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psnet.ahrq.gov/web-mm/hypoxic-gas-supply-cross-connected-pipelines
February 05, 2020 - situation is easily recognized because the low oxygen alarm will sound if the system has been set up correctly
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psnet.ahrq.gov/node/33605/psn-pdf
March 12, 2021 - Medication Administration Errors
March 12, 2021
MacDowell P, Cabri A, Davis M. Medication Administration Errors. PSNet [internet]. 2021.
https://psnet.ahrq.gov/primer/medication-administration-errors
Updated in March 2021. Originally published in January 2018 by researchers at the University of California,
San Fra…
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psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis
October 28, 2020 - Hospital-Acquired Diabetic Ketoacidosis.
Citation Text:
Zuidema D, Bagley B, Tan CL. Hospital-Acquired Diabetic Ketoacidosis.. 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/node/33564/psn-pdf
March 15, 2025 - Computerized Provider Order Entry
March 15, 2025
Computerized Provider Order Entry. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/computerized-provider-order-entry
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice…
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psnet.ahrq.gov/primer/computerized-provider-order-entry
March 15, 2025 - Computerized Provider Order Entry
Citation Text:
Computerized Provider Order Entry. 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/web-mm/crossing-line
December 01, 2012 - When correctly positioned, the tip of the catheter lies at the cavo-atrial junction, at the level of
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psnet.ahrq.gov/web-mm/unfamiliar-catheter
November 01, 2006 - education, 100% of the nurses were aware of the correct clamping sequence, and 80% performed the procedure correctly
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psnet.ahrq.gov/innovation/standardized-marking-procedure-ent-operations-prevent-wrong-site-surgery-development
February 01, 2013 - EMERGING INNOVATIONS
A standardized marking procedure for ENT operations to prevent wrong-site surgery: development, establishment and subsequent evaluation among patients and medical personnel.
Citation Text:
Rohrmeier C, Abudan Al-Masry N, Keerl R, et al. A standardized marking procedure for ENT…
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psnet.ahrq.gov/web-mm/weight-and-height-juxtaposition-electronic-medical-record-causing-accidental-medication
March 15, 2023 - Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose
Citation Text:
Jain NP, Dakwa D. Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…
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psnet.ahrq.gov/web-mm/hyperglycemia-and-switching-subcutaneous-insulin
May 19, 2021 - users means both physical performance (e.g., programming a technology) and cognitive performance (e.g., correctly
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psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
July 08, 2022 - and their severity. 11 However, the technology is only useful if it is properly used and functions correctly
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psnet.ahrq.gov/web-mm/timely-diagnosis-esophageal-perforation
September 27, 2023 - Timely diagnosis of esophageal perforation
Citation Text:
Utter GH, Cooke DT. Timely diagnosis of esophageal perforation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney
April 01, 2010 - SPOTLIGHT CASE
Two Wrongs Don't Make a Right (Kidney)
Citation Text:
DeVine JG. Two Wrongs Don't Make a Right (Kidney). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/direct-oral-anticoagulants-are-high-risk-medications-potentially-complex-dosing
August 21, 2005 - back to the care provider in their own words. 26 In the present case, the patient was provided with correctly
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psnet.ahrq.gov/web-mm/did-we-forget-something
April 28, 2021 - Did We Forget Something?
Citation Text:
Gibbs VC. Did We Forget Something?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/node/43897/psn-pdf
August 21, 2015 - Guidelines for Adult IV Push Medications.
August 21, 2015
Horsham, PA: The Institute for Safe Medication Practices; July 2015.
https://psnet.ahrq.gov/issue/guidelines-adult-iv-push-medications
To address the lack of standards on intravenous (IV) push medication administration, this guidance reflects
applied expert…
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psnet.ahrq.gov/web-mm/inside-time-out
March 01, 2004 - The Inside of a Time Out
Citation Text:
Feldman DL. The Inside of a Time Out. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/web-mm/communication-failure-whos-charge
April 01, 2018 - handovers of care is rather abysmal ( 2,4 ) and, it can be argued, is even still not being approached correctly
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psnet.ahrq.gov/web-mm/other-hand
December 12, 2012 - allergy bracelets, overhead signs, tattoos) relies on clinicians to verify their accuracy, apply them correctly
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psnet.ahrq.gov/web-mm/fatal-oversight-misdiagnosis-nocturnal-chest-pain-elevated-d-dimer
May 01, 2005 - progressive and accelerating nocturnal angina in a patient with multiple cardiac risk factors was not correctly