minding-gaps-assessing-communication-outcomes-electronic-preconsultation-exchange
November 30, 2016 - Study
Minding the gaps: assessing communication outcomes of electronic preconsultation exchange.
Citation Text:
Price EL, Sewell JL, Chen AH, et al. Minding the Gaps: Assessing Communication Outcomes of Electronic Preconsultation Exchange. Jt Comm J Qual Patient Saf. 2016;42(8):341-54.
…
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psnet.ahrq.gov/issue/why-do-we-still-page-each-other-examining-frequency-types-and-senders-pages-academic-medical
September 11, 2019 - Study
Why do we still page each other? Examining the frequency, types and senders of pages in academic medical services.
Citation Text:
Carlile N, Rhatigan JJ, Bates DW. Why do we still page each other? Examining the frequency, types and senders of pages in academic medical services. BMJ…
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psnet.ahrq.gov/issue/evaluation-medium-term-consequences-implementing-commercial-computerized-physician-order
December 21, 2022 - Study
Evaluation of medium-term consequences of implementing commercial computerized physician order entry and clinical decision support prescribing systems in two 'early adopter' hospitals.
Citation Text:
Cresswell K, Bates DW, Williams R, et al. Evaluation of medium-term consequences o…
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psnet.ahrq.gov/issue/patient-outcomes-dose-reduction-or-discontinuation-long-term-opioid-therapy-systematic-review
April 08, 2019 - Review
Classic
Patient outcomes in dose reduction or discontinuation of long-term opioid therapy: a systematic review.
Citation Text:
Frank JW, Lovejoy TI, Becker WC, et al. Patient Outcomes in Dose Reduction or Discontinuation of Long-Term Opioid Therapy: A Sys…
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psnet.ahrq.gov/issue/association-label-drug-use-and-adverse-drug-events-adult-population
February 03, 2011 - Study
Classic
Association of off-label drug use and adverse drug events in an adult population.
Citation Text:
Eguale T, Buckeridge DL, Verma A, et al. Association of Off-label Drug Use and Adverse Drug Events in an Adult Population. JAMA Intern Med. 2016;176(1)…
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psnet.ahrq.gov/issue/mitigation-patient-harm-testing-errors-family-medicine-offices-report-american-academy-family
June 11, 2008 - Study
Mitigation of patient harm from testing errors in family medicine offices: a report from the American Academy of Family Physicians National Research Network.
Citation Text:
Graham DG, Harris DM, Elder NC, et al. Mitigation of patient harm from testing errors in family medicine of…
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psnet.ahrq.gov/issue/program-prevent-catheter-associated-urinary-tract-infection-acute-care
December 21, 2017 - Study
Classic
A program to prevent catheter-associated urinary tract infection in acute care.
Citation Text:
Saint S, Greene T, Krein SL, et al. A Program to Prevent Catheter-Associated Urinary Tract Infection in Acute Care. New Engl J Med. 2016;374(22):2111-211…
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psnet.ahrq.gov/issue/clinical-decision-support-systems-could-be-modified-reduce-alert-fatigue-while-still
December 21, 2022 - Commentary
Clinical decision support systems could be modified to reduce 'alert fatigue' while still minimizing the risk of litigation.
Citation Text:
Kesselheim AS, Cresswell K, Phansalkar S, et al. Clinical decision support systems could be modified to reduce 'alert fatigue' while stil…
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psnet.ahrq.gov/node/867428/psn-pdf
December 18, 2024 - Additionally, all the requirements are
available on our website, so really anyone can use them to get
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psnet.ahrq.gov/node/855058/psn-pdf
October 31, 2023 - Some requirements today, such as those from
the Joint Commission,3 require organizations to be more
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psnet.ahrq.gov/perspective/patient-safety-physician-office-setting
November 04, 2015 - Patient Safety in the Physician Office Setting
Nancy C. Elder, MD, MSPH | May 1, 2006
View more articles from the same authors.
Citation Text:
Elder NC. Patient Safety in the Physician Office Setting. PSNet [internet]. Rockville (MD): Agency for Healthcare Researc…
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psnet.ahrq.gov/web-mm/diuretics-and-electrolyte-abnormalities
February 15, 2017 - Diuretics and Electrolyte Abnormalities
Citation Text:
Dreischulte T. Diuretics and Electrolyte Abnormalities. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Google Scholar BibTeX EndNote X3 …
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psnet.ahrq.gov/web-mm/coming-short-maintaining-safety-face-drug-shortages
November 01, 2012 - Coming Up Short: Maintaining Safety in the Face of Drug Shortages
Citation Text:
Plogsted S. Coming Up Short: Maintaining Safety in the Face of Drug Shortages. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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…
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psnet.ahrq.gov/web-mm/staggered-sensitivity-results
May 01, 2013 - Staggered Sensitivity Results
Citation Text:
Guglielmo JB. Staggered Sensitivity Results. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/web-mm/air-side-caution
April 21, 2015 - Air on the Side of Caution
Citation Text:
Robertson JM, Pozner CN. Air on the Side of Caution. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/web-mm/refused-medication-error
November 01, 2005 - Refused Medication Error
Citation Text:
Foley M. Refused Medication Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/saved-ecmo
May 05, 2017 - Saved by ECMO
Citation Text:
Weiss NA. Saved by ECMO . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/node/49769/psn-pdf
September 01, 2016 - Complaints as Safety Surveillance
September 1, 2016
Morris JL, Bismark M. Complaints as Safety Surveillance. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/complaints-safety-surveillance
The Case
A 42-year-old woman presented to the emergency department with abdominal pain. She said the pain
came on sudden…