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psnet.ahrq.gov/node/33662/psn-pdf
January 01, 2008 - JD: We built a very comprehensive clinical quality dashboard for the company. … When I left, we were installing a very robust risk management and patient
safety system from a company
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psnet.ahrq.gov/issue/using-good-design-eliminate-medical-errors
December 09, 2020 - Newspaper/Magazine Article
Using good design to eliminate medical errors.
Citation Text:
Using good design to eliminate medical errors. Jaffe E.
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psnet.ahrq.gov/issue/progress-preventing-name-confusion-errors
May 07, 2018 - Newspaper/Magazine Article
Progress with preventing name confusion errors.
Citation Text:
Progress with preventing name confusion errors. ISMP Medication Safety Alert! Acute Care Edition. August 9, 2007;12:1-3.
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psnet.ahrq.gov/node/33632/psn-pdf
April 01, 2006 - In Conversation with… Michael Cohen, RPh, MS, ScD
(hon)
April 1, 2006
In Conversation with… Michael Cohen, RPh, MS, ScD (hon). PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon
Robert Wachter, Editor, AHRQ WebM&M: Tell us a little bit about your background and how…
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psnet.ahrq.gov/node/33826/psn-pdf
February 01, 2017 - Most places I've visited, most people really do
care deeply about the work, the company, and the customers … That created long queues and the company had to figure out how to re-
standardize some elements of it
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psnet.ahrq.gov/node/33789/psn-pdf
August 01, 2015 - If you
were an insurance company and wanted to see what the doctor did, you could look retrospectively
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psnet.ahrq.gov/node/865411/psn-pdf
March 27, 2024 - The Accreditation Council for Continuing Medical
Education (ACCME) defines an ineligible company as
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psnet.ahrq.gov/node/866995/psn-pdf
October 30, 2024 - The Accreditation Council for Continuing Medical
Education (ACCME) defines an ineligible company as
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psnet.ahrq.gov/node/866343/psn-pdf
December 31, 2024 - The Accreditation Council for Continuing Medical
Education (ACCME) defines an ineligible company as
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psnet.ahrq.gov/issue/double-key-bounce-and-double-keying-errors
February 01, 2023 - Newspaper/Magazine Article
Double key bounce and double keying errors.
Citation Text:
Double key bounce and double keying errors. ISMP Medication Safety Alert! Acute care edition. January 12, 2006.
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psnet.ahrq.gov/issue/iv-potassium-given-epidurally-getting-route-problem
April 20, 2022 - Newspaper/Magazine Article
IV potassium given epidurally: getting to the "route" of the problem.
Citation Text:
IV potassium given epidurally: getting to the "route" of the problem. ISMP Medication Safety Alert! Acute care edition. April 6, 2006.
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psnet.ahrq.gov/web-mm/hemorrhagic-shock-after-elective-spine-surgery-failure-rescue-after-limited-response-nursing
October 31, 2023 - The Accreditation Council for Continuing Medical Education (ACCME) defines an ineligible company as “
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psnet.ahrq.gov/web-mm/strongyloides-hidden-traveler-and-potentially-lethal-missed-diagnosis
August 25, 2021 - The Accreditation Council for Continuing Medical Education (ACCME) defines an ineligible company as “
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psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown
June 28, 2023 - The Accreditation Council for Continuing Medical Education (ACCME) defines an ineligible company as “
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psnet.ahrq.gov/node/72589/psn-pdf
December 23, 2020 - According to a study by The Doctor’s Company and CRICO, the captive malpractice insurer of the
Harvard-affiliated … In the Doctors
Company-CRICO study cited above, patients’ failure to complete recommended appointments
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psnet.ahrq.gov/node/49728/psn-pdf
March 01, 2015 - Medication Mix-Up: From Bad to Worse
March 1, 2015
Wollitz A, O'Connor MF. Medication Mix-Up: From Bad to Worse. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/medication-mix-bad-worse
The Case
A 69-year-old man with chronic kidney disease and essential hypertension was admitted to the hospital
with chest …
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psnet.ahrq.gov/web-mm/round-trip-service
April 26, 2023 - Round-Trip Service
Citation Text:
McGrath MH. Round-Trip Service. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/issue/mri-suites-safety-outside-bore
April 28, 2021 - Commentary
MRI suites: safety outside the bore.
Citation Text:
MRI suites: safety outside the bore. Gilk T. Patient Safety and Quality Healthcare. September/October 2006:1-8.
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psnet.ahrq.gov/web-mm/thin-air
March 01, 2006 - Reading, MA: Addison-Wesley Publishing Company; 1995. 5. Gosbee J. … Reading, MA: Addison-Wesley Publishing Company; 1995:515-553. 10. Heimann C.
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psnet.ahrq.gov/issue/fatal-gas-line-mix-how-avoid-making-gastly-mistake
April 29, 2018 - Newspaper/Magazine Article
Fatal gas line mix-up: How to avoid making this "gastly" mistake.
Citation Text:
Fatal gas line mix-up: How to avoid making this "gastly" mistake. ISMP Medication Safety Alert! Acute care edition. December 16, 2004
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