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psnet.ahrq.gov/web-mm/departure-central-line-ritual
October 13, 2018 - Departure From Central Line Ritual
Citation Text:
Ballard DW, Vinson DR, Mark DG. Departure From Central Line Ritual. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/fatal-oversight-misdiagnosis-nocturnal-chest-pain-elevated-d-dimer
May 01, 2005 - systematic review of the performance characteristics of clinical event monitor signals used to detect adverse … drug events in the hospital setting.
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psnet.ahrq.gov/sites/default/files/2021-05/final_psnet_spotlight_inadvertent_bolus_of_norepinephrine_pp.pdf
January 01, 2021 - infusions further increase the likelihood of
an IV medication error taking place and a subsequent adverse … drug event
– The Institute for Safe Medication Practices (ISMP) reports that that 56% of
medication … Analysis of risk factors for adverse drug events in critically ill patients.
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psnet.ahrq.gov/web-mm/over-counter-oversight
March 21, 2009 - complications, patients undergoing surgery represent a population that may be particularly vulnerable to adverse … drug events from medication errors.
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psnet.ahrq.gov/perspective/conversation-withgerald-b-hickson-md
December 01, 2009 - In Conversation with…Gerald B. Hickson, MD
December 1, 2009
Also Read an Essay
Citation Text:
In Conversation with…Gerald B. Hickson, MD . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2…
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psnet.ahrq.gov/node/49786/psn-pdf
March 01, 2017 - common overuse of
antibiotics and the known complications including Clostridium difficile infection and adverse … drug reactions.
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psnet.ahrq.gov/web-mm/cvc-removal-procedure-any-other
October 01, 2018 - September 23, 2020
Hospitalization due to adverse drug events in older adults with cancer
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psnet.ahrq.gov/web-mm/carpe-diem-seize-day
September 01, 2012 - Carpe Diem (Seize the Day)
Citation Text:
Krumholz A. Carpe Diem (Seize the Day). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/medication-mix-bad-worse
March 01, 2018 - Medication Mix-Up: From Bad to Worse
Citation Text:
Wollitz A, O'Connor MF. Medication Mix-Up: From Bad to Worse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/perspective/how-identify-and-manage-problem-behaviors
December 01, 2009 - How to Identify and Manage Problem Behaviors
Alan H. Rosenstein, MD, MBA; Michelle O'Daniel, MSG, MHA | December 1, 2009
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Rosenstein AH, O'Daniel M. How to Identify and Manage Prob…
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psnet.ahrq.gov/web-mm/ventricular-wall-injury-during-diagnostic-cardiac-catheterization
September 01, 2012 - Ventricular Wall Injury during a Diagnostic Cardiac Catheterization
Citation Text:
Pham TH, Atreja S. Ventricular Wall Injury during a Diagnostic Cardiac Catheterization. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/node/49614/psn-pdf
November 01, 2010 - Effect of an electronic medication reconciliation application
and process redesign on potential adverse … drug events: a cluster-randomized trial.
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psnet.ahrq.gov/web-mm/lost-transitions-care-managing-opioid-dependent-patient-frequent-hospitalizations
October 27, 2022 - SPOTLIGHT CASE
Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations
Citation Text:
Tan F, Johl K, Kotova M. Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations. PSNet [internet]. Rockville (MD): Agency for He…
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psnet.ahrq.gov/web-mm/medication-handling-and-compounding-errors-operating-room
May 16, 2022 - Evaluation of perioperative medication errors and adverse drug events.
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psnet.ahrq.gov/node/865466/psn-pdf
March 27, 2024 - Equity in Patient Safety
March 27, 2024
Thomas A, Lee M, Mossburg S. Equity in Patient Safety. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/equity-patient-safety
Introduction
Safety and equity are among the central components that determine quality of care, according to nonprofit
advisory agencies l…
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psnet.ahrq.gov/perspective/conversation-regina-hoffman-about-building-capacity-patient-safety
July 31, 2023 - We were working not on falls or adverse drug reactions, but on the overarching issues that could make
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psnet.ahrq.gov/perspective/building-capacity-patient-safety
July 31, 2023 - We were working not on falls or adverse drug reactions, but on the overarching issues that could make
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psnet.ahrq.gov/node/852699/psn-pdf
August 30, 2023 - measures associated with healthcare-acquired conditions, such as central-line bloodstream infections and
adverse … drug events.
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psnet.ahrq.gov/node/49676/psn-pdf
February 01, 2013 - Death by PCA
February 1, 2013
Hicks RW. Death by PCA. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/death-pca
The Case
A healthy 21-year-old pregnant woman delivered a healthy baby via Caesarean section after an
uncomplicated pregnancy. Two hours after delivery, the post-anesthesia care unit (PACU) nurse …
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psnet.ahrq.gov/node/33813/psn-pdf
August 01, 2016 - Safety In Dentistry
August 1, 2016
Ramoni R, Walji MF, Kalenderian E. Safety In Dentistry. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/safety-dentistry
Perspective
In a famous scene from the 1976 film, Marathon Man, Laurence Olivier, playing dentist Dr. Christian Szell
tortures Babe Levy (played by…