U.S. Department of Health and Human Services
Agency for Healthcare Research and Quality: Advancing Excellence in Health Care
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Centers for Disease Control and Prevention.
Dialysis is a common procedure that carries risks if not performed correctly. This initiative represents a collective effort that aims to develop, share, and test a set of interventions and tools to ensure the safety of dialysis.
Pregnancy-related deaths: saving women’s lives before, during and after delivery.
CDC Vital Signs. May 7, 2019.
A multidisciplinary model for reviewing severe maternal morbidity cases and teaching residents patient safety principles.
Ogunyemi D, Hage N, Kim SK, Friedman P. Jt Comm J Qual Patient Saf. 2019 Mar 20; [Epub ahead of print].
Why do hundreds of US women die annually in childbirth?
Slomski A. JAMA. 2019;321:1239-1241.
Achieving dialysis safety: the critical role of higher-functioning teams.
Wong LP. Semin Dial. 2019;32:266-273.
SIS Patient Safety Committee. Spine Intervention Society.
Measuring hospital-acquired complications associated with low-value care.
Badgery-Parker T, Pearson SA, Dunn S, Elshaug AG. JAMA Intern Med. 2019;179:499-505.
The impact of patient–physician alliance on trust following an adverse event.
Shoemaker K, Smith CP. Patient Educ Couns. 2019 Feb 22; [Epub ahead of print].
How to be a very safe maternity unit: an ethnographic study.
Liberati EG, Tarrant C, Willars J, et al. Soc Sci Med. 2019;223:64-72.
Effect of a cluster randomised team training intervention on adverse perinatal and maternal outcomes: a stepped wedge study.
Romijn A, Ravelli ACJ, de Bruijne MC, et al. BJOG. 2019;126:907-914.
Impact of the Agency for Healthcare Research and Quality's Safety Program for Perinatal Care.
Kahwati LC, Sorensen AV, Teixeira-Poit S, et al. Jt Comm J Qual Patient Saf. 2019;45:231–240.
Assessment of incorrect surgical procedures within and outside the operating room. A follow-up study from US Veterans Health Administration medical centers.
Neily J, Soncrant C, Mills PD, et al. JAMA Network Open. 2018;1:e185147.
Reversing the rise in maternal mortality.
Kozhimannil KB. Health Aff (Millwood). 2018;37:1901-1904.
What we can do about maternal mortality—and how to do it quickly.
Mann S, Hollier LM, McKay K, Brown H. N Engl J Med. 2018;379:1689-1691.
Unintentionally retained foreign objects: a descriptive study of 308 sentinel events and contributing factors.
Steelman VM, Shaw C, Shine L, Hardy-Fairbanks AJ. Jt Comm J Qual Patient Saf. 2019;45:249–258.
Young A, Kelly J, Schnaars C, Ungar L. USA Today.
An analysis of adverse events in the rehabilitation department: using the Veterans Affairs root cause analysis system.
Hagley GW, Mills PD, Shiner B, Hemphill RR. Phys Ther. 2018;98:223-230.
A Painful Medication Reconciliation Mishap
Roger Chou, MD
Nil per os orders for imaging: a teachable moment.
Wickerham AL, Schultz EJ, Lewine EB. JAMA Intern Med. 2017;177:1670-1671.
Nurses' knowledge and teaching of possible postpartum complications.
Suplee PD, Bingham D, Kleppel L. MCN Am J Matern Child Nurs. 2017;42:338-344.
Exploring approaches to patient safety: the case of spinal manipulation therapy.
Rozmovits L, Mior S, Boon H. BMC Complement Altern Med. 2016;16:164.
Pediatric airway management and prehospital patient safety: results of a national Delphi survey by the Children's Safety Initiative-Emergency Medical Services for Children.
Hansen M, Meckler G, O'Brien K, et al. Pediatr Emerg Care. 2016;32:603-607.
Disclosure of medical errors involving gametes and embryos.
Ethics Committee of the American Society for Reproductive Medicine. Fertil Steril. 2016;106:59-63.
Systematic review of physiologic monitor alarm characteristics and pragmatic interventions to reduce alarm frequency.
Paine CW, Goel VV, Ely E, et al. J Hosp Med. 2016;11:136-144.
Safety in Radiology
Antonio Pinto, MD, PhD
Overview of adverse events related to invasive procedures in the intensive care unit.
Pottier V, Daubin C, Lerolle N, et al. Am J Infect Control. 2012;40:241-246.
PSNET: Patient Safety Network
PSNet is produced for the Agency for Healthcare Research and Quality by a team of editors at the University of California, San Francisco with guidance from a prominent Technical Expert/Advisory Panel. The AHRQ PSNet site was designed and implemented by Silverchair.
Agency for Healthcare Research and Quality
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Telephone: (301) 427-1364