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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49803/psn-pdf
    January 01, 2018 - Point-of-care Mixup: 1 Shot Turns Into 3 August 1, 2017 Berberich RF. Point-of-care Mixup: 1 Shot Turns Into 3. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/point-care-mixup-1-shot-turns-3 The Case A 2-month-old boy was brought in for a routine 2-month well-child visit. The exam was completed and the app…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846169/psn-pdf
    March 15, 2023 - Distraction of the Anesthesiologist and Lack of Resuscitation Drugs Resulting in Delayed Treatment of Laryngospasm. March 15, 2023 Bohringer C. Distraction of the Anesthesiologist and Lack of Resuscitation Drugs Resulting in Delayed Treatment of Laryngospasm. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/…

  3. Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport | PSNet

    psnet.ahrq.gov/web-mm/misplaced-vial-medication-kit-variability-contributes-medication-error-during-patient
    March 12, 2021 - Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport Citation Text: MacDowell P, McGee E. Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Q…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33632/psn-pdf
    April 01, 2006 - In Conversation with… Michael Cohen, RPh, MS, ScD (hon) April 1, 2006 In Conversation with… Michael Cohen, RPh, MS, ScD (hon). PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon Robert Wachter, Editor, AHRQ WebM&M: Tell us a little bit about your background and how…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846935/psn-pdf
    March 29, 2023 - Maternal Safety and Perinatal Mental Health March 29, 2023 Allen C, Van CM, Mossburg S. Maternal Safety and Perinatal Mental Health . PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/maternal-safety-and-perinatal-mental-health Maternal patient safety is a critical aspect of healthcare given the complex pr…

  6. Microsoft PowerPoint - FINAL Nov_Spotlight Case_Premature Closing-Snycope_11.20.2020-revised.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-11/final_nov_spotlight_case_premature_closing-snycope_11.20.2020-revised.pdf
    January 01, 2020 - Microsoft PowerPoint - FINAL Nov_Spotlight Case_Premature Closing-Snycope_11.20.2020-revised.pptx Spotlight Premature Closure: Was it Just Syncope? Source and Credits • This presentation is based on the November 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit i…

  7. Duplicate Therapies in Retail Pharmacy | PSNet

    psnet.ahrq.gov/web-mm/duplicate-therapies-retail-pharmacy
    August 05, 2022 - Duplicate therapy errors have the potential to be serious and may result in adverse drug events (ADE

  8. Hidden Mystery | PSNet

    psnet.ahrq.gov/web-mm/hidden-mystery
    December 01, 2011 - SPOTLIGHT CASE Hidden Mystery Citation Text: Brunette DD. Hidden Mystery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …

  9. Development of an instrument to measure seniors' patient safety health beliefs: the Seniors Empowerment and Advocacy in Patient Safety (SEAPS) survey. | PSNet

    psnet.ahrq.gov/issue/development-instrument-measure-seniors-patient-safety-health-beliefs-seniors-empowerment-and
    February 15, 2011 - Study Development of an instrument to measure seniors' patient safety health beliefs: the Seniors Empowerment and Advocacy in Patient Safety (SEAPS) survey. Citation Text: Elder NC, Regan SL, Pallerla H, et al. Development of an instrument to measure seniors’ patient safety health beli…

  10. Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims. | PSNet

    psnet.ahrq.gov/issue/missed-and-delayed-diagnoses-ambulatory-setting-study-closed-malpractice-claims
    October 26, 2010 - Study Classic Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims. Citation Text: Gandhi TK, Kachalia A, Thomas EJ, et al. Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims. An…

  11. Towards safer healthcare: qualitative insights from a process view of organisational learning from failure. | PSNet

    psnet.ahrq.gov/issue/towards-safer-healthcare-qualitative-insights-process-view-organisational-learning-failure
    July 21, 2021 - Study Towards safer healthcare: qualitative insights from a process view of organisational learning from failure. Citation Text: Monazam Tabrizi N, Masri F. Towards safer healthcare: qualitative insights from a process view of organisational learning from failure. BMJ Open. 2021;11(8):e0…

  12. Addressing veteran health-related social needs: how Joint Commission standards accelerated integration and expansion of tools and services in the Veterans Health Administration. | PSNet

    psnet.ahrq.gov/issue/addressing-veteran-health-related-social-needs-how-joint-commission-standards-accelerated
    November 24, 2021 - Commentary Addressing veteran health-related social needs: how Joint Commission standards accelerated integration and expansion of tools and services in the Veterans Health Administration. Citation Text: List JM, Russell LE, Hausmann LRM, et al. Addressing veteran health-related social n…

  13. A national analysis of ED presentations for early pregnancy and complications: implications for post-Roe America. | PSNet

    psnet.ahrq.gov/issue/national-analysis-ed-presentations-early-pregnancy-and-complications-implications-post-roe
    September 07, 2016 - Study A national analysis of ED presentations for early pregnancy and complications: implications for post-Roe America. Citation Text: Goodwin G, Marra E, Ramdin C, et al. A national analysis of ED presentations for early pregnancy and complications: implications for post-Roe America. Am…

  14. Development of rapid response capabilities in a large COVID-19 alternate care site using Failure Modes and Effect Analysis with in situ simulation. | PSNet

    psnet.ahrq.gov/issue/development-rapid-response-capabilities-large-covid-19-alternate-care-site-using-failure
    September 16, 2020 - Commentary Development of rapid response capabilities in a large COVID-19 alternate care site using Failure Modes and Effect Analysis with in situ simulation. Citation Text: Levy N, Zucco L, Ehrlichman RJ, et al. Development of rapid response capabilities in a large COVID-19 alternate ca…

  15. Interactive questioning in critical care during handovers: a transcript analysis of communication behaviours by physicians, nurses and nurse practitioners. | PSNet

    psnet.ahrq.gov/issue/interactive-questioning-critical-care-during-handovers-transcript-analysis-communication
    August 11, 2021 - Study Interactive questioning in critical care during handovers: a transcript analysis of communication behaviours by physicians, nurses and nurse practitioners. Citation Text: Rayo MF, Mount-Campbell AF, O'Brien JM, et al. Interactive questioning in critical care during handovers: a tra…

  16. Changes in outcomes for internal medicine inpatients after work-hour regulations. | PSNet

    psnet.ahrq.gov/issue/changes-outcomes-internal-medicine-inpatients-after-work-hour-regulations
    September 30, 2012 - Study Classic Changes in outcomes for internal medicine inpatients after work-hour regulations. Citation Text: Horwitz LI, Kosiborod M, Lin Z, et al. Changes in outcomes for internal medicine inpatients after work-hour regulations. Ann Intern Med. 2007;147(2):…

  17. Patient Safety Recommendations for COVID-19 Epidemic Outbreak: 3.0 | PSNet

    psnet.ahrq.gov/issue/patient-safety-recommendations-covid-19-epidemic-outbreak-lessons-italian-experience
    February 15, 2023 - Book/Report Patient Safety Recommendations for COVID-19 Epidemic Outbreak: 3.0 Citation Text: Patient Safety Recommendations for COVID-19 Epidemic Outbreak: 3.0 La Regina M, Tanzini M, Venneri F, et al for the Italian Network for Health Safety. Dublin, Ireland: International Society for …

  18. Pain management best practices from multispecialty organizations during the COVID-19 pandemic and public health crises. | PSNet

    psnet.ahrq.gov/issue/pain-management-best-practices-multispecialty-organizations-during-covid-19-pandemic-and
    November 16, 2022 - Commentary Pain management best practices from multispecialty organizations during the COVID-19 pandemic and public health crises. Citation Text: Cohen SP, Baber ZB, Buvanendran A, et al. Pain Management Best Practices from Multispecialty Organizations During the COVID-19 Pandemic and Pu…

  19. Organizational culture, team climate and diabetes care in small office-based practices. | PSNet

    psnet.ahrq.gov/issue/organizational-culture-team-climate-and-diabetes-care-small-office-based-practices
    April 01, 2010 - Study Organizational culture, team climate and diabetes care in small office-based practices. Citation Text: Bosch M, Dijkstra R, Wensing M, et al. Organizational culture, team climate and diabetes care in small office-based practices. BMC Health Serv Res. 2008;8:180. doi:10.1186/1472-…

  20. Error reduction in pediatric chemotherapy: computerized order entry and failure modes and effects analysis. | PSNet

    psnet.ahrq.gov/issue/error-reduction-pediatric-chemotherapy-computerized-order-entry-and-failure-modes-and-effects
    August 02, 2010 - Study Error reduction in pediatric chemotherapy: computerized order entry and failure modes and effects analysis. Citation Text: Kim G, Chen AR, Arceci RJ, et al. Error reduction in pediatric chemotherapy: computerized order entry and failure modes and effects analysis. Arch Pediatr Ad…
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