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psnet.ahrq.gov/node/39699/psn-pdf
November 02, 2010 - Medical engagement in organisation-wide safety and
quality-improvement programmes: experience in the UK
Safer Patients Initiative.
November 2, 2010
Parand A, Burnett S, Benn J, et al. Medical engagement in organisation-wide safety and quality-
improvement programmes: experience in the UK Safer Patients Initiative.…
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psnet.ahrq.gov/node/38639/psn-pdf
May 20, 2009 - Eight CT lessons that we learned the hard way: an
analysis of current patterns of radiological error and
discrepancy with particular emphasis on CT.
May 20, 2009
McCreadie G, Oliver TB. Eight CT lessons that we learned the hard way: an analysis of current patterns of
radiological error and discrepancy with particu…
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psnet.ahrq.gov/node/41325/psn-pdf
October 06, 2016 - How reliable are clinical systems in the UK NHS? A study
of seven NHS organisations.
October 6, 2016
Burnett S, Franklin BD, Moorthy K, et al. How reliable are clinical systems in the UK NHS? A study of
seven NHS organisations. BMJ Qual Saf. 2012;21(6):466-72. doi:10.1136/bmjqs-2011-000442.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/35737/psn-pdf
July 15, 2010 - Shepherding change: how the market, healthcare
providers, and public policy can deliver quality care for
the 21st century.
July 15, 2010
Kennedy P, Pronovost P. Shepherding change: how the market, healthcare providers, and public policy
can deliver quality care for the 21st century. Crit Care Med. 2006;34(3 Suppl)…
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psnet.ahrq.gov/node/60279/psn-pdf
April 29, 2020 - Exploring challenges in quality and safety work in nursing
homes and home care - a case study as basis for theory
development.
April 29, 2020
Johannessen T, Ree E, Aase I, et al. Exploring challenges in quality and safety work in nursing homes and
home care – a case study as basis for theory development. BMC Healt…
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psnet.ahrq.gov/node/39598/psn-pdf
September 20, 2011 - A July spike in fatal medication errors: a possible effect
of new medical residents.
September 20, 2011
Phillips DP, Barker GEC. A July spike in fatal medication errors: a possible effect of new medical residents.
J Gen Intern Med. 2010;25(8):774-9. doi:10.1007/s11606-010-1356-3.
https://psnet.ahrq.gov/issue/july-…
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psnet.ahrq.gov/node/36044/psn-pdf
April 27, 2010 - Expected and unanticipated consequences of the quality
and information technology revolutions.
April 27, 2010
Wachter R. Expected and unanticipated consequences of the quality and information technology
revolutions. JAMA. 2006;295(23):2780-3.
https://psnet.ahrq.gov/issue/expected-and-unanticipated-consequences-qua…
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psnet.ahrq.gov/node/860380/psn-pdf
January 10, 2024 - Validity of 16 AHRQ Patient Safety Indicators to identify
in-hospital complications: a medical record review across
nine Swiss hospitals.
January 10, 2024
Havranek MM, Rüter F, Bilger S, et al. Validity of 16 AHRQ Patient Safety Indicators to identify in-hospital
complications: a medical record review across nine …
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psnet.ahrq.gov/node/37227/psn-pdf
December 15, 2011 - Intensive care unit safety incidents for medical versus
surgical patients: a prospective multicenter study.
December 15, 2011
Sinopoli DJ, Needham DM, Thompson DA, et al. Intensive care unit safety incidents for medical versus
surgical patients: a prospective multicenter study. J Crit Care. 2007;22(3):177-83.
http…
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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