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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-43
September 26, 2017 - Commentary
ISMP medication error report analysis.
Citation Text:
Cohen MR, Smetzer JL. Safer Connectors in the United Kingdom; Value of the Independent Double-Check; Medication Errors Column in 35th Year. Hosp Pharm. 2010;45(3). doi:10.1310/hpj4503-191.
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-42
September 26, 2017 - Commentary
ISMP medication error report analysis.
Citation Text:
Cohen MR, Smetzer JL. Oral Syringes: A Crucial and Economical Risk-Reduction Strategy that has Not Been Fully Utilized; Caution regarding Once-Weekly Levothyroxine; When Drug Strengths Differ by 10-Fold; Lower Colchicine Do…
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-44
September 26, 2017 - Commentary
ISMP medication error report analysis.
Citation Text:
Cohen MR, Smetzer JL. Neuromuscular Blocker Mix-up in the Pharmacy; ISMP and Doctor's Digest Launch New iPhone Application; “UD” for “Ut Dictum”—an Ambiguous and Dangerous Abbreviation; Order by Metric Weight, Not Volume.…
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psnet.ahrq.gov/issue/dont-abandon-second-victims-medical-errors
September 26, 2017 - Commentary
Don't abandon the "second victims" of medical errors.
Citation Text:
Smetzer JL. Don't abandon the "second victims" of medical errors. Nursing (Brux). 2012;42(2):54-8. doi:10.1097/01.NURSE.0000410310.38734.e0.
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psnet.ahrq.gov/issue/unlabeled-containers-lead-patients-death
September 26, 2017 - Commentary
Unlabeled containers lead to patient's death.
Citation Text:
Cohen MR, Smetzer JL. Unlabeled containers lead to patient's death. Jt Comm J Qual Patient Saf. 2005;31(7):414-7.
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Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote …
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psnet.ahrq.gov/issue/american-hospital-association-mckesson-quest-quality-prize-0
March 28, 2018 - Award Recipient
American Hospital Association-McKesson Quest for Quality Prize.
Citation Text:
American Hospital Association-McKesson Quest for Quality Prize. Jt Comm J Qual Patient Saf. 2007;33(10):592-604.
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psnet.ahrq.gov/web-mm/unintended-consequences-cpoe
September 01, 2004 - SPOTLIGHT CASE
Unintended Consequences of CPOE
Citation Text:
Wears RL. Unintended Consequences of CPOE. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/node/49442/psn-pdf
May 01, 2004 - Non-Infectious Conditions
Abscess
Legionella, Mycoplasma,
Chlamydia (depending on initial
antibiotic choice
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.95_slideshow.ppt
May 01, 2005 - Choice of computed tomography, transesophageal echocardiography, magnetic resonance imaging, and aortography
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psnet.ahrq.gov/issue/fear-covid-19-leads-other-patients-decline-critical-treatment
June 24, 2020 - Newspaper/Magazine Article
Fear of Covid-19 leads other patients to decline critical treatment.
Citation Text:
Hafner K. Fear of Covid-19 leads other patients to decline critical treatment. New York Times. 2020;May 25.
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psnet.ahrq.gov/issue/nobody-cared-women-who-have-reported-mistreatment-while-giving-birth-say-cdc-report-validates
April 27, 2022 - Newspaper/Magazine Article
'Nobody cared': Women who have reported mistreatment while giving birth say CDC report validates their trauma. Advocates call for systemic change in treatment of pregnant people.
Citation Text:
'Nobody cared': Women who have reported mistreatment while giving b…
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psnet.ahrq.gov/issue/risk-mitigation-large-scale-systems-lessons-high-reliability-organizations
January 30, 2019 - Commentary
Classic
Risk mitigation in large scale systems: lessons from high reliability organizations.
Citation Text:
Risk mitigation in large scale systems: lessons from high reliability organizations. Grabowski M, Roberts K. Calif Manag Rev. 1997;39(4):152-16…
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psnet.ahrq.gov/issue/oversedation-patient-obstructive-sleep-apnea-prior-imaging
September 02, 2020 - Commentary
Oversedation of a patient with obstructive sleep apnea prior to imaging.
Citation Text:
Blay E, Barnard C, Bilimoria KY. Oversedation of a Patient With Obstructive Sleep Apnea Prior to Imaging. JAMA. 2018;319(5):495-496. doi:10.1001/jama.2017.22004.
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psnet.ahrq.gov/issue/view-cockpit-what-airline-industry-can-teach-us-about-patient-safety
January 08, 2020 - Commentary
View from the cockpit: what the airline industry can teach us about patient safety.
Citation Text:
Doucette JN. View from the cockpit: what the airline industry can teach us about patient safety. Nursing (Brux). 2006;36(11):50-53.
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psnet.ahrq.gov/issue/systematic-approaches-adverse-events-obstetrics-part-1-part-2
May 18, 2022 - Commentary
Systematic approaches to adverse events in obstetrics, Part 1 & Part 2.
Citation Text:
Pettker CM. Systematic approaches to adverse events in obstetrics, Part I: Event identification and classification. Semin Perinatol. 2017;41(3). doi:10.1053/j.semperi.2017.03.003.
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psnet.ahrq.gov/issue/delivering-truth-challenges-and-opportunities-error-disclosure-obstetrics
December 01, 2021 - Commentary
Delivering the truth: challenges and opportunities for error disclosure in obstetrics.
Citation Text:
Carranza L, Lyerly AD, Lipira L, et al. Delivering the Truth. Obstetrics & Gynecology. 2014;123(3). doi:10.1097/aog.0000000000000130.
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psnet.ahrq.gov/web-mm/standard-deviations
January 01, 2006 - Decision-making capacity is defined by four criteria: (i) ability to communicate a choice, (ii) ability … of care requires that a competent patient's informed refusal should be honored even if the patient's choice
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psnet.ahrq.gov/issue/covid-19-delaying-routine-care-chronic-disease-startups-brace-slew-complications
May 02, 2018 - Newspaper/Magazine Article
With Covid-19 delaying routine care, chronic disease startups brace for a slew of complications.
Citation Text:
With Covid-19 delaying routine care, chronic disease startups brace for a slew of complications. Brodwin E. STAT. April 14, 2020.
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psnet.ahrq.gov/issue/medicolegal-aspect-error-pathology-search-jury-verdicts-and-settlements
February 04, 2016 - Review
The medicolegal aspect of error in pathology: a search of jury verdicts and settlements.
Citation Text:
Kornstein MJ, Byrne SP. The medicolegal aspect of error in pathology: a search of jury verdicts and settlements. Arch Pathol Lab Med. 2007;131(4):615-618.
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psnet.ahrq.gov/issue/do-some-surgical-implants-do-more-harm-good
January 14, 2011 - Newspaper/Magazine Article
Do some surgical implants do more harm than good?
Citation Text:
Do some surgical implants do more harm than good? Groopman J. New Yorker Online. April 13, 2020.
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