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psnet.ahrq.gov/issue/mistakes-were-made-me
January 23, 2019 - Commentary
Mistakes were made (by me).
Citation Text:
Manesh R. Mistakes Were Made (by Me). JAMA Intern Med. 2017;177(10). doi:10.1001/jamainternmed.2017.3781.
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psnet.ahrq.gov/issue/why-are-so-many-women-being-misdiagnosed
September 14, 2011 - Newspaper/Magazine Article
Why are so many women being misdiagnosed?
Citation Text:
Why are so many women being misdiagnosed? Mickle K. Glamour. August 11, 2017.
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psnet.ahrq.gov/issue/reducing-prognostic-errors-new-imperative-quality-healthcare
June 21, 2016 - Commentary
Reducing prognostic errors: a new imperative in quality healthcare.
Citation Text:
Khullar D, Jena AB. Reducing prognostic errors: a new imperative in quality healthcare. BMJ. 2016;352:i1417. doi:10.1136/bmj.i1417.
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psnet.ahrq.gov/issue/teamwork-and-communication-surgical-teams-implications-patient-safety
March 25, 2020 - Study
Teamwork and communication in surgical teams: implications for patient safety.
Citation Text:
Teamwork and communication in surgical teams: implications for patient safety. Mills P; Neily J; Dunn E.
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psnet.ahrq.gov/issue/radiation-oncology-incident-learning-system
April 22, 2020 - Multi-use Website
Radiation Oncology Incident Learning System.
Citation Text:
Radiation Oncology Incident Learning System. American Society for Radiation Oncology and American Association of Physicists in Medicine.
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psnet.ahrq.gov/issue/pathways-patient-safety
May 06, 2015 - Toolkit
Pathways for Patient Safety.
Citation Text:
Pathways for Patient Safety. Chicago, IL: Health Research and Educational Trust, Institute for Safe Medication Practices, Medical Group Management Association; 2009.
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psnet.ahrq.gov/issue/usp-drug-safety-review-medication-errors-involving-nmbas
July 27, 2005 - Newspaper/Magazine Article
USP drug safety review: medication errors involving NMBAs.
Citation Text:
USP drug safety review: medication errors involving NMBAs. Santell JP. Drug Topics. May 22, 2006.
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psnet.ahrq.gov/issue/disrespectful-behavior-healthcare-has-it-improved-please-take-our-survey
May 19, 2021 - Newspaper/Magazine Article
Disrespectful behavior in healthcare: has it improved? Please take our survey!
Citation Text:
Disrespectful behavior in healthcare: has it improved? Please take our survey! ISMP Medication Safety Alert! Acute care edition. September 9, 2021;26(18);1-5.
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psnet.ahrq.gov/issue/fda-advise-err-avoid-using-error-prone-abbreviation-tpa
April 29, 2015 - Newspaper/Magazine Article
FDA Advise-ERR: avoid using the error-prone abbreviation, TPA.
Citation Text:
FDA Advise-ERR: avoid using the error-prone abbreviation, TPA. ISMP Medication Safety Alert! Acute Care Edition. September 24, 2015;20:1,4-5.
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psnet.ahrq.gov/issue/pharmacist-staffing-and-use-technology-small-rural-hospitals-implications-medication-safety
August 01, 2012 - Book/Report
Pharmacist Staffing and the Use of Technology in Small Rural Hospitals: Implications for Medication Safety.
Citation Text:
Pharmacist Staffing and the Use of Technology in Small Rural Hospitals: Implications for Medication Safety. Casey MM, Moscovice I, Davidson G. Minn…
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psnet.ahrq.gov/issue/enacting-washington-state-patient-safety-act-requiring-hospital-staffing-plans-nursing
May 04, 2015 - Legislation/Case Law
Enacting the Washington state patient safety act requiring hospital staffing plans for nursing services and establishing recordkeeping and reporting requirements.
Citation Text:
Enacting the Washington state patient safety act requiring hospital staffing plans for n…
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psnet.ahrq.gov/issue/symposium-simulation-science-health-and-medicine
April 03, 2017 - Special or Theme Issue
Symposium on Simulation Science in Health and Medicine.
Citation Text:
Symposium on Simulation Science in Health and Medicine. J Emerg Trauma Shock. 2010;3:348-394.
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psnet.ahrq.gov/issue/oxford-professional-practice-handbook-patient-safety
June 16, 2012 - Book/Report
Oxford Professional Practice: Handbook of Patient Safety.
Citation Text:
Oxford Professional Practice: Handbook of Patient Safety. Lachman P, Runnacles J, Jayadev A et al, eds. London, England; Oxford University Press; 2022. ISBN: 9780192846877.
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psnet.ahrq.gov/issue/safer-care-acutely-ill-patient-learning-serious-incidents
August 07, 2018 - Book/Report
Safer Care for the Acutely Ill Patient: Learning from Serious Incidents.
Citation Text:
Safer Care for the Acutely Ill Patient: Learning from Serious Incidents. Thomson R, Luettel D, Healey F, Scobie S. London, England: National Patient Safety Agency; 2007. ISBN 978095563…
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psnet.ahrq.gov/issue/ethics-using-qi-methods-improve-health-care-quality-and-safety
August 11, 2008 - Book/Report
The Ethics of Using QI Methods to Improve Health Care Quality and Safety.
Citation Text:
The Ethics of Using QI Methods to Improve Health Care Quality and Safety. Baily MA, Bottrell M, Lynn J, Jennings J. Hastings Center Report; 2006(July-August): S2-S40.
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psnet.ahrq.gov/issue/conversation-among-stakeholders-medical-malpractice
January 11, 2023 - Meeting/Conference Proceedings
A Conversation Among Stakeholders on Medical Malpractice.
Citation Text:
A Conversation Among Stakeholders on Medical Malpractice. Collaborative for Accountability and Improvement. April 26, 2022.
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psnet.ahrq.gov/issue/10-ways-guarantee-lawsuit
February 10, 2021 - Newspaper/Magazine Article
10 ways to guarantee a lawsuit.
Citation Text:
Rice B. 10 ways to guarantee a lawsuit. Medical economics. 2005;82(13):66-9.
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psnet.ahrq.gov/issue/enhancing-prescription-medicine-adherence-national-plan
April 28, 2021 - Book/Report
Enhancing Prescription Medicine Adherence: A National Plan.
Citation Text:
Enhancing Prescription Medicine Adherence: A National Plan. Rockville, MD: National Council on Patient Information and Education; 2007.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.188_slideshow.ppt
November 01, 2008 - Spotlight Case [MONTH] 2003
Spotlight Case November 2008
Dangerous Shift
Source and Credits
This presentation is based on the November 2008
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Emily S. Patterson, PhD
Institute for Ergonomics, Ohi…
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psnet.ahrq.gov/node/49425/psn-pdf
November 01, 2003 - Misread Label
November 1, 2003
Franklin BD. Misread Label. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/misread-label
The Case
An infant was born with sluggish respirations. During labor the infant’s mother had received meperidine
[Demerol, a pain medication], a narcotic with a half-life of 2.5-4.0 hours…