-
psnet.ahrq.gov/node/41963/psn-pdf
February 01, 2013 - National study on the distribution, causes, and
consequences of voluntarily reported medication errors
between the ICU and non-ICU settings.
February 1, 2013
Latif A, Rawat N, Pustavoitau A, et al. National study on the distribution, causes, and consequences of
voluntarily reported medication errors between the IC…
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psnet.ahrq.gov/node/38986/psn-pdf
February 10, 2015 - Medicare's policy not to pay for treating hospital-acquired
conditions: the impact.
February 10, 2015
McNair PD, Luft HS, Bindman AB. Medicare's policy not to pay for treating hospital-acquired conditions: the
impact. Health Aff (Millwood). 2009;28(5):1485-1493. doi:10.1377/hlthaff.28.5.1485.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/72649/psn-pdf
January 20, 2021 - Wrong-site surgery in Pennsylvania during 2015–2019: a
study of variables associated with 368 events from 178
facilities.
January 20, 2021
Yonash RA, Taylor M. Wrong-Site Surgery in Pennsylvania During 2015–2019: A Study of Variables
Associated With 368 Events From 178 Facilities. Patient Safety. 2020;2(4):24-39.
…
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psnet.ahrq.gov/node/46450/psn-pdf
August 20, 2018 - Improving Diagnostic Quality and Safety Final Report.
August 20, 2018
Washington, DC: National Quality Forum. September 19, 2017.
https://psnet.ahrq.gov/issue/improving-diagnostic-quality-and-safety-final-report
Although diagnostic error is a well-recognized source of preventable patient harm, measuring and
mitiga…
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psnet.ahrq.gov/node/61113/psn-pdf
January 01, 2021 - Do falls and other safety issues occur more often during
handovers when nurses are away from patients? Findings
from a retrospective study design.
November 11, 2020
Demaria J, Valent F, Danielis M, et al. Do falls and other safety issues occur more often during handovers
when nurses are away from patients? Finding…
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psnet.ahrq.gov/node/33667/psn-pdf
April 01, 2008 - Connie's Story: A Nurse's Personal Experience with
MRSA
April 1, 2008
Lehfeldt C. Connie's Story: A Nurse's Personal Experience with MRSA. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/connies-story-nurses-personal-experience-mrsa
Perspective
The voices of patients are often missing from discussions …
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psnet.ahrq.gov/node/73207/psn-pdf
May 05, 2021 - Diagnostic accuracy of prehospital triage tools for
identifying major trauma in elderly injured patients: a
systematic review.
May 5, 2021
Fuller G, Pandor A, Essat M, et al. Diagnostic accuracy of prehospital triage tools for identifying major
trauma in elderly injured patients: a systematic review. J Trauma Acut…
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psnet.ahrq.gov/node/866901/psn-pdf
October 09, 2024 - Reader bias in breast cancer screening related to cancer
prevalence and artificial intelligence decision support-a
reader study.
October 9, 2024
Al-Bazzaz H, Janicijevic M, Strand F. Reader bias in breast cancer screening related to cancer prevalence
and artificial intelligence decision support—a reader study. Eur…
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psnet.ahrq.gov/node/35855/psn-pdf
October 25, 2013 - HealthGrades Quality Study: Third Annual Patient Safety
in American Hospitals Study.
October 25, 2013
Denver, CO: HealthGrades; 2006.
https://psnet.ahrq.gov/issue/healthgrades-quality-study-third-annual-patient-safety-american-hospitals-
study
This third annual report on the safety of hospitalized Medicare patien…
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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
-
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
-
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
-
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
-
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
-
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