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psnet.ahrq.gov/node/43765/psn-pdf
February 04, 2015 - Differences in medication knowledge and risk of errors
between graduating nursing students and working
registered nurses: comparative study.
February 4, 2015
Simonsen BO, Daehlin GK, Johansson I, et al. Differences in medication knowledge and risk of errors
between graduating nursing students and working registere…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.293_slideshow.ppt
March 01, 2013 - Spotlight Case July 2008
Spotlight Case
A Weighty Mistake
*
*
Source and Credits
This presentation is based on the March 2013
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Seth J. Bokser, MD, MPH, Associate Professor of Pediatrics & Medical…
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psnet.ahrq.gov/issue/decreasing-prescribing-errors-during-pediatric-emergencies-randomized-simulation-trial
October 08, 2013 - Study
Decreasing prescribing errors during pediatric emergencies: a randomized simulation trial.
Citation Text:
Larose G, Levy A, Bailey B, et al. Decreasing Prescribing Errors During Pediatric Emergencies: A Randomized Simulation Trial. Pediatrics. 2017;139(3). doi:10.1542/peds.2016-320…
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psnet.ahrq.gov/web-mm/looking-meds-all-wrong-places
June 16, 2021 - that requires a dose calculation, each clinician needs to independently follow a series of steps in calculating
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psnet.ahrq.gov/node/49517/psn-pdf
August 01, 2006 - Miscalculated Risk
August 1, 2006
Strassels SA. Miscalculated Risk. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/miscalculated-risk
The Case
A healthy 36-year-old man was admitted to a teaching hospital for acute low back strain after lifting his 2-
week-old infant. He received Vicodin (hydrocodone and a…
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psnet.ahrq.gov/web-mm/miscalculated-risk
March 01, 2015 - Miscalculated Risk
Citation Text:
Strassels SA. Miscalculated Risk. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…
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psnet.ahrq.gov/issue/safety-numbers-evidence-based-development-medicine-management-learning-tool
June 30, 2013 - Special or Theme Issue
Safety in Numbers: Evidence-based Development of a Medicine Management Learning Tool.
Citation Text:
Safety in Numbers: Evidence-based Development of a Medicine Management Learning Tool. Holland K, ed. Nurse Educ Pract. 2013;13(2):e1-e87.
Copy Citation …
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psnet.ahrq.gov/node/33761/psn-pdf
February 01, 2014 - or
nurse might go to a quiet space to review orders or complete other high-risk functions such as calculating
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.45_slideshow.ppt
January 01, 2004 - Spotlight Case [MONTH] 2003
Spotlight Case January 2004
Crushing Chest Pain:
A Missed Opportunity
Source and Credits
This presentation is based on the Jan. 2004
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Mark Grabe…
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psnet.ahrq.gov/web-mm/fatal-error-neonate-does-just-culture-provide-answer
June 24, 2020 - In the process of calculating the dose with the concentration of lipid emulsion available on the unit
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psnet.ahrq.gov/web-mm/dont-wait-collect-accurate-weight-case-subtherapeutic-insulin-therapy
July 01, 2008 - tasks during a time of high task load. 22 CDS automates the multistep process of insulin ordering by calculating
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psnet.ahrq.gov/node/49621/psn-pdf
March 01, 2011 - information technology will be far exceeded by the removal of
mathematical errors and oversights in calculating
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psnet.ahrq.gov/issue/decreasing-errors-pediatric-continuous-intravenous-infusions
January 06, 2017 - Study
Decreasing errors in pediatric continuous intravenous infusions.
Citation Text:
Lehmann CU, Kim G, Gujral R, et al. Decreasing errors in pediatric continuous intravenous infusions. Pediatr Crit Care Med. 2006;7(3):225-30.
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Format:
Google Scholar PubMed …
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psnet.ahrq.gov/issue/what-causes-prescribing-errors-children-scoping-review
September 09, 2015 - Review
What causes prescribing errors in children? Scoping review.
Citation Text:
Conn RL, Kearney O, Tully MP, et al. What causes prescribing errors in children? Scoping review. BMJ Open. 2019;9(8):e028680. doi:10.1136/bmjopen-2018-028680.
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Format:
DOI Google …
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psnet.ahrq.gov/issue/standardized-formulary-reduce-pediatric-medication-dosing-errors-mixed-methods-study
August 25, 2021 - Study
A standardized formulary to reduce pediatric medication dosing errors: a mixed methods study.
Citation Text:
Bosson N, Kaji AH, Gausche-Hill M. A standardized formulary to reduce pediatric medication dosing errors: a mixed methods study. Prehosp Emerg Care. 2022;26(4):492-502. doi:…
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psnet.ahrq.gov/issue/clinical-data-sharing-improves-quality-measurement-and-patient-safety
April 21, 2021 - Study
Clinical data sharing improves quality measurement and patient safety.
Citation Text:
D’Amore JD, McCrary LK, Denson J, et al. Clinical data sharing improves quality measurement and patient safety. J Am Med Inform Assoc. 2021;28(7):1534-1542. doi:10.1093/jamia/ocab039.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.332_slideshow.ppt
September 01, 2014 - PowerPoint Presentation
Spotlight
A Lot of Pain (Medications)
1
This presentation is based on the September 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Shoshana J. Herzig, MD, MPH, Division of General Medicine, Beth Israel Deaconess Medic…
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psnet.ahrq.gov/issue/impact-electronic-medical-records-data-sources-adverse-drug-event-quality-measure
July 31, 2013 - Study
The impact of electronic medical records data sources on an adverse drug event quality measure.
Citation Text:
Kahn MG, Ranade D. The impact of electronic medical records data sources on an adverse drug event quality measure. J Am Med Inform Assoc. 2010;17(2):185-91. doi:10.1136/…
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psnet.ahrq.gov/issue/paramedics-and-effects-shift-work-sleep-literature-review
July 24, 2017 - Review
Paramedics and the effects of shift work on sleep: a literature review.
Citation Text:
Sofianopoulos S, Williams B, Archer F. Paramedics and the effects of shift work on sleep: a literature review. Emerg Med J. 2012;29(2):152-5. doi:10.1136/emj.2010.094342.
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F…
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psnet.ahrq.gov/node/49781/psn-pdf
January 01, 2017 - Hazards of Loading Doses
January 1, 2017
Mucksavage JJ, Tesoro EP. Hazards of Loading Doses. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/hazards-loading-doses
The Case
A 40-year-old woman was recently discharged after a prolonged hospitalization for seizures and a cardiac
arrest. Two days after discharg…