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psnet.ahrq.gov/node/33788/psn-pdf
June 01, 2015 - wrong-site-wrong-procedure-and-wrong-patient-surgery
https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
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psnet.ahrq.gov/perspective/wild-west-patient-safety-office-based-anesthesia
April 01, 2003 - The Wild West: Patient Safety in Office-Based Anesthesia
Rainu Kaushal, MD MPH; Sekhar Upadhyayula, MD; David M. Gaba, MD; Lucian L. Leape, MD | May 1, 2006
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Citation Text:
Kaushal R, Upadhyayula S, Gaba DM, et al. The Wild…
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psnet.ahrq.gov/perspective/methicillin-resistant-staphylococcus-aureus
June 24, 2010 - Methicillin-Resistant Staphylococcus aureus
Gary A. Noskin, MD | April 1, 2008
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Citation Text:
Noskin GA. Methicillin-Resistant Staphylococcus aureus. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qua…
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psnet.ahrq.gov/perspective/conversation-ann-l-hendrich-rn-phd
February 26, 2025 - In Conversation With… Ann L. Hendrich, RN, PhD
December 1, 2011
Citation Text:
In Conversation With… Ann L. Hendrich, RN, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/perspective/conversation-withpatrick-tighe-about-artificial-intelligence
March 27, 2024 - Such domains include adverse drug events, clinical decompensation, and diagnostic errors. … or caution against potential treatment-related complications, thus reducing diagnostic errors and adverse … drug events .
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psnet.ahrq.gov/perspective/artificial-intelligence-and-patient-safety-promise-and-challenges
March 27, 2024 - Such domains include adverse drug events, clinical decompensation, and diagnostic errors. … or caution against potential treatment-related complications, thus reducing diagnostic errors and adverse … drug events .
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psnet.ahrq.gov/node/842919/psn-pdf
February 01, 2023 - Hospital-Acquired Diabetic Ketoacidosis.
February 1, 2023
Zuidema D, Bagley B, Tan CL. Hospital-Acquired Diabetic Ketoacidosis. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis
The Cases
Case #1: A 46-year-old Hindi-speaking resident of a skilled nursing facility (SNF) …
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psnet.ahrq.gov/web-mm/one-dose-fifty-pills
January 13, 2021 - Pharmacist participation on physician rounds and adverse drug events in the intensive care unit.
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psnet.ahrq.gov/node/33746/psn-pdf
March 01, 2013 - In Conversation With… David M. Gaba, MD
March 1, 2013
In Conversation With… David M. Gaba, MD. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-david-m-gaba-md
Editor's note: David M. Gaba, MD, is a Professor of Anesthesia at the Stanford University School of
Medicine. An international leade…
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psnet.ahrq.gov/perspective/conversation-withcarolyn-clancy-md
September 01, 2005 - Effect of bar code technology on the incidence of medication dispensing errors and potential adverse … drug events in a hospital pharmacy. … High rates of adverse drug events in a highly computerized hospital.
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psnet.ahrq.gov/node/49522/psn-pdf
November 01, 2006 - Computerized surveillance of adverse drug events in
hospital patients. JAMA. 1991;266:2847-2851.
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psnet.ahrq.gov/web-mm/falling-through-crack-bedrails
February 19, 2020 - SPOTLIGHT CASE
Falling Through the Crack (in the Bedrails)
Citation Text:
Dykes PC, Vacca V, Leung WY. Falling Through the Crack (in the Bedrails). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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F…
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psnet.ahrq.gov/node/49465/psn-pdf
December 22, 2021 - Electronic Err
October 1, 2004
Tang PC. Electronic Err. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/electronic-err
The Case
A 75-year-old woman with coronary artery disease presented to the emergency department (ED) with chest
pain that that had not responded to three sublingual nitroglycerin tablets at…
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psnet.ahrq.gov/perspective/playing-well-others-translocational-research-patient-safety
September 01, 2005 - Effect of bar code technology on the incidence of medication dispensing errors and potential adverse … drug events in a hospital pharmacy. … High rates of adverse drug events in a highly computerized hospital.
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psnet.ahrq.gov/issue/healthcare-411-mistake-proofing-health-care-environment
October 12, 2011 - June 27, 2018
Reducing and Preventing Adverse Drug Events to Decrease Hospital Costs.
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psnet.ahrq.gov/web-mm/misidentifying-unidentified-john-doe-and-ehr
September 27, 2017 - Misidentifying the Unidentified – John Doe and the EHR
Citation Text:
Janowak CF, Janowak LM. Misidentifying the Unidentified – John Doe and the EHR. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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…
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psnet.ahrq.gov/node/851971/psn-pdf
July 31, 2023 - Failure to Adhere to Dietary Restrictions Leading to
Complications and Poor Follow-up
July 31, 2023
Bohringer C, Bourgeois J, Xiong G, et al. Failure to adhere to dietary restrictions leading to complications
and poor follow-up. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/failure-adhere-dietary-restricti…
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psnet.ahrq.gov/node/33654/psn-pdf
August 01, 2007 - boards right now are actually asking for their own data on things
like hospital-acquired infections and adverse … drug events, close to real time.
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psnet.ahrq.gov/web-mm/complicated-course-severe-alcohol-withdrawal-dexmedetomidine-infusion
June 14, 2023 - Medication Administration Errors Medication errors are common in the hospital setting and can cause adverse … drug events. 25 Up to 33% of reported medication errors concern medication administration and 22%
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psnet.ahrq.gov/web-mm/snfs-opening-black-box
August 27, 2012 - Potentially inappropriate medications defined by STOPP criteria and the risk of adverse drug events in