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psnet.ahrq.gov/node/45115/psn-pdf
September 07, 2016 - Despite federal legislation, shortages of drugs used in
acute care settings remain persistent and prolonged.
September 7, 2016
Chen SI, Fox ER, Hall K, et al. Despite Federal Legislation, Shortages Of Drugs Used In Acute Care
Settings Remain Persistent And Prolonged. Health Aff (Millwood). 2016;35(5):798-804.
doi:…
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psnet.ahrq.gov/node/35908/psn-pdf
March 03, 2011 - Patient safety in surgery.
March 3, 2011
Makary MA, Sexton B, Freischlag JA, et al. Patient safety in surgery. Ann Surg. 2006;243(5):628-32;
discussion 632-5.
https://psnet.ahrq.gov/issue/patient-safety-surgery
This AHRQ-supported study used a surgery-specific safety questionnaire (modified from the Safety
Attitu…
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psnet.ahrq.gov/node/851061/psn-pdf
June 28, 2023 - Learning from experience: a qualitative study of
surgeons' perspectives on reporting and dealing with
serious adverse events.
June 28, 2023
Øyri SF, Søreide K, Søreide E, et al. Learning from experience: a qualitative study of surgeons’
perspectives on reporting and dealing with serious adverse events. BMJ Open Qu…
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psnet.ahrq.gov/node/60892/psn-pdf
September 09, 2020 - Applying thematic synthesis to interpretation and
commentary in epidemiological studies: identifying what
contributes to successful interventions to promote hand
hygiene in patient care.
September 9, 2020
Drey N, Gould D, Purssell E, et al. Applying thematic synthesis to interpretation and commentary in
epidemiol…
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psnet.ahrq.gov/node/35570/psn-pdf
May 27, 2011 - Unexpected increased mortality after implementation of a
commercially sold computerized physician order entry
system.
May 27, 2011
Han YY, Carcillo JA, Venkataraman ST, et al. Unexpected increased mortality after implementation of a
commercially sold computerized physician order entry system. Pediatrics. 2005;116(…
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psnet.ahrq.gov/node/841143/psn-pdf
January 01, 2023 - Conceptual and practical challenges associated with
understanding patient safety within community-based
mental health services.
December 7, 2022
Averill P, Vincent CA, Reen G, et al. Conceptual and practical challenges associated with understanding
patient safety within community?based mental health services. Heal…
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psnet.ahrq.gov/node/836929/psn-pdf
April 13, 2022 - The impact of "missed nursing care" or "care not done"
on adults in health care: a rapid review for the Consensus
Development Project.
April 13, 2022
Willis E, Brady C. The impact of “missed nursing care” or “care not done” on adults in health care: A rapid
review for the Consensus Development Project. Nurs Open. …
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psnet.ahrq.gov/node/46041/psn-pdf
September 20, 2017 - The economic burden of nurse-sensitive adverse events
in 22 medical-surgical units: retrospective and matching
analysis.
September 20, 2017
Tchouaket E, Dubois C-A, D'Amour D. The economic burden of nurse-sensitive adverse events in 22
medical-surgical units: retrospective and matching analysis. J Adv Nurs. 2017;7…
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psnet.ahrq.gov/node/861288/psn-pdf
January 24, 2024 - The impact of rationing nursing care on patient safety: a
systematic review.
January 24, 2024
Uchmanowicz I, Lisiak M, Wleklik M, et al. The impact of rationing nursing care on patient safety: a
systematic review. Med Sci Monit. 2024;30:e942031. doi:10.12659/msm.942031.
https://psnet.ahrq.gov/issue/impact-rationin…
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psnet.ahrq.gov/issue/emergency-nursing-and-medical-error-survey-two-states
January 25, 2010 - December 1, 2011
Are temporary staff associated with more severe emergency department
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psnet.ahrq.gov/issue/ismp-quarterwatch-reports
June 07, 2017 - June 13, 2018
Severe hyperglycemia in patients incorrectly using insulin pens at home
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psnet.ahrq.gov/issue/2017-ismp-medication-safety-self-assessment-communityambulatory-pharmacy
June 07, 2017 - May 11, 2017
Severe hyperglycemia in patients incorrectly using insulin pens at home.
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psnet.ahrq.gov/issue/patient-safety-24
December 01, 2011 - July 8, 2013
Are temporary staff associated with more severe emergency department medication
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psnet.ahrq.gov/issue/nursing-care-quality-nqf
September 06, 2011 - July 8, 2009
Antecedents of severe and nonsevere medication errors.
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psnet.ahrq.gov/node/49811/psn-pdf
November 01, 2017 - worsening respiratory status, liver abnormalities, and colonic pseudo-obstruction were all
consistent with severe … These are rare but life-threatening conditions that result from either decompensated
thyrotoxicosis or severe … Effects Score
Absent 0
Mild (agitation) 10
Moderate (delirium, psychosis, extreme lethargy) 20
Severe … 25
Congestive Heart Failure Score
Absent 0
Mild (pedal edema) 5
Moderate (bibasilar rales) 10
Severe
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.25_slideshow.ppt
July 01, 2003 - advanced care discussions
Case: Code Status Confusion
A 60-year-old woman with a history of severe … preferences in scenarios with uncertain outcomes
i.e., successful cardiac resuscitation with resultant severe
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psnet.ahrq.gov/issue/10-medication-safety-tips-hospitalized-patients
February 06, 2019 - June 13, 2018
Severe hyperglycemia in patients incorrectly using insulin pens at home
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psnet.ahrq.gov/issue/ismp-long-term-care-advise-err
June 07, 2017 - June 13, 2018
Severe hyperglycemia in patients incorrectly using insulin pens at home
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psnet.ahrq.gov/issue/clinical-issues-series
July 05, 2006 - 2006
National Partnership for Maternal Safety: consensus bundle on support after a severe
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psnet.ahrq.gov/issue/fatal-gas-line-mix-how-avoid-making-gastly-mistake
April 29, 2018 - September 12, 2016
ALERT: reports of severe harm after intravenous administration of