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psnet.ahrq.gov/node/37196/psn-pdf
June 06, 2018 - Fatal 1,000-fold overdoses can occur, particularly in
neonates, by transposing mcg and mg.
June 6, 2018
ISMP Medication Safety Alert! Acute Care Edition. September 6, 2007;12:1-4.
https://psnet.ahrq.gov/issue/fatal-1000-fold-overdoses-can-occur-particularly-neonates-transposing-mcg-
and-mg
This article analyzes a…
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psnet.ahrq.gov/node/35961/psn-pdf
May 24, 2006 - BBC News 'wrong guy' is revealed.
May 24, 2006
BBC News.
https://psnet.ahrq.gov/issue/bbc-news-wrong-guy-revealed
As evidence that identification errors occur in industries other than health care, this article describes how a
graduate student interviewing for a job at the BBC studios was mistakenly put on televisi…
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psnet.ahrq.gov/node/47802/psn-pdf
March 04, 2019 - The path to diagnostic excellence includes feedback to
calibrate how clinicians think.
March 4, 2019
Meyer AND, Singh H. The Path to Diagnostic Excellence Includes Feedback to Calibrate How Clinicians
Think. JAMA. 2019;321(8):737-738. doi:10.1001/jama.2019.0113.
https://psnet.ahrq.gov/issue/path-diagnostic-excelle…
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psnet.ahrq.gov/node/43827/psn-pdf
January 14, 2015 - The surprising way to stay safe in the hospital.
January 14, 2015
https://psnet.ahrq.gov/issue/surprising-way-stay-safe-hospital
This news article summarizes the results of a survey exploring how patients' perceptions of respect from
hospital staff corresponds with the potential for medical error. Recommended strat…
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psnet.ahrq.gov/node/33817/psn-pdf
October 01, 2016 - Health Care Data Science for Quality Improvement and
Patient Safety
October 1, 2016
Rajkomar A. Health Care Data Science for Quality Improvement and Patient Safety. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/health-care-data-science-quality-improvement-and-patient-safety
Perspective
Background
Ha…
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psnet.ahrq.gov/web-mm/one-toxic-drug-not-another
October 02, 2019 - In this case, we would hope the physician would seek answers to a series of questions before providing … There are no easy answers here.
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psnet.ahrq.gov/node/45186/psn-pdf
June 15, 2017 - Patient and family empowerment as agents of ambulatory
care safety and quality.
June 15, 2017
Roter DL, Wolff JL, Wu AW, et al. Patient and family empowerment as agents of ambulatory care safety
and quality. BMJ Qual Saf. 2017;26(6):508-512. doi:10.1136/bmjqs-2016-005489.
https://psnet.ahrq.gov/issue/patient-and-f…
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psnet.ahrq.gov/node/43579/psn-pdf
October 08, 2014 - Implications of Health Literacy for Public Health:
Workshop Summary.
October 8, 2014
Hewitt M, Hernandez LM; Roundtable on Health Literacy, Board on Population Health and Public Health
Practice, Institute of Medicine. Washington, DC: National Academies Press; 2014. ISBN: 9780309303651.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/46551/psn-pdf
October 25, 2017 - Inpatient notes: diagnostic excellence starts with an
incessant watch.
October 25, 2017
Dhaliwal G. Annals for Hospitalists Inpatient Notes - Diagnostic Excellence Starts With an Incessant Watch.
Ann Intern Med. 2017;167(8):HO2-HO3. doi:10.7326/m17-2447.
https://psnet.ahrq.gov/issue/inpatient-notes-diagnostic-exce…
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psnet.ahrq.gov/node/34786/psn-pdf
March 28, 2005 - Errors in drug computations during newborn intensive
care.
March 28, 2005
Perlstein PH, Callison C, White M, et al. Errors in Drug Computations During Newborn Intensive Care. Arch
Pediatr Adolesc Med. 1979;133(4):376-379. doi:10.1001/archpedi.1979.02130040030006.
https://psnet.ahrq.gov/issue/errors-drug-computatio…
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psnet.ahrq.gov/issue/southern-california-patient-safety-collaborative
April 29, 2009 - Multi-use Website
Southern California Patient Safety Collaborative.
Citation Text:
Convergence Health Consulting; Hospital Association of Southern California; National Health Foundation.
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psnet.ahrq.gov/node/43548/psn-pdf
October 01, 2014 - Patients' online access to their electronic health records
and linked online services: a systematic interpretative
review.
October 1, 2014
de Lusignan S, Mold F, Sheikh A, et al. Patients' online access to their electronic health records and linked
online services: a systematic interpretative review. BMJ Open. 201…
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psnet.ahrq.gov/node/46100/psn-pdf
July 11, 2017 - The tension between promoting mobility and preventing
falls in the hospital.
July 11, 2017
Growdon ME, Shorr RI, Inouye SK. The Tension Between Promoting Mobility and Preventing Falls in the
Hospital. JAMA Intern Med. 2017;177(6):759-760. doi:10.1001/jamainternmed.2017.0840.
https://psnet.ahrq.gov/issue/tension-be…
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psnet.ahrq.gov/issue/treatment-overkill
October 19, 2020 - Audiovisual
Treatment Overkill.
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October 17, 2018
Medical care overuse is emerging as a patient safety hazard that can result in harms such as unnee…
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psnet.ahrq.gov/node/43845/psn-pdf
September 26, 2016 - Disrupting diagnostic reasoning: do interruptions,
instructions, and experience affect the diagnostic
accuracy and response time of residents and emergency
physicians?
September 26, 2016
Monteiro SD, Sherbino JD, Ilgen JS, et al. Disrupting diagnostic reasoning: do interruptions, instructions,
and experience affe…
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psnet.ahrq.gov/node/43954/psn-pdf
May 13, 2015 - Training safer surgeons: how do patients view the role of
simulation in orthopaedic training?
May 13, 2015
Akhtar K, Sugand K, Wijendra A, et al. Training safer surgeons: How do patients view the role of simulation
in orthopaedic training? Patient Saf Surg. 2015;9:11. doi:10.1186/s13037-015-0058-5.
https://psnet.a…
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psnet.ahrq.gov/node/45129/psn-pdf
August 03, 2016 - Sleep and circadian misalignment for the hospitalist: a
review.
August 3, 2016
Schaefer EW, Williams M, Zee PC. Sleep and circadian misalignment for the hospitalist: a review. J Hosp
Med. 2012;7(6):489-96. doi:10.1002/jhm.1903.
https://psnet.ahrq.gov/issue/sleep-and-circadian-misalignment-hospitalist-review
Given…
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psnet.ahrq.gov/node/44361/psn-pdf
November 20, 2015 - Communication in healthcare: a narrative review of the
literature and practical recommendations.
November 20, 2015
Vermeir P, Vandijck D, Degroote S, et al. Communication in healthcare: a narrative review of the literature
and practical recommendations. Int J Clin Pract. 2015;69(11):1257-67. doi:10.1111/ijcp.12686.…
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psnet.ahrq.gov/issue/minor-mistakes-deadly-results
April 02, 2008 - December 3, 2014
Hamilton father misdiagnosed with lung cancer demands answers.
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psnet.ahrq.gov/node/33641/psn-pdf
November 01, 2006 - Would your answers be different if the air embolus occurred when the patient was supine?