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psnet.ahrq.gov/node/49710/psn-pdf
May 01, 2014 - is currently being studied to determine if it can help decrease readmissions, adverse
events, and deaths
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psnet.ahrq.gov/node/33711/psn-pdf
May 01, 2011 - Medicine's report on medical mistakes, To Err is Human, described surprising numbers of
projected deaths
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psnet.ahrq.gov/web-mm/miscalculated-risk
March 01, 2015 - Confusion between opioid analgesics results in deaths. USP Quality Review No. 46. February 1995.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.113_slideshow.ppt
January 01, 2006 - Embolism
More than 100,000 people die from PE per year in U.S.
30-day mortality of PE is 10%
50% of deaths
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psnet.ahrq.gov/node/33619/psn-pdf
September 01, 2005 - whether it would be worthwhile to try to repeat the studies that
led to the estimates of 44,000-98,000 deaths
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psnet.ahrq.gov/web-mm/cultural-dimensions-depression
September 01, 2018 - December 23, 2020
Retrospective analysis of reported suicide deaths and attempts on Veterans
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psnet.ahrq.gov/web-mm/walking-out-hospital-after-attempted-suicide
March 29, 2023 - June 30, 2021
Retrospective analysis of reported suicide deaths and attempts on Veterans
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psnet.ahrq.gov/node/49492/psn-pdf
November 01, 2005 - 100,000 Lives Campaign (4) to promote six changes proven to improve patient care
and prevent avoidable deaths
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psnet.ahrq.gov/web-mm/finding-fault-default-alert
August 28, 2024 - to identify incident characteristics and contributing factors for medical or surgical complication deaths
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psnet.ahrq.gov/web-mm/mid-summer-fog
September 29, 2017 - The clinical transformation of Ascension Health: eliminating all preventable injuries and deaths
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psnet.ahrq.gov/web-mm/double-dosing-rules
February 03, 2010 - May 19, 2021
Association of unexpected newborn deaths with changes in obstetric and neonatal
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psnet.ahrq.gov/node/49872/psn-pdf
August 08, 2019 - Spinal Epidural Abscess
August 8, 2019
Lu Y, Salvador D. Spinal Epidural Abscess. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/spinal-epidural-abscess
The Case
A 30-year-old woman with a history of prior spine surgery presented to the emergency department with a
few days of progressive low back pain. She…
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psnet.ahrq.gov/node/50930/psn-pdf
February 21, 2020 - Pharmacist Role in Patient Safety
February 21, 2020
Dopp AL, Hall KK. Pharmacist Role in Patient Safety. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/pharmacist-role-patient-safety
Background: The Evolving Role of the Pharmacist
Medication errors are highly pervasive across all settings of care,[1] w…
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psnet.ahrq.gov/web-mm/lapse-antibiotics-leads-sepsis
November 21, 2021 - Lapse in Antibiotics Leads to Sepsis
Citation Text:
Levy MM. Lapse in Antibiotics Leads to Sepsis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/two-pills-same-drug
May 27, 2011 - Two Pills, Same Drug
Citation Text:
Horsky J, Patel VL. Two Pills, Same Drug. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/web-mm/right-electrocardiogram-wrong-patient
April 24, 2024 - Right Electrocardiogram, Wrong Patient
Citation Text:
Chen C, Venugopal S. Right Electrocardiogram, Wrong Patient. 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/bleeding-risk
November 01, 2003 - Bleeding Risk
Citation Text:
Crowther MA. Bleeding Risk. 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/web-mm/acute-care-admission-behavioral-health-patient
July 19, 2023 - Acute Care Admission of the Behavioral Health Patient
Citation Text:
Weiss AP, Rosenbaum JF. Acute Care Admission of the Behavioral Health Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/web-mm/local-anesthesia-induced-coma-during-total-knee-arthroplasty
October 27, 2021 - Local Anesthesia-Induced Coma During Total Knee Arthroplasty.
Citation Text:
Aldwinckle R. Local Anesthesia-Induced Coma During Total Knee Arthroplasty.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/web-mm/2-week-itch
June 16, 2019 - The 2-Week Itch
Citation Text:
Cohen MR. The 2-Week Itch. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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