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psnet.ahrq.gov/issue/impact-national-multimodal-intervention-prevent-catheter-related-bloodstream-infection-icu
September 13, 2023 - Study
Impact of a national multimodal intervention to prevent catheter-related bloodstream infection in the ICU: the Spanish experience.
Citation Text:
Palomar M, Álvarez-Lerma F, Riera A, et al. Impact of a national multimodal intervention to prevent catheter-related bloodstream infec…
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psnet.ahrq.gov/issue/reduction-preventable-time-critical-dose-omissions-impact-electronic-medication-management
February 03, 2016 - Study
Reduction in preventable time-critical dose omissions: impact of electronic medication management systems on in-patients.
Citation Text:
Graudins LV, Crute S, Poole SG, et al. Reduction in preventable time-critical dose omissions: impact of electronic medication management systems …
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psnet.ahrq.gov/issue/untangling-infusion-confusion-comparative-evaluation-interventions-simulated-intensive-care
September 01, 2021 - Study
Untangling infusion confusion: a comparative evaluation of interventions in a simulated intensive care setting.
Citation Text:
Pinkney SJ, Fan M, Koczmara C, et al. Untangling Infusion Confusion: A Comparative Evaluation of Interventions in a Simulated Intensive Care Setting. Crit …
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psnet.ahrq.gov/node/49416/psn-pdf
September 01, 2003 - of shortages in critical
care are not available, the American Association of Critical Care Nurses states
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psnet.ahrq.gov/curated-library/organizational-learning
November 10, 2025 - Based on interviews with safety leaders across the United... … Based on interviews with safety leaders across the United States, this article discusses how different … a Memory set out to understand what was known about the scale and nature of serious failures in the United … The findings and analysis have been used to modernize the United Kingdom’s process for understanding
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psnet.ahrq.gov/node/40161/psn-pdf
January 19, 2011 - 2010 John M. Eisenberg Patient Safety and Quality Award
Recipients.
January 19, 2011
Joint Commission. January 12, 2011.
https://psnet.ahrq.gov/issue/2010-john-m-eisenberg-patient-safety-and-quality-award-recipients
The Eisenberg Award honors individuals and organizations who have made vital accomplishments in
im…
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psnet.ahrq.gov/node/39742/psn-pdf
August 09, 2013 - AHRQ WebM&M in 2012, and discussed his career as well as the current state of patient safety in the
United
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psnet.ahrq.gov/node/49829/psn-pdf
May 01, 2018 - death, permanent harm, or severe temporary harm) has been mandated by The Joint Commission in the
United … States for more than 15 years (2) and is widely adopted in many other high-income nations.(3)
Despite … Some developments in the United Kingdom are also encouraging. … London, United Kingdom:
Palgrave Macmillan; 2014. ISBN: 9781349306329.
8.
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psnet.ahrq.gov/node/847934/psn-pdf
April 26, 2023 - psnet.ahrq.gov/issue/improvement-patient-safety-may-precede-policy-changes-trends-patient-safety-indicators-united … psnet.ahrq.gov/issue/improvement-patient-safety-may-precede-policy-changes-trends-patient-safety-indicators-united … PSIs and their downstream consequences, based on patients'
preferences for outcome-related health states … psnet.ahrq.gov/issue/improvement-patient-safety-may-precede-policy-changes-trends-patient-safety-indicators-united
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psnet.ahrq.gov/innovation/suicide-prevention-emergency-department-population-ed-safe
July 23, 2024 - Innovator
Summary
Suicide is the 12 th leading cause of death in the United … States, and the 3 rd leading cause of death for people ages 15-24. 1 More than 4% of all emergency … positive for suicidal ideation but who were discharged from the ED. 3 When patients were in crisis states … Suicide mortality in the United States, 2001-2021 . NCHS Data Brief, no. 464. April 2023.
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psnet.ahrq.gov/primer/communication-between-clinicians
September 15, 2024 - Associations between safety outcomes and communication practices among pediatric nurses in the United … States.
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psnet.ahrq.gov/web-mm/wandering-floors-safety-and-security-risks-patient-wandering
August 21, 2007 - SPOTLIGHT CASE
Wandering Off the Floors: Safety and Security Risks of Patient Wandering
Citation Text:
Smith TA. Wandering Off the Floors: Safety and Security Risks of Patient Wandering. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Huma…
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psnet.ahrq.gov/issue/impact-technology-prescribing-errors-pediatric-intensive-care-and-after-study
November 16, 2022 - Study
The impact of technology on prescribing errors in pediatric intensive care: a before and after study.
Citation Text:
Howlett MM, Butler E, Lavelle KM, et al. The impact of technology on prescribing errors in pediatric intensive care: a before and after study. Appl Clin Inform. 2020…
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psnet.ahrq.gov/issue/clinical-diagnoses-vs-autopsy-findings-early-deceased-septic-patients-intensive-care
September 22, 2021 - Study
Clinical diagnoses vs. autopsy findings in early deceased septic patients in the intensive care: a retrospective cohort study.
Citation Text:
Driessen RGH, Latten BGH, Bergmans DCJJ, et al. Clinical diagnoses vs. autopsy findings in early deceased septic patients in the intensive c…
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psnet.ahrq.gov/issue/diagnostic-errors-pediatric-and-neonatal-icu-systematic-review
October 29, 2012 - Review
Diagnostic errors in the pediatric and neonatal ICU: a systematic review.
Citation Text:
Custer JW, Winters BD, Goode V, et al. Diagnostic errors in the pediatric and neonatal ICU: a systematic review. Pediatr Crit Care Med. 2015;16(1):29-36. doi:10.1097/PCC.0000000000000274.
Co…
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psnet.ahrq.gov/issue/cross-sectional-study-relationship-between-utilization-root-cause-analysis-and-patient-safety
January 11, 2017 - Study
A cross-sectional study on the relationship between utilization of root cause analysis and patient safety at 139 Department of Veterans Affairs medical centers.
Citation Text:
Percarpio KB, Watts V. A cross-sectional study on the relationship between utilization of root cause ana…
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psnet.ahrq.gov/issue/preventing-harm-icu-building-culture-safety-and-engaging-patients-and-families
March 14, 2022 - Review
Preventing harm in the ICU—building a culture of safety and engaging patients and families.
Citation Text:
Thornton KC, Schwarz JJ, Gross K, et al. Preventing Harm in the ICU-Building a Culture of Safety and Engaging Patients and Families. Crit Care Med. 2017;45(9):1531-1537. doi:…
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psnet.ahrq.gov/issue/automated-detection-harm-healthcare-information-technology-systematic-review
April 11, 2011 - Review
Automated detection of harm in healthcare with information technology: a systematic review.
Citation Text:
Govindan M, Van Citters AD, Nelson EC, et al. Automated detection of harm in healthcare with information technology: a systematic review. Qual Saf Health Care. 2010;19(5):e…
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psnet.ahrq.gov/node/49849/psn-pdf
January 01, 2019 - past 20 years have seen the emergence of a national movement to improve hospital-based safety in
the United … States.
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psnet.ahrq.gov/node/49586/psn-pdf
May 01, 2009 - drug administration error was reported for every 133 anesthetics administered.(2) More recently,
the United … States Pharmacopeia's MEDMARX database identified 3298 medication errors in the OR from
1998 to 2005