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psnet.ahrq.gov/node/73549/psn-pdf
July 28, 2021 - Local Anesthesia-Induced Coma During Total Knee
Arthroplasty.
July 28, 2021
Aldwinckle R. Local Anesthesia-Induced Coma During Total Knee Arthroplasty. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/local-anesthesia-induced-coma-during-total-knee-arthroplasty
The Case
A 61-year-old male patient weighing 57…
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psnet.ahrq.gov/web-mm/dont-wait-collect-accurate-weight-case-subtherapeutic-insulin-therapy
July 01, 2008 - August 3, 2022
Prevalence, nature, severity and preventability of adverse drug events … February 16, 2022
An initiative to reduce insulin-related adverse drug events in a children's
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psnet.ahrq.gov/node/49857/psn-pdf
March 01, 2019 - Duplicate Insulin Order
March 1, 2019
Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/duplicate-insulin-order
The Case
A 45-year-old man with a history of insulin-dependent diabetes mellitus was seen in the emergency
department (ED) for complaints of letharg…
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psnet.ahrq.gov/web-mm/specimen-almost-lost
September 21, 2022 - March 19, 2018
Advancing medication safety: establishing a National Action Plan for Adverse … Drug Event Prevention.
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psnet.ahrq.gov/node/49770/psn-pdf
September 01, 2016 - Wrong-Time Error With High-Alert Medication
September 1, 2016
Yang A, Nelson LS. Wrong-Time Error With High-Alert Medication. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/wrong-time-error-high-alert-medication
The Case
A 60-year-old man was admitted to the hospital for a total knee arthroplasty. During th…
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psnet.ahrq.gov/issue/managing-hospitalized-patients-ambulatory-pumps-findings-ismp-survey-part-1
November 18, 2015 - Newspaper/Magazine Article
Managing hospitalized patients with ambulatory pumps: findings from an ISMP survey—Part 1.
Citation Text:
Managing hospitalized patients with ambulatory pumps: findings from an ISMP survey—Part 1. ISMP Medication Safety Alert! Acute care edition. November 19, 2…
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psnet.ahrq.gov/issue/secret-data-hospital-inspections-may-soon-become-public
January 30, 2019 - Newspaper/Magazine Article
Secret data on hospital inspections may soon become public.
Citation Text:
Secret data on hospital inspections may soon become public. Ornstein C. Health Shots. National Public Radio and ProPublica. April 18, 2017.
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psnet.ahrq.gov/issue/error-disclosure-pathology-and-laboratory-medicine-review-literature
July 28, 2021 - Review
Error disclosure in pathology and laboratory medicine: a review of the literature.
Citation Text:
Perkins IU. Error Disclosure in Pathology and Laboratory Medicine: A Review of the Literature. AMA J Ethics. 2016;18(8):809-16. doi:10.1001/journalofethics.2016.18.8.nlit1-1608.
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psnet.ahrq.gov/issue/building-high-reliability-organization-one-systems-patient-safety-journey
November 23, 2005 - Commentary
Building a high-reliability organization: one system's patient safety journey.
Citation Text:
Building a high-reliability organization: one system's patient safety journey. J Healthc Manag. 2017;62.
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psnet.ahrq.gov/issue/safe-practices-better-healthcare-2006-update
September 06, 2011 - Book/Report
Safe Practices for Better Healthcare: 2006 Update.
Citation Text:
Safe Practices for Better Healthcare: 2006 Update. Washington DC: National Quality Forum; 2007.
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psnet.ahrq.gov/issue/final-report-commission-care
September 29, 2017 - Book/Report
Final Report of the Commission on Care.
Citation Text:
Final Report of the Commission on Care. Washington, DC: Commission on Care; June 2016.
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psnet.ahrq.gov/issue/implementing-closing-loop-safe-practices-diagnostic-results
March 10, 2021 - Book/Report
Implementing Closing the Loop. Safe Practices for Diagnostic Results
Citation Text:
Implementing Closing the Loop. Safe Practices for Diagnostic Results Partnership for HIT Patient Safety. Plymouth Meeting, PA: ECRI Institute; 2020.
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psnet.ahrq.gov/issue/diagnostic-centers-excellence-x01-clinical-trial-not-allowed
May 04, 2016 - Grant Announcement
Diagnostic Centers of Excellence (X01 Clinical Trial Not Allowed).
Citation Text:
Diagnostic Centers of Excellence (X01 Clinical Trial Not Allowed). PAR-23-120. Bethesda, MD: National Institutes of Health; March 7, 2023
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psnet.ahrq.gov/issue/normalization-deviance-healthcare-delivery
November 19, 2014 - Commentary
The normalization of deviance in healthcare delivery.
Citation Text:
Banja J. The normalization of deviance in healthcare delivery. Bus Horiz. 2010;53(2):139.
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psnet.ahrq.gov/issue/patient-safety-systems-case-management
December 22, 2008 - Review
Patient safety systems for case management.
Citation Text:
Greenberg L. Patient safety systems for case management. Lippincotts Case Manag. 2004;9(5):223-229. doi:10.1097/00129234-200409000-00004.
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psnet.ahrq.gov/issue/prescription-errors-psychiatry-multi-centre-study
September 27, 2017 - Study
Prescription errors in psychiatry - a multi-centre study.
Citation Text:
Stubbs J, Haw C, Taylor D. Prescription errors in psychiatry - a multi-centre study. J Psychopharmacol. 2006;20(4):553-61.
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psnet.ahrq.gov/issue/please-dont-sleep-through-wake-call
May 07, 2018 - Newspaper/Magazine Article
Please don't sleep through this wake-up call.
Citation Text:
Please don't sleep through this wake-up call. ISMP Medication Safety Alert! Acute Care Edition. May 2, 2001.
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psnet.ahrq.gov/issue/ongoing-nightmare-people-obesity-face-major-obstacles-when-seeking-medical-care
November 09, 2022 - Newspaper/Magazine Article
'An ongoing nightmare': people with obesity face major obstacles when seeking medical care.
Citation Text:
'An ongoing nightmare': people with obesity face major obstacles when seeking medical care. Schapiro R. NBC News. June 27, 2021.
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psnet.ahrq.gov/issue/taking-aim-infusion-confusion
June 06, 2018 - Commentary
Taking aim at infusion confusion.
Citation Text:
Burdeu G, Crawford R, Van de Vreede M, et al. Taking aim at infusion confusion. J Nurs Care Qual. 2006;21(2):151-159.
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psnet.ahrq.gov/issue/hospital-discharge-and-readmission
March 27, 2005 - Review
Hospital discharge and readmission.
Citation Text:
Hospital discharge and readmission. Alper E, O'Malley TA, Greenwald J. UpToDate. February 3, 2023.
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