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psnet.ahrq.gov/node/47547/psn-pdf
February 13, 2019 - Prevention of prescription opioid misuse and projected
overdose deaths in the United States.
February 13, 2019
Chen Q, Larochelle MR, Weaver DT, et al. Prevention of Prescription Opioid Misuse and Projected
Overdose Deaths in the United States. JAMA Netw Open. 2019;2(2):e187621.
doi:10.1001/jamanetworkopen.2018.76…
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psnet.ahrq.gov/perspective/conversation-gordon-schiff-md
February 26, 2025 - In Conversation With… Gordon Schiff, MD
July 1, 2018
Citation Text:
In Conversation With… Gordon Schiff, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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…
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psnet.ahrq.gov/node/47735/psn-pdf
June 24, 2019 - The Financial and Human Cost of Medical Error... and
How Massachusetts Can Lead the Way on Patient Safety.
June 24, 2019
Boston, MA: Betsy Lehman Center for Patient Safety; June 2019.
https://psnet.ahrq.gov/issue/financial-and-human-cost-medical-error-and-how-massachusetts-can-lead-
way-patient-safety
The Betsy L…
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psnet.ahrq.gov/node/49621/psn-pdf
March 01, 2011 - Volume Too Low: In and Out
March 1, 2011
Miller MR. Volume Too Low: In and Out . PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/volume-too-low-and-out
Case Objectives
Appreciate that because of multiple factors, children are at high risk for medical errors.
Describe the importance of weight-based dosing of…
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psnet.ahrq.gov/node/42831/psn-pdf
October 31, 2014 - Overdiagnosis in low-dose computed tomography
screening for lung cancer.
October 31, 2014
Patz EF, Pinsky P, Gatsonis C, et al. Overdiagnosis in low-dose computed tomography screening for lung
cancer. JAMA Intern Med. 2014;174(2):269-74. doi:10.1001/jamainternmed.2013.12738.
https://psnet.ahrq.gov/issue/overdiagno…
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psnet.ahrq.gov/node/42652/psn-pdf
October 31, 2014 - Safety in numbers: the development of Leapfrog's
composite patient safety score for US hospitals.
October 31, 2014
Austin M, D'Andrea G, Birkmeyer JD, et al. Safety in numbers: the development of Leapfrog's composite
patient safety score for U.S. hospitals. J Patient Saf. 2014;10(1):64-71.
doi:10.1097/PTS.0b013e31…
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psnet.ahrq.gov/node/34688/psn-pdf
March 28, 2005 - Adverse drug events in hospitalized patients: excess
length of stay, extra costs, and attributable mortality.
March 28, 2005
Classen DC, Pestotnik SL, Evans RS, et al. Adverse drug events in hospitalized patients. Excess length of
stay, extra costs, and attributable mortality. JAMA. 1997;277(4):301-6.
https://psne…
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psnet.ahrq.gov/node/47752/psn-pdf
May 29, 2019 - How do nurses use early warning scoring systems to
detect and act on patient deterioration to ensure patient
safety? A scoping review.
May 29, 2019
Wood C, Chaboyer W, Carr P. How do nurses use early warning scoring systems to detect and act on
patient deterioration to ensure patient safety? A scoping review. Int …
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psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room
July 28, 2021 - Drug calculation errors in anesthesiology residents and faculty: an analysis of contributing factors.
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psnet.ahrq.gov/node/33605/psn-pdf
March 12, 2021 - Variability of weights used for calculation can increase
medication dose errors.6 Given this variability
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psnet.ahrq.gov/node/49431/psn-pdf
January 01, 2004 - Crushing Chest Pain: A Missed Opportunity
January 1, 2004
Graber ML. Crushing Chest Pain: A Missed Opportunity. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/crushing-chest-pain-missed-opportunity
Case Objectives
Appreciate the challenges of diagnosing aortic dissection
Describe a Bayesian approach to dia…
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psnet.ahrq.gov/web-mm/crushing-chest-pain-missed-opportunity
February 01, 2007 - SPOTLIGHT CASE
Crushing Chest Pain: A Missed Opportunity
Citation Text:
Graber ML. Crushing Chest Pain: A Missed Opportunity. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
Google …
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psnet.ahrq.gov/node/44131/psn-pdf
May 13, 2015 - Patient–doctor continuity and diagnosis of cancer:
electronic medical records study in general practice.
May 13, 2015
Ridd MJ, Ferreira DLS, Montgomery AA, et al. Patient-doctor continuity and diagnosis of cancer: electronic
medical records study in general practice. Br J Gen Pract. 2015;65(634):e305-11.
doi:10.33…
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psnet.ahrq.gov/node/45610/psn-pdf
November 01, 2017 - Economic value of pharmacist-led medication
reconciliation for reducing medication errors after
hospital discharge.
November 1, 2017
Najafzadeh M, Schnipper JL, Shrank WH, et al. Economic value of pharmacist-led medication reconciliation
for reducing medication errors after hospital discharge. Am J Manag Care. 201…
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psnet.ahrq.gov/node/44560/psn-pdf
January 23, 2017 - What is the return on investment for implementation of a
crew resource management program at an academic
medical center?
January 23, 2017
Moffatt-Bruce SD, Hefner JL, Mekhjian H, et al. What Is the Return on Investment for Implementation of a
Crew Resource Management Program at an Academic Medical Center? Am J Med…
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psnet.ahrq.gov/node/43448/psn-pdf
August 20, 2014 - Cost-benefit analysis of a medical emergency team in a
children's hospital.
August 20, 2014
Bonafide CP, Localio R, Song L, et al. Cost-benefit analysis of a medical emergency team in a children's
hospital. Pediatrics. 2014;134(2):235-41. doi:10.1542/peds.2014-0140.
https://psnet.ahrq.gov/issue/cost-benefit-analys…
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psnet.ahrq.gov/node/49395/psn-pdf
April 01, 2003 - Medication Overdose
April 1, 2003
Kaushal R. Medication Overdose. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/medication-overdose
The Case
A 15-year-old boy with end-stage AIDS was admitted to the pediatric ICU with mental status changes. He
was diagnosed with status epilepticus and started on a loading…
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psnet.ahrq.gov/node/845358/psn-pdf
March 29, 2023 - Implementation of a medication reconciliation risk
stratification tool integrated within an electronic health
record: a case series of three academic medical centers.
March 29, 2023
Chu ES, El-Kareh R, Biondo A, et al. Implementation of a medication reconciliation risk stratification tool
integrated within an elec…
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psnet.ahrq.gov/node/46122/psn-pdf
January 01, 2021 - Leapfrog Hospital Safety Score, Magnet designation, and
healthcare-associated infections in United States
hospitals.
December 21, 2017
Pakyz AL, Wang H, Ozcan YA, et al. Leapfrog Hospital Safety Score, Magnet Designation, and Healthcare-
Associated Infections in United States Hospitals. J Patient Saf. 2021;17(6):4…
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psnet.ahrq.gov/issue/indiana-patient-safety-center
January 08, 2020 - Multi-use Website
Indiana Patient Safety Center.
Citation Text:
Indiana Patient Safety Center. Indiana Hospital Association; IHA.
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