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psnet.ahrq.gov/issue/simulation-executive-suite-lessons-learned-building-patient-safety-leadership
July 21, 2017 - Study
Simulation in the executive suite: lessons learned for building patient safety leadership.
Citation Text:
Rosen MA, Goeschel CA, Che X-X, et al. Simulation in the Executive Suite: Lessons Learned for Building Patient Safety Leadership. Simul Healthc. 2015;10(6):372-377.
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psnet.ahrq.gov/issue/large-scale-deployment-global-trigger-tool-across-large-hospital-system-refinements
November 23, 2014 - Study
Large-scale deployment of the Global Trigger Tool across a large hospital system: refinements for the characterisation of adverse events to support patient safety learning opportunities.
Citation Text:
Good VS, Saldaña M, Gilder R, et al. Large-scale deployment of the Global Trig…
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psnet.ahrq.gov/issue/meitheal-pharmaceuticals-inc-issues-voluntary-nationwide-recall-cisatracurium-besylate
February 03, 2021 - Press Release/Announcement
Meitheal Pharmaceuticals, Inc. issues voluntary nationwide recall of Cisatracurium Besylate Injection, USP 10mg per 5mL due to mislabeling.
Citation Text:
Meitheal Pharmaceuticals, Inc. issues voluntary nationwide recall of Cisatracurium Besylate Injection, USP…
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psnet.ahrq.gov/issue/fda-drug-safety-communication-fda-warns-about-prescribing-and-dispensing-errors-resulting
August 05, 2020 - Press Release/Announcement
FDA Drug Safety Communication: FDA warns about prescribing and dispensing errors resulting from brand name confusion with antidepressant Brintellix (vortioxetine) and antiplatelet Brilinta (ticagrelor).
Citation Text:
FDA Drug Safety Communication: FDA warns ab…
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psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please
September 01, 2011 - In most of the institutions I've ever worked, both in the United States and Canada, probably the single … In Australia, they've invested in call centers—which would probably never work in the United States—where … 2023
Implementing computerized provider order entry in acute care hospitals in the United … States could generate substantial savings to society.
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psnet.ahrq.gov/primer/retained-surgical-items-definition-and-epidemiology
September 15, 2024 - Most states that require mandatory event reporting, the American Hospital Association Coding Clinic, … Incidence and OR team awareness of “near-miss” and retained surgical sharps: a national survey on United … States operating rooms.
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psnet.ahrq.gov/node/49549/psn-pdf
December 06, 2007 - Elopement
December 1, 2007
Gerardi D. Elopement. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/elopement
Case Objectives
Define elopement and differentiate it from wandering and leaving against medical advice.
Identify leading contributors to elopement events.
Describe strategies for preventing elopement…
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psnet.ahrq.gov/web-mm/when-indications-drug-administration-blur
May 26, 2021 - SPOTLIGHT CASE
When the Indications for Drug Administration Blur
Citation Text:
Munsch J, Doroy A. When the Indications for Drug Administration Blur . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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…
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psnet.ahrq.gov/perspective/conversation-edwin-boudreaux-about-suicide-prevention
March 25, 2025 - Prevention
March 25, 2025
Introduction Suicide is one of the leading causes of death in the United … States, accounting for nearly 50,000 deaths in 2022, a 36% rise since 2000. 1 In addition, over 13 … [Available at] Key Substance Use and Mental Health Indicators in the United States: Results from the
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psnet.ahrq.gov/perspective/suicide-prevention
March 24, 2025 - Download Citation
Introduction Suicide is one of the leading causes of death in the United … States, accounting for nearly 50,000 deaths in 2022, a 36% rise since 2000. 1 In addition, over 13 … [Available at] Key Substance Use and Mental Health Indicators in the United States: Results from the
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psnet.ahrq.gov/node/49577/psn-pdf
January 01, 2009 - However, it is likely that tens of thousands of people in the United States are employing CSII.(2) The
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psnet.ahrq.gov/web-mm/e-prescribing-e-error
February 03, 2021 - Across the United States, the number of prescribers sending electronic prescriptions has increased since … prescriptions.( 18 ) Of 3850 prescriptions reviewed in the final sample originating from three different states … October 26, 2022
Ambulatory prescribing errors among community-based providers in two states
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psnet.ahrq.gov/issue/unanticipated-death-after-discharge-home-emergency-department
November 16, 2022 - Study
Unanticipated death after discharge home from the emergency department.
Citation Text:
Sklar DP, Crandall CS, Loeliger E, et al. Unanticipated Death After Discharge Home From the Emergency Department. Ann Emerg Med. 2007;49(6). doi:10.1016/j.annemergmed.2006.11.018.
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psnet.ahrq.gov/issue/reviewing-impact-computerized-provider-order-entry-clinical-outcomes-quality-systematic
May 21, 2009 - Review
Reviewing the impact of computerized provider order entry on clinical outcomes: the quality of systematic reviews.
Citation Text:
Weir C, Staggers N, Laukert T. Reviewing the impact of computerized provider order entry on clinical outcomes: The quality of systematic reviews. Int…
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psnet.ahrq.gov/issue/do-written-disclosures-serious-events-increase-risk-malpractice-claims-one-health-care
October 12, 2011 - Study
Do written disclosures of serious events increase risk of malpractice claims? One health care system's experience.
Citation Text:
Painter LM, Kidwell KM, Kidwell RP, et al. Do Written Disclosures of Serious Events Increase Risk of Malpractice Claims? One Health Care System's Experi…
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psnet.ahrq.gov/issue/more-1000-preventable-deaths-day-too-many-need-improve-patient-safety
September 02, 2016 - Congressional Testimony
More Than 1,000 Preventable Deaths a Day Is Too Many: The Need to Improve Patient Safety.
Citation Text:
More Than 1,000 Preventable Deaths a Day Is Too Many: The Need to Improve Patient Safety. Hearing Before the Subcommittee on Primary Health and Aging, 113th Co…
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psnet.ahrq.gov/web-mm/it-safe-be-direct
September 30, 2015 - Emergency department overcrowding in the United States: an emerging threat to patient safety and public
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psnet.ahrq.gov/web-mm/dont-wait-collect-accurate-weight-case-subtherapeutic-insulin-therapy
July 01, 2008 - Incorporate Clinical Pharmacists in the ED The Joint Commission Standard for Medication Management states
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psnet.ahrq.gov/node/33698/psn-pdf
August 01, 2010 - In Conversation with...Richard P. Shannon, MD
August 1, 2010
In Conversation with..Richard P. Shannon, MD. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/conversation-withrichard-p-shannon-md
Editor's note: Richard P. Shannon, MD, is the Frank Wister Thomas Professor of Medicine at the
University of Pe…
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psnet.ahrq.gov/web-mm/result-stopped-here
December 01, 2006 - A survey of 623 laboratories in the United States revealed that, for inpatients, laboratory personnel