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  1. Prevalence, underlying causes, and preventability of sepsis-associated mortality in US acute care hospitals. | PSNet

    psnet.ahrq.gov/issue/prevalence-underlying-causes-and-preventability-sepsis-associated-mortality-us-acute-care
    August 20, 2018 - Study Classic Prevalence, underlying causes, and preventability of sepsis-associated mortality in US acute care hospitals. Citation Text: Rhee C, Jones TM, Hamad Y, et al. Prevalence, Underlying Causes, and Preventability of Sepsis-Associated Mortality in US Acu…

  2. Examining the validity of AHRQ's Patient Safety Indicators (PSIs): is variation in PSI composite score related to hospital organizational factors? | PSNet

    psnet.ahrq.gov/issue/examining-validity-ahrqs-patient-safety-indicators-psis-variation-psi-composite-score-related
    November 10, 2010 - Study Examining the validity of AHRQ's Patient Safety Indicators (PSIs): is variation in PSI composite score related to hospital organizational factors? Citation Text: Shin MH, Sullivan JL, Rosen AK, et al. Examining the validity of AHRQ's patient safety indicators (PSIs): is variation i…

  3. Using AHRQ Patient Safety Indicators to detect postdischarge adverse events in the Veterans Health Administration. | PSNet

    psnet.ahrq.gov/issue/using-ahrq-patient-safety-indicators-detect-postdischarge-adverse-events-veterans-health
    June 04, 2014 - Study Using AHRQ Patient Safety Indicators to detect postdischarge adverse events in the Veterans Health Administration. Citation Text: Mull HJ, Borzecki A, Chen Q, et al. Using AHRQ patient safety indicators to detect postdischarge adverse events in the Veterans Health Administration. A…

  4. Emergency department contribution to the prescription opioid epidemic. | PSNet

    psnet.ahrq.gov/issue/emergency-department-contribution-prescription-opioid-epidemic
    June 21, 2016 - Study Classic Emergency department contribution to the prescription opioid epidemic. Citation Text: Axeen S, Seabury SA, Menchine M. Emergency Department Contribution to the Prescription Opioid Epidemic. Ann Emerg Med. 2018;71(6):659-667.e3. doi:10.1016/j.anneme…

  5. Opioid prescribing for opioid-naive patients in emergency departments and other settings: characteristics of prescriptions and association with long-term use. | PSNet

    psnet.ahrq.gov/issue/opioid-prescribing-opioid-naive-patients-emergency-departments-and-other-settings
    August 29, 2018 - Study Opioid prescribing for opioid-naive patients in emergency departments and other settings: characteristics of prescriptions and association with long-term use. Citation Text: Jeffery MM, Hooten M, Hess EP, et al. Opioid Prescribing for Opioid-Naive Patients in Emergency Departments …

  6. Using estimated true safety event rates versus flagged safety event rates: does it change hospital profiling and payment? | PSNet

    psnet.ahrq.gov/issue/using-estimated-true-safety-event-rates-versus-flagged-safety-event-rates-does-it-change
    December 15, 2011 - Study Using estimated true safety event rates versus flagged safety event rates: does it change hospital profiling and payment? Citation Text: Rosen AK, Chen Q, Borzecki A, et al. Using estimated true safety event rates versus flagged safety event rates: does it change hospital profiling…

  7. Demonstrating high reliability on accountability measures at The Johns Hopkins Hospital. | PSNet

    psnet.ahrq.gov/issue/demonstrating-high-reliability-accountability-measures-johns-hopkins-hospital
    January 27, 2016 - Study Demonstrating high reliability on accountability measures at The Johns Hopkins Hospital. Citation Text: Pronovost P, Demski R, Callender T, et al. Demonstrating high reliability on accountability measures at the Johns Hopkins Hospital. Jt Comm J Qual Patient Saf. 2013;39(12):531…

  8. The impact of hospital-acquired conditions on Medicare program payments. | PSNet

    psnet.ahrq.gov/issue/impact-hospital-acquired-conditions-medicare-program-payments
    November 18, 2016 - Study The impact of hospital-acquired conditions on Medicare program payments. Citation Text: Kandilov AMG, Coomer NM, Dalton K. The impact of hospital-acquired conditions on Medicare program payments. Medicare Medicaid Res Rev. 2014;4(4). doi:10.5600/mmrr.004.04.a01. Copy Citation …

  9. An epistemology of patient safety research: a framework for study design and interpretation. | PSNet

    psnet.ahrq.gov/issue/epistemology-patient-safety-research-framework-study-design-and-interpretation
    February 23, 2011 - Study Classic An epistemology of patient safety research: a framework for study design and interpretation. Citation Text: Brown C, Hofer T, Johal A, et al. An epistemology of patient safety research: a framework for study design and interpretation. Part 4. One s…

  10. Factors associated with hospital admission after outpatient surgery in the Veterans Health Administration. | PSNet

    psnet.ahrq.gov/issue/factors-associated-hospital-admission-after-outpatient-surgery-veterans-health-administration
    August 17, 2018 - Study Factors associated with hospital admission after outpatient surgery in the Veterans Health Administration. Citation Text: 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…

  11. Incorrect surgical procedures within and outside of the operating room. | PSNet

    psnet.ahrq.gov/issue/incorrect-surgical-procedures-within-and-outside-operating-room
    November 21, 2011 - Study Incorrect surgical procedures within and outside of the operating room. Citation Text: Neily J, Mills PD, Eldridge N, et al. Incorrect surgical procedures within and outside of the operating room. Arch Surg. 2009;144(11):1028-34. doi:10.1001/archsurg.2009.126. Copy Citation F…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865972/psn-pdf
    May 29, 2024 - Development and evaluation of patient safety interventions: perspectives of operational safety leaders and patient safety organizations. May 29, 2024 Gomes KM, Handley J, Pruitt ZM, et al. Development and evaluation of patient safety interventions: perspectives of operational safety leaders and patient safety orga…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41037/psn-pdf
    September 06, 2016 - Drug Shortages: FDA's Ability to Respond Should Be Strengthened. September 6, 2016 Testimony before the Committee on Health, Education, Labor, and Pensions, US Senate. US Government Accountability Office. GAO-12-315T (December 15, 2011) https://psnet.ahrq.gov/issue/drug-shortages-fdas-ability-respond-should-be-str…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72680/psn-pdf
    January 27, 2021 - It’s time to consider national culture when designing team training initiatives in healthcare. January 27, 2021 Rice JC, Daouk-Öyry L, Hitti E. It’s time to consider national culture when designing team training initiatives in healthcare. BMJ Qual Saf. 2021;30(5):412-417. doi:10.1136/bmjqs-2020-010918. https://psn…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47927/psn-pdf
    July 31, 2019 - In-hospital mortality associated with the misdiagnosis or unidentified site of infection at admission. July 31, 2019 Abe T, Tokuda Y, Shiraishi A, et al. In-hospital mortality associated with the misdiagnosis or unidentified site of infection at admission. Crit Care. 2019;23(1):202. doi:10.1186/s13054-019-2475-9. …

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39078/psn-pdf
    May 21, 2014 - Assessing Patient Safety Practices and Outcomes in the U.S. Health Care System. May 21, 2014 Farley DO, Ridgely MS, Mendel P, et al. Santa Monica, CA: RAND Corporation; 2009. ISBN: 9780833047748. https://psnet.ahrq.gov/issue/assessing-patient-safety-practices-and-outcomes-us-health-care-system This publication re…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33881/psn-pdf
    August 01, 2019 - In Conversation With… Erik Hollnagel, PhD June 1, 2019 In Conversation With… Erik Hollnagel, PhD. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-erik-hollnagel-phd Editor's note: Dr. Hollnagel is Senior Professor of Patient Safety at the University of Jönköping (Sweden) as well as Visiting…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44880/psn-pdf
    September 06, 2016 - Drug shortages forcing hard decisions on rationing treatments. September 6, 2016 Fink S. New York Times. January 29, 2016. https://psnet.ahrq.gov/issue/drug-shortages-forcing-hard-decisions-rationing-treatments Drug shortages have become a routine challenge in medicine. Reporting on the impact of medication short…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41149/psn-pdf
    February 22, 2012 - Miscoding, misclassification and misdiagnosis of diabetes in primary care. February 22, 2012 de Lusignan S, Sadek N, Mulnier H, et al. Miscoding, misclassification and misdiagnosis of diabetes in primary care. Diabet Med. 2012;29(2):181-9. doi:10.1111/j.1464-5491.2011.03419.x. https://psnet.ahrq.gov/issue/miscodin…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40185/psn-pdf
    December 29, 2014 - Variation in the rates of adverse events between hospitals and hospital departments. December 29, 2014 Zegers M, de Bruijne M, Spreeuwenberg P, et al. Variation in the rates of adverse events between hospitals and hospital departments. Int J Qual Health Care. 2011;23(2):126-33. doi:10.1093/intqhc/mzq086. https://…
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