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psnet.ahrq.gov/issue/moving-beyond-misuse-and-diversion-urgent-need-consider-role-iatrogenic-addiction-current
July 18, 2012 - Commentary
Moving beyond misuse and diversion: the urgent need to consider the role of iatrogenic addiction in the current opioid epidemic.
Citation Text:
Beauchamp GA, Winstanley EL, Ryan SA, et al. Moving beyond misuse and diversion: the urgent need to consider the role of iatrogenic a…
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psnet.ahrq.gov/node/60029/psn-pdf
March 11, 2020 - Prevalence, nature and predictors of omitted medication
doses in mental health hospitals: a multi-centre study.
March 11, 2020
Keers RN, Hann M, Alshehri GH, et al. Prevalence, nature and predictors of omitted medication doses in
mental health hospitals: A multi-centre study. PLoS One. 2020;15(2):e0228868.
doi:10.…
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psnet.ahrq.gov/node/48056/psn-pdf
June 15, 2019 - Patients' conceptualizations of responsibility for
healthcare: a typology for understanding differing
attributions in the context of patient safety.
June 15, 2019
Heavey E, Waring J, De Brún A, et al. Patients' Conceptualizations of Responsibility for Healthcare: A
Typology for Understanding Differing Attributions…
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psnet.ahrq.gov/node/38521/psn-pdf
September 19, 2016 - Inpatient suicide: preventing a common sentinel event.
September 19, 2016
Tishler CL, Reiss NS. Inpatient suicide: preventing a common sentinel event. Gen Hosp Psychiatry.
2009;31(2):103-9. doi:10.1016/j.genhosppsych.2008.09.007.
https://psnet.ahrq.gov/issue/inpatient-suicide-preventing-common-sentinel-event
Suici…
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psnet.ahrq.gov/node/44734/psn-pdf
July 11, 2017 - Contextual errors in medical decision making: overlooked
and understudied.
July 11, 2017
Weiner SJ, Schwartz A. Contextual Errors in Medical Decision Making: Overlooked and Understudied.
Acad Med. 2016;91(5):657-62. doi:10.1097/ACM.0000000000001017.
https://psnet.ahrq.gov/issue/contextual-errors-medical-decision-m…
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psnet.ahrq.gov/web-mm/compare-and-contrast
July 16, 2019 - The clinician considering the use of a contrast study in an at-risk patient must consider first the possibility
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psnet.ahrq.gov/node/46199/psn-pdf
September 27, 2017 - The development and implementation of checklists in
obstetrics.
September 27, 2017
Medicine S for M-F, Bernstein PS, Combs A, et al. The development and implementation of checklists in
obstetrics. Am J Obstet Gynecol. 2017;217(2):B2-B6. doi:10.1016/j.ajog.2017.05.032.
https://psnet.ahrq.gov/issue/development-and-i…
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psnet.ahrq.gov/web-mm/missed-candor-implementation-opportunities
November 11, 2020 - related to an offer of compensation would not be applicable to this case but would be important when considering
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psnet.ahrq.gov/primer/retained-surgical-items-definition-and-epidemiology
September 15, 2024 - Retained Surgical Items: Definition and Epidemiology.
Citation Text:
Romano PS, Gibbs VC. Retained Surgical Items: Definition and Epidemiology.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
Copy Citation
Format:
…
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psnet.ahrq.gov/node/866265/psn-pdf
July 31, 2024 - Misplaced Vial: Medication Kit Variability Contributes to
Medication Error During Patient Transport
July 31, 2024
MacDowell P, McGee E. Misplaced Vial: Medication Kit Variability Contributes to Medication Error During
Patient Transport. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/misplaced-vial-medicatio…
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psnet.ahrq.gov/web-mm/transfer-or-not-transfer
November 23, 2016 - In considering this question, the first issue is determining whether the patient would have been classified
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psnet.ahrq.gov/node/44751/psn-pdf
February 17, 2016 - Patients' views of adverse events in primary and
ambulatory care: a systematic review to assess methods
and the content of what patients consider to be adverse
events.
February 17, 2016
Lang S, Garrido MV, Heintze C. Patients' views of adverse events in primary and ambulatory care: a
systematic review to assess m…
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psnet.ahrq.gov/node/837784/psn-pdf
August 05, 2022 - So, I think there are at least four main issues
when we are considering safety and implementing health … patients to take a critical look at
the background of the apps they want to use or the devices they are considering
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psnet.ahrq.gov/node/49602/psn-pdf
April 01, 2010 - Anticoagulation: Held Too Long
April 1, 2010
Dunn AS. Anticoagulation: Held Too Long. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/anticoagulation-held-too-long
The Case
A 68-year-old woman with a history of mitral valve replacement with a mechanical valve was admitted with
abdominal pain. Because of the…
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psnet.ahrq.gov/node/36947/psn-pdf
September 09, 2011 - The safety of warfarin therapy in the nursing home
setting.
September 9, 2011
Gurwitz JH, Field T, Radford MJ, et al. The safety of warfarin therapy in the nursing home setting. Am J
Med. 2007;120(6):539-44.
https://psnet.ahrq.gov/issue/safety-warfarin-therapy-nursing-home-setting
The anticoagulant warfarin is co…
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psnet.ahrq.gov/node/46045/psn-pdf
December 22, 2018 - Validating domains of patient contextual factors essential
to preventing contextual errors: a qualitative study
conducted at Chicago area Veterans Health
Administration sites.
December 22, 2018
Binns-Calvey AE, Malhiot A, Kostovich CT, et al. Validating Domains of Patient Contextual Factors
Essential to Preventin…
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psnet.ahrq.gov/web-mm/home-medications-contribute-unique-opportunity-error-discharge-hospital
May 16, 2022 - of medications that are effective for treating the conditions commonly seen at that facility while considering
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psnet.ahrq.gov/perspective/patient-safety-medical-nursing-and-other-clinical-education
January 31, 2020 - curricula for ways the competencies are already being taught and assessed is a good first step before considering
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psnet.ahrq.gov/web-mm/liver-failure-after-chemotherapy-did-we-forget-something
May 01, 2019 - Moreover, the admitting team erred by not considering the possibility of hepatitis as the cause of the
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psnet.ahrq.gov/web-mm/premature-or-overdue
December 23, 2020 - Instead of considering induction, the physicians now weighed options of either proceeding with an amniocentesis