-
psnet.ahrq.gov/web-mm/mistaken-dose-naloxone
March 21, 2009 - Erika Cutler, PharmD
Pharmacy and Therapeutics Coordinator
University of California, Davis
Assistant
-
psnet.ahrq.gov/node/33816/psn-pdf
October 01, 2016 - Both the Office of the National Coordinator for Health Information
Technology and a private consortium
-
psnet.ahrq.gov/issue/review-alleged-patient-deaths-patient-wait-times-and-scheduling-practices-phoenix-va-health
May 01, 2015 - Book/Report
Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System.
Citation Text:
Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System. Washington, DC: VA Office o…
-
psnet.ahrq.gov/node/840475/psn-pdf
November 30, 2022 - Complexity and challenges of the clinical diagnosis and
management of Long COVID.
November 30, 2022
O’Hare AM, Vig EK, Iwashyna TJ, et al. Complexity and challenges of the clinical diagnosis and
management of Long COVID. JAMA Netw Open. 2022;5(11):e2240332.
doi:10.1001/jamanetworkopen.2022.40332.
https://psnet.ah…
-
psnet.ahrq.gov/node/73857/psn-pdf
September 22, 2021 - A theoretical model of flow disruptions for the anesthesia
team during cardiovascular surgery.
September 22, 2021
Boquet A, Cohen T, Diljohn F, et al. A theoretical model of flow disruptions for the anesthesia team during
cardiovascular surgery. J Patient Saf. 2021;17(6):e534-e539. doi:10.1097/pts.0000000000000406.…
-
psnet.ahrq.gov/node/72654/psn-pdf
January 20, 2020 - What is an ethically informed approach to managing
patient safety risk during discharge planning?
January 20, 2020
West JC. What Is an Ethically Informed Approach to Managing Patient Safety Risk During Discharge
Planning? AMA J Ethics. 2020;22(!1):e919-e923. doi:10.1001/amajethics.2020.919.
https://psnet.ahrq.gov/…
-
psnet.ahrq.gov/node/73714/psn-pdf
September 15, 2021 - Evaluation of Quality, Safety, and Value in Veterans
Health Administration Facilities, FY 2020.
September 15, 2021
Washington, DC: Veterans Affairs Office of Inspector General; August 26, 2021. Report No. 21-01502-240.
https://psnet.ahrq.gov/issue/evaluation-quality-safety-and-value-veterans-health-administration-f…
-
psnet.ahrq.gov/node/836836/psn-pdf
March 30, 2022 - Deficiencies after the New Electronic Health Record Go-
Live at the Mann-Grandstaff VA Medical Center in
Spokane, WA.
March 30, 2022
Washington, DC: VA Office of Inspector General; March 17, 2022.
https://psnet.ahrq.gov/issue/deficiencies-after-new-electronic-health-record-go-live-mann-grandstaff-va-
medical-cent…
-
psnet.ahrq.gov/node/72650/psn-pdf
January 20, 2021 - A roadmap to advance patient safety in ambulatory care.
January 20, 2021
Singh H, Carayon P. A roadmap to advance patient safety in ambulatory care. JAMA. 2020;324(24):2481-
2482. doi:10.1001/jama.2020.18551.
https://psnet.ahrq.gov/issue/roadmap-advance-patient-safety-ambulatory-care
Preventable harm, such as diag…
-
psnet.ahrq.gov/node/845347/psn-pdf
March 01, 2023 - Race differences in a malpractice event database in a
large healthcare system.
March 1, 2023
Thomas AD, Pandit C, Krevat S. Race differences in a malpractice event database in a large healthcare
system. J Patient Saf. 2023;19(2):67-70. doi:10.1097/pts.0000000000001090.
https://psnet.ahrq.gov/issue/race-differences…
-
psnet.ahrq.gov/node/72643/psn-pdf
January 13, 2021 - Ockenden Report. Emerging Fndings and
Recommendations from the Independent Review of
Maternity Services at the Shrewsbury and Telford
Hospital NHS Trust.
January 13, 2021
London UK: Crown Copyright; December 10, 2020. ISBN: 9781528623049.
https://psnet.ahrq.gov/issue/ockenden-report-emerging-fndings-a…
-
psnet.ahrq.gov/node/840487/psn-pdf
November 30, 2022 - Interprofessional team collaboration and work
environment health in 68 US intensive care units.
November 30, 2022
Pun BT, Jun J, Tan A, et al. Interprofessional team collaboration and work environment health in 68 US
intensive care units. Am J Crit Care. 2022;31(6):443-451. doi:10.4037/ajcc2022546.
https://psnet.a…
-
psnet.ahrq.gov/node/49863/psn-pdf
May 01, 2019 - Good Catch in the Operating Room
May 1, 2019
Day J, Paige JT. Good Catch in the Operating Room. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/good-catch-operating-room
The Case
A 46-year-old woman with extensive history of back pain from lumbar stenosis was scheduled for an
elective laminectomy and spinal…
-
psnet.ahrq.gov/node/39023/psn-pdf
November 19, 2018 - Pediatric Readiness in the Emergency Department.
November 19, 2018
Remick K, Gausche-Hill M, Joseph MM, et al. Pediatric Readiness in the Emergency Department.
Pediatrics. 2018;142(5):e20182459. doi:10.1542/peds.2018-2459.
https://psnet.ahrq.gov/issue/pediatric-readiness-emergency-department
This revised set of gu…
-
psnet.ahrq.gov/node/44068/psn-pdf
April 15, 2015 - Contemporary View of Medication-Related Harm. A New
Paradigm.
April 15, 2015
National Coordinating Council for Medication Error Reporting and Prevention; NCCMERP.
https://psnet.ahrq.gov/issue/contemporary-view-medication-related-harm-new-paradigm
Medication errors are a common factor in health care–associated harm…
-
psnet.ahrq.gov/node/45353/psn-pdf
July 20, 2016 - Using the web or an app instead of seeing a doctor?
Caution is advised.
July 20, 2016
Frakt A. New York Times. July 11, 2016.
https://psnet.ahrq.gov/issue/using-web-or-app-instead-seeing-doctor-caution-advised
Patients are increasingly using online symptom checkers for medical information and health care
recommen…
-
psnet.ahrq.gov/node/42861/psn-pdf
January 15, 2014 - Transitioning Newborns From NICU to Home: A Resource
Toolkit.
January 15, 2014
Rockville, MD: Agency for Healthcare Research and Quality; December 2013. AHRQ Publication No.
12(14)-0054-EF.
https://psnet.ahrq.gov/issue/transitioning-newborns-nicu-home-resource-toolkit
Infants discharged from the neonatal intensiv…
-
psnet.ahrq.gov/node/44312/psn-pdf
November 06, 2015 - Beyond the team: understanding interprofessional work
in two North American ICUs.
November 6, 2015
Alexanian JA, Kitto S, Rak KJ, et al. Beyond the Team: Understanding Interprofessional Work in Two North
American ICUs. Crit Care Med. 2015;43(9):1880-6. doi:10.1097/CCM.0000000000001136.
https://psnet.ahrq.gov/issue…
-
psnet.ahrq.gov/node/35280/psn-pdf
June 30, 2009 - The influence of the structure and culture of medical
group practices on prescription drug errors.
June 30, 2009
Kralewski JE, Dowd BE, Heaton A, et al. The influence of the structure and culture of medical group
practices on prescription drug errors. Med care. 2005;43(8):817-825.
https://psnet.ahrq.gov/issue/infl…
-
psnet.ahrq.gov/node/37286/psn-pdf
December 23, 2011 - Different roles, same goal: risk and quality management
partnering for patient safety. By the ASHRM Monographs
Task Force.
December 23, 2011
Bokar V, Perry DG. Different Roles, Same Goal: Risk And Quality Management Partnering For Patient
Safety. By The Ashrm Monographs Task Force.; 2007:17-23, 25. doi:10.1002/jhr…