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psnet.ahrq.gov/node/33894/psn-pdf
April 11, 2011 - Prevention of medication errors in the pediatric inpatient
setting.
April 11, 2011
Stucky ER; American Academy of Pediatrics Committee on Drugs; American Academy of Pediatrics
Committee on Hospital Care. Pediatrics. 2003;112(2):431-436.
https://psnet.ahrq.gov/issue/prevention-medication-errors-pediatric-inpat…
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psnet.ahrq.gov/issue/medication-reconciliation-hospitalists
February 18, 2011 - Toolkit
Medication Reconciliation for Hospitalists.
Citation Text:
Medication Reconciliation for Hospitalists. Society of Hospital Medicine.
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psnet.ahrq.gov/issue/patient-safety-through-teamwork-and-communication-toolkit
October 25, 2013 - Toolkit
Patient Safety Through Teamwork and Communication Toolkit.
Citation Text:
Patient Safety Through Teamwork and Communication Toolkit. Denver Health.
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psnet.ahrq.gov/issue/new-york-city-puts-hospital-error-data-online
January 23, 2019 - Newspaper/Magazine Article
New York City puts hospital error data online.
Citation Text:
New York City puts hospital error data online. Kershaw S.
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psnet.ahrq.gov/issue/standardize-4-safety
June 17, 2014 - Multi-use Website
Standardize 4 Safety.
Citation Text:
Standardize 4 Safety. American Society of Health-System Pharmacists.
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psnet.ahrq.gov/issue/health-literacy-and-patient-safety-help-patients-understand-manual-clinicians-2nd-ed
November 26, 2008 - Book/Report
Health Literacy and Patient Safety: Help Patients Understand. Manual for Clinicians. 2nd ed.
Citation Text:
Health Literacy and Patient Safety: Help Patients Understand. Manual for Clinicians. 2nd ed. Weiss BD. Chicago, IL: American Medical Association Foundation; 2007.
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psnet.ahrq.gov/node/38439/psn-pdf
December 23, 2012 - Legality of technicians' involvement in medication
reconciliation not clear.
December 23, 2012
Thompson CA. Legality of technicians' involvement in medication reconciliation not clear. American journal
of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists.
2009;66…
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psnet.ahrq.gov/node/49671/psn-pdf
November 01, 2012 - Electrocardiogram Results: ***READ ME***
November 1, 2012
Alpert JS. Electrocardiogram Results: ***READ ME***. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/electrocardiogram-results-read-me
The Case
A 63-year-old woman with labile hypertension presented to the emergency department (ED) with new onset
che…
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psnet.ahrq.gov/node/49824/psn-pdf
March 01, 2018 - Missing ECG and Missed Diagnosis Lead to Dangerous
Delay
March 1, 2018
O'Connor RE. Missing ECG and Missed Diagnosis Lead to Dangerous Delay. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/missing-ecg-and-missed-diagnosis-lead-dangerous-delay
The Case
A 35-year-old woman with no prior cardiac history calle…
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psnet.ahrq.gov/node/35203/psn-pdf
December 14, 2010 - Practice Advisory on Intraoperative Awareness and Brain
Function Monitoring.
December 14, 2010
Awareness AS of ATF on I. Practice advisory for intraoperative awareness and brain function monitoring: a
report by the american society of anesthesiologists task force on intraoperative awareness.
Anesthesiology. 2006;1…
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psnet.ahrq.gov/node/38194/psn-pdf
January 02, 2017 - Munson Medical Center: embedding a culture of safety
and QI into the organization.
January 2, 2017
Haslinger T. Munson Medical Center: embedding a culture of safety and QI into the organization. Jt Comm
J Qual Patient Saf. 2008;34(11):665-70.
https://psnet.ahrq.gov/issue/munson-medical-center-embedding-culture-saf…
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psnet.ahrq.gov/node/49504/psn-pdf
March 01, 2006 - Liposuction Gone Awry
March 1, 2006
Yates JA. Liposuction Gone Awry. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/liposuction-gone-awry
The Case
A 54-year-old man with HIV was referred to a plastic surgeon for cosmetic surgery. In the plastic surgeon’s
office, he underwent neck and facial liposuction wit…
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psnet.ahrq.gov/node/35211/psn-pdf
June 13, 2011 - JCAHO views medication reconciliation as adverse-event
prevention.
June 13, 2011
Thompson CA. JCAHO views medication reconciliation as adverse-event prevention. American journal of
health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists.
2005;62(15):1528, 1530, 1532.
…
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psnet.ahrq.gov/node/39342/psn-pdf
March 03, 2010 - Discharge missteps can send seniors back to hospital.
March 3, 2010
Korc B, Landers SJ. American Medical News. February 15, 2010.
https://psnet.ahrq.gov/issue/discharge-missteps-can-send-seniors-back-hospital
This news article uses an example of a preventable readmission to illustrate how ineffective communication
…
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psnet.ahrq.gov/node/34733/psn-pdf
November 19, 2015 - Out of the Crisis.
November 19, 2015
Deming WE. Cambridge, MA: Massachusetts Institute of Technology, Center for Advanced Engineering
Study, 1986. ISBN: 9780911379013.
https://psnet.ahrq.gov/issue/out-crisis
Deming believes that American companies need to transform their method of management to engage and
compete…
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psnet.ahrq.gov/node/47649/psn-pdf
January 09, 2019 - ASH Clinical Practice Guidelines on Venous
Thromboembolism.
January 9, 2019
Washington DC; American Society of Hematology.
https://psnet.ahrq.gov/issue/ash-clinical-practice-guidelines-venous-thromboembolism
The American Society of Hematology produced a series of guidelines on prophylaxis for venous
thromboemboli…
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psnet.ahrq.gov/issue/never-events-utah-hospitals-saw-nearly-60-serious-errors-2007
July 08, 2009 - Newspaper/Magazine Article
Never events: Utah hospitals saw nearly 60 serious errors in 2007.
Citation Text:
Never events: Utah hospitals saw nearly 60 serious errors in 2007. May H. Salt Lake Tribune. August 18, 2008.
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psnet.ahrq.gov/issue/small-patients-big-consequences-medical-errors
February 09, 2011 - Newspaper/Magazine Article
Small patients, big consequences in medical errors.
Citation Text:
Small patients, big consequences in medical errors. Tarkan L. New York Times. September 14, 2008;Health section:7.
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psnet.ahrq.gov/issue/there-and-home-again-safely
September 29, 2017 - Book/Report
There and Home Again, Safely.
Citation Text:
There and Home Again, Safely. Sokol PE, Wynia MK; AMA Expert Panel on Care Transitions. Chicago, IL: American Medical Association; February 2013.
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psnet.ahrq.gov/issue/guide-patient-safety-medical-practice
March 11, 2015 - Book/Report
A Guide to Patient Safety in the Medical Practice.
Citation Text:
A Guide to Patient Safety in the Medical Practice. Vance JE. Chicago, IL: American Medical Association: 2008.
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