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psnet.ahrq.gov/node/45883/psn-pdf
March 25, 2017 - The challenges of electronic health records and diabetes
electronic prescribing: implications for safety net care for
diverse populations.
March 25, 2017
Ratanawongsa N, Chan LLS, Fouts MM, et al. The Challenges of Electronic Health Records and Diabetes
Electronic Prescribing: Implications for Safety Net Care for …
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psnet.ahrq.gov/issue/reports-hospital-and-asc-performance
October 02, 2024 - Book/Report
Reports on Hospital and ASC Performance.
Citation Text:
Reports On Hospital And Asc Performance. Washington DC: The Leapfrog Group; September 2024.
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-11
June 16, 2019 - Commentary
ISMP medication error report analysis.
Citation Text:
ISMP medication error report analysis. Cohen MR.
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psnet.ahrq.gov/issue/finding-way-ask-doctors-tough-questions
August 17, 2016 - Newspaper/Magazine Article
Finding a way to ask doctors tough questions.
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March 18, 2009
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psnet.ahrq.gov/node/43953/psn-pdf
March 04, 2015 - Psychological safety and error reporting within Veterans
Health Administration hospitals.
March 4, 2015
Derickson R, Fishman J, Osatuke K, et al. Psychological safety and error reporting within Veterans Health
Administration hospitals. J Patient Saf. 2015;11(1):60-66. doi:10.1097/PTS.0000000000000082.
https://psne…
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psnet.ahrq.gov/node/43712/psn-pdf
December 03, 2014 - How context affects electronic health record–based test
result follow-up: a mixed-methods evaluation.
December 3, 2014
Menon S, Smith MW, Sittig DF, et al. How context affects electronic health record-based test result follow-
up: a mixed-methods evaluation. BMJ Open. 2014;4(11):e005985. doi:10.1136/bmjopen-2014-00…
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psnet.ahrq.gov/node/45293/psn-pdf
February 01, 2017 - Patient safety incidents involving sick children in primary
care in England and Wales: a mixed methods analysis.
February 1, 2017
Rees P, Edwards A, Powell C, et al. Patient Safety Incidents Involving Sick Children in Primary Care in
England and Wales: A Mixed Methods Analysis. PLoS Med. 2017;14(1):e1002217.
doi:1…
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psnet.ahrq.gov/node/845356/psn-pdf
March 29, 2023 - A novel approach for engagement in team training in
high-technology surgery: the robotic-assisted surgery
olympics.
March 29, 2023
Cohen TN, Anger JT, Kanji FF, et al. A novel approach for engagement in team training in high-technology
surgery: the robotic-assisted surgery olympics. J Patient Saf. 2022;18(6):570-5…
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psnet.ahrq.gov/node/40707/psn-pdf
March 11, 2013 - More than words: patients' views on apology and
disclosure when things go wrong in cancer care.
March 11, 2013
Mazor KM, Greene SM, Roblin DW, et al. More than words: patients' views on apology and disclosure
when things go wrong in cancer care. Patient Educ Couns. 2013;90(3):341-346.
doi:10.1016/j.pec.2011.07.010…
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psnet.ahrq.gov/issue/what-correct-site-surgery
October 15, 2018 - Fact Sheet/FAQs
What is Correct-Site Surgery?
Citation Text:
What is Correct-Site Surgery? American College of Surgeons.
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psnet.ahrq.gov/issue/patient-notification-toolkit
September 07, 2016 - Toolkit
Patient Notification Toolkit.
Citation Text:
Patient Notification Toolkit. Centers for Disease Control and Prevention; CDC.
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psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
July 01, 2011 - SPOTLIGHT CASE
Spotlight: Mistaken Attribution, Diagnostic Misstep
Citation Text:
Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/innovation/michigan-hospital-medicine-safety-consortium-hms-finds-infectious-diseases-id-physician
July 23, 2024 - The Michigan Hospital Medicine Safety Consortium (HMS) Finds Infectious Diseases (ID) Physician Approval for Placement of Peripherally Inserted Central Catheters (PICCs) Prevents Unnecessary PICC Use and Reduces Complications
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psnet.ahrq.gov/web-mm/agitated-delirium-contributes-missed-testing-and-delayed-diagnosis-gastric-perforation
June 28, 2023 - SPOTLIGHT CASE
Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation
Citation Text:
Trask J, Carlsen KM, Kuhn BT. Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation. PSNet [internet]. Rockville (MD): Agency for Healt…
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psnet.ahrq.gov/web-mm/insulin-administration-pen-vs-vial-similar-not-interchangeable
December 20, 2023 - Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable
Citation Text:
Camarillo H. Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/web-mm/coming-short-maintaining-safety-face-drug-shortages
November 01, 2012 - Coming Up Short: Maintaining Safety in the Face of Drug Shortages
Citation Text:
Plogsted S. Coming Up Short: Maintaining Safety in the Face of Drug Shortages. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/node/845473/psn-pdf
March 15, 2023 - Remote Patient Monitoring
March 15, 2023
Hood C, Sikka N, Van CM, et al. Remote Patient Monitoring. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/remote-patient-monitoring
Remote Patient Monitoring
The delivery of healthcare through electronic communication, or telehealth, has changed greatly since it…
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psnet.ahrq.gov/node/49769/psn-pdf
September 01, 2016 - Complaints as Safety Surveillance
September 1, 2016
Morris JL, Bismark M. Complaints as Safety Surveillance. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/complaints-safety-surveillance
The Case
A 42-year-old woman presented to the emergency department with abdominal pain. She said the pain
came on sudden…
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psnet.ahrq.gov/web-mm/specimen-almost-lost
September 21, 2022 - Specimen Almost Lost
Citation Text:
Hehe YK. Specimen Almost Lost. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/node/49492/psn-pdf
November 01, 2005 - Reconciling Doses
November 1, 2005
Federico F. Reconciling Doses. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/reconciling-doses
Case Objectives
List the steps involved in medication reconciliation.
Describe the role of each of the stakeholders in medication reconciliation.
Discuss how medication reconc…