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psnet.ahrq.gov/node/49848/psn-pdf
January 01, 2019 - Inadequate Preanesthetic Evaluation, Airway Trouble
November 1, 2018
Blitz J. Inadequate Preanesthetic Evaluation, Airway Trouble. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/inadequate-preanesthetic-evaluation-airway-trouble
The Case
Case #1:
A 34-year-old woman was scheduled for a hysteroscopy under g…
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psnet.ahrq.gov/node/49545/psn-pdf
September 01, 2007 - Coming Undone: Failure of Closure Device
September 1, 2007
Baez-Escudero JL, Levine GN. Coming Undone: Failure of Closure Device. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device
The Case
A 65-year-old man underwent coronary angiography because of atypical exertional chest…
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psnet.ahrq.gov/node/33743/psn-pdf
December 01, 2012 - Quality and Safety Challenges in Critical Care: Preventing
and Treating Delirium in the Intensive Care Unit
December 1, 2012
Vasilevskis EE, Ely WE, Dittus RS. Quality and Safety Challenges in Critical Care: Preventing and Treating
Delirium in the Intensive Care Unit. PSNet [internet]. 2012.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/web-mm/wandering-floors-safety-and-security-risks-patient-wandering
August 21, 2007 - SPOTLIGHT CASE
Wandering Off the Floors: Safety and Security Risks of Patient Wandering
Citation Text:
Smith TA. Wandering Off the Floors: Safety and Security Risks of Patient Wandering. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Huma…
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psnet.ahrq.gov/node/49497/psn-pdf
December 01, 2005 - Slippery Slide Into Life
December 1, 2005
Halamek LP. Slippery Slide Into Life. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/slippery-slide-life
The Case
A 25-year-old woman presented to the hospital in labor and at full gestation after receiving uncomplicated
prenatal care. A third-year obstetrics and g…
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-42
September 26, 2017 - Commentary
ISMP medication error report analysis.
Citation Text:
Cohen MR, Smetzer JL. Oral Syringes: A Crucial and Economical Risk-Reduction Strategy that has Not Been Fully Utilized; Caution regarding Once-Weekly Levothyroxine; When Drug Strengths Differ by 10-Fold; Lower Colchicine Do…
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psnet.ahrq.gov/issue/unaccountable-what-hospitals-wont-tell-you-and-how-transparency-can-revolutionize-health-care
July 07, 2021 - Book/Report
Unaccountable: What Hospitals Won't Tell You and How Transparency Can Revolutionize Health Care.
Citation Text:
Unaccountable: What Hospitals Won't Tell You and How Transparency Can Revolutionize Health Care. Makary M. New York, NY: Bloomsbury Press; 2012. ISBN: 9781608198368…
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psnet.ahrq.gov/issue/creating-communication-coaching-structure-and-support-your-crp-program
January 25, 2023 - Webinar
Creating a Communication Coaching Structure and Support for your CRP Program.
Citation Text:
Creating a Communication Coaching Structure and Support for your CRP Program. Collaborative for Accountability and Improvement. September 15, 2022.
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psnet.ahrq.gov/issue/untold-story-cyberattack-hospital-and-dying-woman
August 25, 2021 - Newspaper/Magazine Article
The untold story of a cyberattack, a hospital and a dying woman.
Citation Text:
The untold story of a cyberattack, a hospital and a dying woman. Ralston W. Wired Magazine. November 11, 2020.
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psnet.ahrq.gov/issue/pain-was-unbearable-so-why-did-doctors-turn-her-away
November 25, 2020 - Newspaper/Magazine Article
The pain was unbearable. So why did doctors turn her away?
Citation Text:
The pain was unbearable. So why did doctors turn her away? Szalavitz M. Wired Magazine. August 11, 2021.
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P…
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psnet.ahrq.gov/issue/drug-name-confusion-preventing-medication-errors
January 29, 2018 - Newspaper/Magazine Article
Drug name confusion: preventing medication errors.
Citation Text:
Rados C. Drug name confusion: preventing medication errors. FDA consumer. 2005;39(4):35-7.
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Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote …
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psnet.ahrq.gov/issue/patient-safety-private-hospitals-known-and-unknown-risk
June 18, 2013 - Book/Report
Patient Safety in Private Hospitals: the Known and the Unknown Risk.
Citation Text:
Patient Safety in Private Hospitals: the Known and the Unknown Risk. Leys C, Toft B. London, UK: Centre for Health and the Public Interest; August 2014.
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psnet.ahrq.gov/issue/first-annual-review-data-submitted-ismp-national-vaccine-errors-reporting-program-verp
June 10, 2018 - Newspaper/Magazine Article
First annual review of data submitted to the ISMP National Vaccine Errors Reporting Program (VERP).
Citation Text:
First annual review of data submitted to the ISMP National Vaccine Errors Reporting Program (VERP). ISMP Medication Safety Alert! Acute Care Editi…
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psnet.ahrq.gov/issue/strengthen-your-resolve-no-unlabeled-containers-anywhere-ever
November 16, 2015 - Newspaper/Magazine Article
Strengthen your resolve: no unlabeled containers anywhere, ever!
Citation Text:
Strengthen your resolve: no unlabeled containers anywhere, ever! ISMP Medication Safety Alert! Acute Care Edition. November 6, 2014;19:1-4.
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psnet.ahrq.gov/issue/fda-advise-err-avoid-using-error-prone-abbreviation-tpa
April 29, 2015 - Newspaper/Magazine Article
FDA Advise-ERR: avoid using the error-prone abbreviation, TPA.
Citation Text:
FDA Advise-ERR: avoid using the error-prone abbreviation, TPA. ISMP Medication Safety Alert! Acute Care Edition. September 24, 2015;20:1,4-5.
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psnet.ahrq.gov/issue/sops-nursing-home-survey-what-you-need-know
May 29, 2013 - Meeting/Conference Proceedings
SOPS Nursing Home Survey: What You Need to Know.
Citation Text:
SOPS Nursing Home Survey: What You Need to Know. Agency for Healthcare Research and Quality. May 3, 2022.
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psnet.ahrq.gov/issue/widows-mission-change-nc-dental-sedation-rules
March 10, 2021 - Newspaper/Magazine Article
A widow’s mission to change NC dental sedation rules.
Citation Text:
A widow’s mission to change NC dental sedation rules. Blythe A. NC Health News. March 10, 2022
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psnet.ahrq.gov/issue/ers-are-swamped-seriously-ill-patients-although-many-dont-have-covid
November 01, 2023 - Newspaper/Magazine Article
ERs are swamped with seriously ill patients, although many don’t have Covid.
Citation Text:
ERs are swamped with seriously ill patients, although many don’t have Covid. Wells K. Health Shots. National Public Radio. October 29, 2021.
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psnet.ahrq.gov/issue/analysis-reported-drug-interactions-recipe-harm-patients
January 20, 2016 - Newspaper/Magazine Article
Analysis of reported drug interactions: a recipe for harm to patients.
Citation Text:
Analysis of reported drug interactions: a recipe for harm to patients. Grissinger M. PA-PSRS Patient Saf Advis. December 2016;13:137-148.
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psnet.ahrq.gov/issue/serious-reportable-events-massachusetts
May 03, 2023 - Book/Report
Serious Reportable Events in Massachusetts.
Citation Text:
Serious Reportable Events in Massachusetts. Fillo KT, Saunders K. Bureau of Health Care Safety and Quality, Department of Public Health. Boston, MA: Commonwealth of Massachusetts; 2023.
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