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psnet.ahrq.gov/issue/cedars-sinai-doctors-cling-pen-and-paper-transition-electronic-medical-records-proves
June 15, 2005 - Newspaper/Magazine Article
Cedars-Sinai doctors cling to pen and paper: transition to electronic medical records proves difficult.
Citation Text:
Cedars-Sinai doctors cling to pen and paper: transition to electronic medical records proves difficult. Connolly C. Washington Post. March…
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psnet.ahrq.gov/issue/nurse-physician-communications-connecting-safety
July 29, 2009 - Newspaper/Magazine Article
Nurse-to-physician communications: connecting for safety.
Citation Text:
Nurse-to-physician communications: connecting for safety. Shannon DW; Myers LA.
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psnet.ahrq.gov/issue/seven-potentially-deadly-prescribing-errors
June 12, 2013 - Newspaper/Magazine Article
Seven (potentially) deadly prescribing errors.
Citation Text:
Seven (potentially) deadly prescribing errors. Graham LR, Scudder L, Stokowski L. Medscape. October 22, 2015.
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psnet.ahrq.gov/issue/sentinel-event
May 30, 2012 - Multi-use Website
Classic
Sentinel Event.
Citation Text:
Sentinel Event. The Joint Commission.
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psnet.ahrq.gov/issue/hard-truths-journey-putting-patients-first
December 04, 2015 - Book/Report
Hard Truths: the Journey to Putting Patients First.
Citation Text:
Hard Truths: the Journey to Putting Patients First. Department of Health. London, England: Crown Publishing; January 2014. ISBN: 9780101877725.
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psnet.ahrq.gov/issue/critical-incident-reviews-significant-adverse-event-reports-and-action-plans
June 26, 2019 - Government Resource
Critical Incident Reviews, Significant Adverse Event Reports and Action Plans.
Citation Text:
Critical Incident Reviews, Significant Adverse Event Reports and Action Plans. St Andrews, Scotland: Scottish Information Commissioner; February 21, 2012. Reference No: 2…
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psnet.ahrq.gov/issue/annual-speak-data-reports
September 14, 2022 - Multi-use Website
Annual Speak Up Data Reports.
Citation Text:
Annual Speak Up Data Reports. Stratford, London; The National Guardian.
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psnet.ahrq.gov/issue/improving-diagnosis-teenage-cancer-trust-report-improving-diagnostic-experience-young-people
November 20, 2013 - Book/Report
Improving Diagnosis: Teenage Cancer Trust Report on Improving the Diagnostic Experience of Young People With Cancer.
Citation Text:
Improving Diagnosis: Teenage Cancer Trust Report on Improving the Diagnostic Experience of Young People With Cancer. London, England: Teenage …
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psnet.ahrq.gov/node/865540/psn-pdf
April 11, 2024 - retrospective study, about 26% of mispositioned nasogastric tubes resulted in complications, including two
deaths
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psnet.ahrq.gov/node/84413/psn-pdf
February 23, 2022 - Lung cancer is the leading cause of cancer deaths and must be considered in patients with historical … the
concern that overprescribing opioids has contributed to the current epidemic of opioid overdose deaths
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psnet.ahrq.gov/node/49682/psn-pdf
April 01, 2013 - time.(14) Misdiagnoses are estimated to account for approximately 40,000–80,000 preventable hospital
deaths … treatment or
through the application of incorrect treatments.(1) This estimate accounts neither for deaths
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psnet.ahrq.gov/web-mm/fecal-contamination-peritoneum-laparoscopic-trocar-injury-routine-operation-goes-wrong
March 03, 2021 - 0.64% of laparoscopic cases, have a 15% mortality rate, and account for 81% of trocar injury-related deaths … Bowel injuries occur in 0.03- 0.18% of cases, have a 2.5-5% mortality rate, and account for 19% of the deaths
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psnet.ahrq.gov/web-mm/mark-my-limb
February 10, 2015 - wrong procedure on the "correct" patient.( 3 ) Some of these occurrences have eventually led to patient deaths
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psnet.ahrq.gov/node/49541/psn-pdf
August 21, 2007 - Accidental deaths, saved lives, and improved quality. N Engl
J Med. 2005;353:1405-1409.
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psnet.ahrq.gov/node/33815/psn-pdf
September 01, 2016 - One concerning study reviewed 32 cases that ended in catastrophic outcomes, including deaths and
malpractice
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psnet.ahrq.gov/node/49839/psn-pdf
August 01, 2018 - sulfonylureas (including
glimepiride) as they can cause hypoglycemia and result in falls and even deaths
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psnet.ahrq.gov/primer/alert-fatigue
March 15, 2025 - A 2011 Boston Globe investigation identified more than 200 deaths over a 5-year period attributable
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psnet.ahrq.gov/web-mm/poorly-advanced-directives
August 01, 2018 - Poorly Advanced Directives
Citation Text:
Anderson WG. Poorly Advanced Directives. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/web-mm/pocket-syringe-swap
July 01, 2006 - Pocket Syringe Swap
Citation Text:
Kulli JC. Pocket Syringe Swap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/web-mm/ventricular-wall-injury-during-diagnostic-cardiac-catheterization
September 01, 2012 - Ventricular Wall Injury during a Diagnostic Cardiac Catheterization
Citation Text:
Pham TH, Atreja S. Ventricular Wall Injury during a Diagnostic Cardiac Catheterization. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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