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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50611/psn-pdf
    October 30, 2019 - The Lost Start Date: an Unknown Risk of E-prescribing October 30, 2019 Wright A, Schiff G. The Lost Start Date: an Unknown Risk of E-prescribing. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/lost-start-date-unknown-risk-e-prescribing Case Objectives List the most common errors associated with computerized…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/842919/psn-pdf
    February 01, 2023 - Hospital-Acquired Diabetic Ketoacidosis. February 1, 2023 Zuidema D, Bagley B, Tan CL. Hospital-Acquired Diabetic Ketoacidosis. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis The Cases Case #1: A 46-year-old Hindi-speaking resident of a skilled nursing facility (SNF) …

  3. Microsoft PowerPoint - FINAL Spotlight Case_Under Pressure.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-06/under_pressure.pdf
    January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_Under Pressure.pptx Spotlight Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture Source and Credits • This presentation is based on the June 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865411/psn-pdf
    March 27, 2024 - Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy March 27, 2024 Lopez C, Tache V. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/uterine-artery-injury-during-…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49684/psn-pdf
    May 01, 2013 - Right Regimen, Wrong Cancer: Patient Catches Medical Error May 1, 2013 Weingart SN, Jacobson J. Right Regimen, Wrong Cancer: Patient Catches Medical Error. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error Case Objectives Appreciate that chemotherapy a…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33837/psn-pdf
    July 01, 2017 - In Conversation With… Michelle Mello, MPhil, JD, PhD July 1, 2017 In Conversation With… Michelle Mello, MPhil, JD, PhD. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-michelle-mello-mphil-jd-phd Editor's note: Michelle Mello is Professor of Law at Stanford Law School and Professor of Healt…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33842/psn-pdf
    January 01, 2018 - Assessing the Safety of Electronic Health Records: What Have We Learned? September 1, 2017 Sittig DF, Singh H. Assessing the Safety of Electronic Health Records: What Have We Learned? PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/assessing-safety-electronic-health-records-what-have-we-learned Perspec…

  8. Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns. | PSNet

    psnet.ahrq.gov/web-mm/hemorrhagic-shock-after-elective-spine-surgery-failure-rescue-after-limited-response-nursing
    October 31, 2023 - SPOTLIGHT CASE Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns. Citation Text: Zakaluzny S. Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns.. PSNet [internet]. Rockville (MD):…

  9. Medication Safety Events Related to Diagnostic Imaging | PSNet

    psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
    January 26, 2022 - Medication Safety Events Related to Diagnostic Imaging Citation Text: Sanchez L, Porras H, Lammers C. Medication Safety Events Related to Diagnostic Imaging. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Fo…

  10. In Conversation With… Rebecca Lawton, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-rebecca-lawton-phd
    March 24, 2025 - In Conversation With… Rebecca Lawton, PhD September 1, 2018  Citation Text: In Conversation With… Rebecca Lawton, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation …

  11. Inpatient Stroke Management in an Adolescent with Type 1 Diabetes and Home Insulin Pump | PSNet

    psnet.ahrq.gov/web-mm/inpatient-stroke-management-adolescent-type-1-diabetes-and-home-insulin-pump
    February 01, 2023 - SPOTLIGHT CASE Inpatient Stroke Management in an Adolescent with Type 1 Diabetes and Home Insulin Pump Citation Text: Bagley B, Zuidema D, Crossen S, et al. Inpatient Stroke Management in an Adolescent with Type 1 Diabetes and Home Insulin Pump . PSNet [internet]. Rockville (MD): Agency for Heal…

  12. The effects of leadership for self-worth, inclusion, trust, and psychological safety on medical error reporting. | PSNet

    psnet.ahrq.gov/issue/effects-leadership-self-worth-inclusion-trust-and-psychological-safety-medical-error
    March 30, 2022 - Study The effects of leadership for self-worth, inclusion, trust, and psychological safety on medical error reporting. Citation Text: Brimhall KC, Tsai C-Y, Eckardt R, et al. The effects of leadership for self-worth, inclusion, trust, and psychological safety on medical error reporting. …

  13. Family safety reporting in medically complex children: parent, staff, and leader perspectives. | PSNet

    psnet.ahrq.gov/issue/family-safety-reporting-medically-complex-children-parent-staff-and-leader-perspectives
    July 20, 2022 - Study Family safety reporting in medically complex children: parent, staff, and leader perspectives. Citation Text: Khan A, Baird JD, Kelly MM, et al. Family safety reporting in medically complex children: parent, staff, and leader perspectives. Pediatrics. 2022;149(6):e2021053913. doi:1…

  14. Describing the evidence linking interprofessional education interventions to improving the delivery of safe and effective patient care: a scoping review. | PSNet

    psnet.ahrq.gov/issue/describing-evidence-linking-interprofessional-education-interventions-improving-delivery-safe
    June 12, 2013 - Review Describing the evidence linking interprofessional education interventions to improving the delivery of safe and effective patient care: a scoping review. Citation Text: Cadet T, Cusimano J, McKearney S, et al. Describing the evidence linking interprofessional education interventio…

  15. Interprofessional learning in multidisciplinary healthcare teams is associated with reduced patient mortality: a quantitative systematic review and meta-analysis. | PSNet

    psnet.ahrq.gov/issue/interprofessional-learning-multidisciplinary-healthcare-teams-associated-reduced-patient
    April 10, 2024 - Review Interprofessional learning in multidisciplinary healthcare teams is associated with reduced patient mortality: a quantitative systematic review and meta-analysis. Citation Text: Webster CS, Coomber T, Liu S, et al. Interprofessional learning in multidisciplinary healthcare teams i…

  16. Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence. | PSNet

    psnet.ahrq.gov/issue/causes-medication-administration-errors-hospitals-systematic-review-quantitative-and
    April 01, 2015 - Review Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence. Citation Text: Keers RN, Williams SD, Cooke J, et al. Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitativ…

  17. Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication station. | PSNet

    psnet.ahrq.gov/issue/designing-distractions-human-factors-approach-decreasing-interruptions-centralised-medication
    July 27, 2018 - Study Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication station. Citation Text: Colligan L, Guerlain S, Steck SE, et al. Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication…

  18. Organizational conditions for engagement in quality and safety improvement: a longitudinal qualitative study of community pharmacies. | PSNet

    psnet.ahrq.gov/issue/organizational-conditions-engagement-quality-and-safety-improvement-longitudinal-qualitative
    November 25, 2020 - Study Organizational conditions for engagement in quality and safety improvement: a longitudinal qualitative study of community pharmacies. Citation Text: Phipps D, Jones CEL, Parker D, et al. Organizational conditions for engagement in quality and safety improvement: a longitudinal qual…

  19. Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 2003. | PSNet

    psnet.ahrq.gov/issue/probabilistic-risk-assessment-accidental-abo-incompatible-thoracic-organ-transplantation-and
    June 24, 2020 - Study Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 2003. Citation Text: Cook RI, Wreathall J, Smith A, et al. Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 200…

  20. Accident analysis of large-scale technological disasters applied to an anaesthetic complication. | PSNet

    psnet.ahrq.gov/issue/accident-analysis-large-scale-technological-disasters-applied-anaesthetic-complication
    November 16, 2022 - Study Classic Accident analysis of large-scale technological disasters applied to an anaesthetic complication. Citation Text: Eagle CJ, Davies JM, Reason J. Accident analysis of large-scale technological disasters applied to an anaesthetic complication. Can J An…
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