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psnet.ahrq.gov/node/36846/psn-pdf
March 03, 2011 - Information technology cannot guarantee patient safety.
March 3, 2011
de Wildt SN, Verzijden R, van den Anker JN, et al. Information technology cannot guarantee patient safety.
BMJ. 2007;334(7598):851-2.
https://psnet.ahrq.gov/issue/information-technology-cannot-guarantee-patient-safety
The authors provide a case …
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psnet.ahrq.gov/node/49726/psn-pdf
March 01, 2015 - However, most studies do
not allow for the calculation of an event rate.(2) Although the exact incidence
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psnet.ahrq.gov/node/49749/psn-pdf
December 01, 2015 - control has positive impacts throughout the system, improving glycemic outcomes (6) while
decreasing calculation
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psnet.ahrq.gov/node/47894/psn-pdf
April 03, 2019 - What does safety commitment mean to leaders? A multi-
method investigation.
April 3, 2019
Fruhen LS, Griffin MA, Andrei DM. What does safety commitment mean to leaders? A multi-method
investigation. J Safety Res. 2019;68:203-214. doi:10.1016/j.jsr.2018.12.011.
https://psnet.ahrq.gov/issue/what-does-safety-commitme…
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psnet.ahrq.gov/node/35954/psn-pdf
August 02, 2010 - Decreasing errors in pediatric continuous intravenous
infusions.
August 2, 2010
Lehmann CU, Kim G, Gujral R, et al. Decreasing errors in pediatric continuous intravenous infusions.
Pediatr Crit Care Med. 2006;7(3):225-30.
https://psnet.ahrq.gov/issue/decreasing-errors-pediatric-continuous-intravenous-infusions
Th…
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psnet.ahrq.gov/node/864847/psn-pdf
March 20, 2024 - Inter-hospital transfer is an independent risk factor for
hospital-associated infection.
March 20, 2024
Gardner C, Rubinfeld IS, Gupta AH, et al. Inter-hospital transfer is an independent risk factor for hospital-
associated infection. Surg Infect (Larchmt). 2024;25(2):125-132. doi:10.1089/sur.2023.077.
https://ps…
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psnet.ahrq.gov/node/49394/psn-pdf
April 01, 2003 - Premature or Overdue?
April 1, 2003
Thomas J, Hannah M. Premature or Overdue? PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/premature-or-overdue
The Case
A 32-year-old woman, gravida 3, para 1, presented for prenatal care at 24 weeks. Her past medical history
was unremarkable, and results of her prenatal …
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psnet.ahrq.gov/node/44188/psn-pdf
June 03, 2015 - The fate of pediatric prescriptions in community
pharmacies.
June 3, 2015
Condren ME, Desselle SP. The fate of pediatric prescriptions in community pharmacies. J Patient Saf.
2015;11(2):79-88. doi:10.1097/PTS.0b013e3182948a7d.
https://psnet.ahrq.gov/issue/fate-pediatric-prescriptions-community-pharmacies
The need…
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psnet.ahrq.gov/node/42216/psn-pdf
June 28, 2013 - Simulation for ward processes of surgical care.
June 28, 2013
Pucher PH, Darzi A, Aggarwal R. Simulation for ward processes of surgical care. Am J Surg.
2013;206(1):96-102. doi:10.1016/j.amjsurg.2012.08.013.
https://psnet.ahrq.gov/issue/simulation-ward-processes-surgical-care
This commentary describes one hospital…
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psnet.ahrq.gov/node/73417/psn-pdf
June 23, 2021 - Classification of failures in the perception of
conversational agents (CAs) and their implications on
patient safety.
June 23, 2021
Aftab H, Shah SHH, Habli I. Classification of failures in the perception of conversational agents (CAs) and
their implications on patient safety. Stud Health Technol Inform. 2021;281:…
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psnet.ahrq.gov/web-mm/lot-pain-medications
September 23, 2020 - SPOTLIGHT CASE
A Lot of Pain (Medications)
Citation Text:
Herzig SJ. A Lot of Pain (Medications). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XM…
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psnet.ahrq.gov/node/49717/psn-pdf
September 01, 2014 - A Lot of Pain (Medications)
September 1, 2014
Herzig SJ. A Lot of Pain (Medications). PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/lot-pain-medications
Case Objectives
Appreciate the challenges of managing acute pain in hospitalized patients on chronic opioids.
Describe the importance of understanding th…
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psnet.ahrq.gov/node/48013/psn-pdf
May 29, 2019 - Economic outcomes associated with safety interventions
by a pharmacist–adjudicated prior authorization consult
service.
May 29, 2019
Jacob S, Britt RB, Bryan WE, et al. Economic Outcomes Associated with Safety Interventions by a
Pharmacist-Adjudicated Prior Authorization Consult Service. J Manag Care Spec Pharm. 2…
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psnet.ahrq.gov/node/47975/psn-pdf
May 29, 2019 - Surgical Innovation, New Techniques and Technologies:
A Guide to Good Practice.
May 29, 2019
London, UK: Royal College of Surgeons of England; 2019.
https://psnet.ahrq.gov/issue/surgical-innovation-new-techniques-and-technologies-guide-good-practice
Introducing innovations in practice involves taking calculated ri…
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psnet.ahrq.gov/node/867230/psn-pdf
December 04, 2024 - Adaption of a trigger tool to identify harmful incidents, no
harm incidents, and near misses in prehospital
emergency care of children.
December 4, 2024
Packendorff N, Magnusson C, Axelsson C, et al. Adaption of a trigger tool to identify harmful incidents, no
harm incidents, and near misses in prehospital emergen…
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psnet.ahrq.gov/web-mm/premature-or-overdue
December 23, 2020 - Premature or Overdue?
Citation Text:
Thomas J, Hannah M. Premature or Overdue?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…
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psnet.ahrq.gov/node/36367/psn-pdf
April 11, 2011 - Emergency medical services system changes reduce
pediatric epinephrine dosing errors in the prehospital
setting.
April 11, 2011
Kaji AH, Gausche-Hill M, Conrad H, et al. Emergency medical services system changes reduce pediatric
epinephrine dosing errors in the prehospital setting. Pediatrics. 2006;118(4):1493-150…
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psnet.ahrq.gov/node/39119/psn-pdf
November 25, 2009 - Effect of a weight-based prescribing method within an
electronic health record on prescribing errors.
November 25, 2009
Ginzburg R, Barr WB, Harris M, et al. Effect of a weight-based prescribing method within an electronic
health record on prescribing errors. Am J Health Syst Pharm. 2009;66(22):2037-41.
doi:10.214…
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psnet.ahrq.gov/node/860724/psn-pdf
January 17, 2024 - Retrospective cohort study of wrong-patient imaging
order errors: how many reach the patient?
January 17, 2024
Kneifati-Hayek JZ, Geist E, Applebaum JR, et al. Retrospective cohort study of wrong-patient imaging
order errors: how many reach the patient? BMJ Qual Saf. 2024;33(2):132-135. doi:10.1136/bmjqs-2023-
016…
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psnet.ahrq.gov/node/837890/psn-pdf
August 24, 2022 - Accuracy of pressure ulcer events in US nursing home
ratings.
August 24, 2022
Chen Z, Gleason LJ, Sanghavi P. Accuracy of pressure ulcer events in US nursing home ratings. Med
Care. 2022;60(10):775-783. doi:10.1097/mlr.0000000000001763.
https://psnet.ahrq.gov/issue/accuracy-pressure-ulcer-events-us-nursing-home-ra…