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psnet.ahrq.gov/node/49821/psn-pdf
February 01, 2018 - Right Place, Right Drug, Wrong Strength
February 1, 2018
Jelincic V, Greenall J. Right Place, Right Drug, Wrong Strength. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/right-place-right-drug-wrong-strength
The Case
A 2-year-old girl was admitted to a hospital burn unit for a 10% total body surface area bur…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.236_slideshow.ppt
March 01, 2011 - Spotlight Case July 2008
Spotlight Case March 2011
Volume Too Low: In and Out
Pediatric Patient Safety
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*
Source and Credits
This presentation is based on the March 2011
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Marlene Miller, MD, MSc…
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psnet.ahrq.gov/web-mm/hemolysis-holdup
July 03, 2016 - Hemolysis Holdup
Citation Text:
Lehman CM. Hemolysis Holdup. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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…
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psnet.ahrq.gov/web-mm/right-place-right-drug-wrong-strength
March 26, 2015 - Right Place, Right Drug, Wrong Strength
Citation Text:
Jelincic V, Greenall J. Right Place, Right Drug, Wrong Strength. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
Copy Citation
Format:
Google Scholar BibTeX En…
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psnet.ahrq.gov/node/49481/psn-pdf
May 01, 2005 - Discharge Against Medical Advice
May 1, 2005
Hwang SW. Discharge Against Medical Advice. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/discharge-against-medical-advice
The Case
A 50-year-old man with a history of alcohol abuse and alcohol-induced dementia was admitted to the
medical service with mild alco…
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psnet.ahrq.gov/web-mm/challenging-case-multiple-suicide-attempts-complex-patient-psychiatric-comorbidities
September 27, 2023 - SPOTLIGHT CASE
Challenging Case of Multiple Suicide Attempts in a Complex Patient with Psychiatric Comorbidities.
Citation Text:
Bourgeois JA, Xiong G. Challenging Case of Multiple Suicide Attempts in a Complex Patient with Psychiatric Comorbidities.. PSNet [internet]. Rockville (MD): Agency for …
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psnet.ahrq.gov/print/pdf/node/838351
July 01, 2024 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Diagnostic Safety Improvement
Curated Library
Foundations
Improving Diagnosis in Health Care.
Committee on Diagnostic Error in Health Care, National Academies of Science, Engineering, and
Medicine. Washington, DC: National Academies Press; …
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psnet.ahrq.gov/web-mm/anchoring-bias-critical-implications
June 15, 2022 - SPOTLIGHT CASE
Anchoring Bias With Critical Implications
Citation Text:
Etchells E. Anchoring Bias With Critical Implications. 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/issue/comments-common-formats-event-reporting-hospital-version-03-beta
September 06, 2011 - Measurement Tool/Indicator
Common Formats for Event Reporting.
Citation Text:
Common Formats for Event Reporting. National Quality Forum.
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Linkedin
…
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psnet.ahrq.gov/issue/fluorouracil-incident-root-cause-analysis-report
September 02, 2014 - Book/Report
Fluorouracil Incident Root Cause Analysis Report.
Citation Text:
Fluorouracil Incident Root Cause Analysis Report. Toronto, CA: Institute for Safe Medication Practices Canada; May 2007.
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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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Pri…
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psnet.ahrq.gov/issue/mha-person-and-family-centered-care
May 13, 2024 - Toolkit
MHA Person- and Family-Centered Care.
Citation Text:
MHA Person- and Family-Centered Care. MHA Keystone Center. Michigan Health and Hospital Association.
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psnet.ahrq.gov/issue/healthcare-cost-and-utilization-project-hcup
December 24, 2008 - Database/Directory
Healthcare Cost and Utilization Project (HCUP).
Citation Text:
Healthcare Cost and Utilization Project (HCUP). Agency for Healthcare Research and Quality.
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Fac…
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psnet.ahrq.gov/issue/national-diabetes-inpatient-audit-2017
January 27, 2016 - Book/Report
National Diabetes Inpatient Audit -- Harms.
Citation Text:
National Diabetes Inpatient Audit -- Harms. Leeds, UK: Health and Social Care Information Centre.
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psnet.ahrq.gov/issue/vincristine-and-other-vinca-alkaloids-should-only-be-given-intravenously-minibag
July 18, 2018 - Press Release/Announcement
Vincristine (and other vinca alkaloids) should only be given intravenously via a minibag.
Citation Text:
Vincristine (and other vinca alkaloids) should only be given intravenously via a minibag. World Health Organization. Alert 115. July 18, 2007.
C…
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psnet.ahrq.gov/issue/patient-safety-2015-final-technical-report
September 29, 2017 - Book/Report
Patient Safety 2015: Final Technical Report.
Citation Text:
Patient Safety 2015: Final Technical Report. Washington, DC: National Quality Forum; 2016.
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psnet.ahrq.gov/issue/national-coordinating-council-medication-error-reporting-and-prevention
April 15, 2015 - Multi-use Website
National Coordinating Council for Medication Error Reporting and Prevention.
Citation Text:
National Coordinating Council for Medication Error Reporting and Prevention. National Coordinating Council for Medication Error Reporting and Prevention.
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psnet.ahrq.gov/issue/initiative-reduce-unnecessary-radiation-exposure-medical-imaging
January 17, 2017 - Government Resource
Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging.
Citation Text:
Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging. Center for Devices and Radiological Health; CDRH; US Food and Drug Administration; FDA.
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psnet.ahrq.gov/node/33827/psn-pdf
February 01, 2017 - While the quality of teamwork is not directly assessed in new payment models (although it
is undoubtedly … related to many of the outcomes that are assessed), that may well change.
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psnet.ahrq.gov/issue/why-patient-summaries-electronic-health-records-do-not-provide-cognitive-support-necessary
January 18, 2013 - January 18, 2013
The effect of hospital electronic health record adoption on nurse-assessed