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psnet.ahrq.gov/issue/smart-pumps-practice-survey-results-reveal-widespread-use-optimization-challenging
December 27, 2018 - Newspaper/Magazine Article
Smart pumps in practice: survey results reveal widespread use, but optimization is challenging.
Citation Text:
Smart pumps in practice: survey results reveal widespread use, but optimization is challenging. ISMP Medication Safety Alert! Acute Care Edition. Apri…
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psnet.ahrq.gov/issue/common-formats-patient-safety-data-collection-diagnostic-safety-01
May 19, 2021 - Press Release/Announcement
Common Formats for Patient Safety Data Collection: Diagnostic Safety 0.1.
Citation Text:
Common Formats for Patient Safety Data Collection: Diagnostic Safety 0.1. The Agency for Healthcare Research and Quality. Fed Register. 2021;86(103): 29263-29264.
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psnet.ahrq.gov/issue/medication-reconciliation-acute-care-setting-opportunity-and-challenge-nursing
June 02, 2021 - Commentary
Medication reconciliation in the acute care setting: opportunity and challenge for nursing.
Citation Text:
Sullivan C, Gleason KM, Rooney D, et al. Medication reconciliation in the acute care setting: opportunity and challenge for nursing. J Nurs Care Qual. 2005;20(2):95-98.…
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psnet.ahrq.gov/issue/next-generation-doctors-may-be-learning-bad-habits-teaching-hospitals-many-safety-violations
June 28, 2023 - Newspaper/Magazine Article
The next generation of doctors may be learning bad habits at teaching hospitals with many safety violations.
Citation Text:
The next generation of doctors may be learning bad habits at teaching hospitals with many safety violations. Blau M. STAT. April 20, 2018…
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psnet.ahrq.gov/issue/staying-safe-simple-tools-safe-surgery
August 02, 2015 - Commentary
Staying safe: simple tools for safe surgery.
Citation Text:
Karl RC. Staying safe: simple tools for safe surgery. Bull Am Coll Surg. 2007;92(4):16-22.
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…
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psnet.ahrq.gov/issue/opioids-iatrogenic-harm-and-disclosure-medical-error
November 21, 2021 - Commentary
Opioids, iatrogenic harm and disclosure of medical error.
Citation Text:
Blinderman CD. Opioids, iatrogenic harm and disclosure of medical error. J Pain Symptom Manage. 2010;39(2):309-13. doi:10.1016/j.jpainsymman.2009.11.242.
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psnet.ahrq.gov/issue/2012-ismp-international-medication-safety-self-assessment-oncology
January 26, 2023 - Press Release/Announcement
2012 ISMP International Medication Safety Self Assessment for Oncology.
Citation Text:
2012 ISMP International Medication Safety Self Assessment for Oncology. Institute for Safe Medication Practices and Institute for Safe Medication Practices Canada.
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psnet.ahrq.gov/issue/healthgrades-quality-study-fifth-annual-patient-safety-american-hospitals-study
August 27, 2013 - Book/Report
HealthGrades Quality Study: Fifth Annual Patient Safety in American Hospitals Study.
Citation Text:
HealthGrades Quality Study: Fifth Annual Patient Safety in American Hospitals Study. Golden, CO: HealthGrades, Inc.; April 2008.
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psnet.ahrq.gov/issue/detection-patient-risk-nurses-theoretical-framework
September 24, 2010 - Commentary
Detection of patient risk by nurses: a theoretical framework.
Citation Text:
Despins LA, Scott-Cawiezell J, Rouder JN. Detection of patient risk by nurses: a theoretical framework. J Adv Nurs. 2010;66(2). doi:10.1111/j.1365-2648.2009.05215.x.
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psnet.ahrq.gov/issue/interruptions-and-medication-errors-part-i
January 03, 2017 - Commentary
Interruptions and medication errors: part I.
Citation Text:
Flanders S, Clark AP. Interruptions and medication errors: part I. Clin Nurse Spec. 2010;24(6):281-5. doi:10.1097/NUR.0b013e3181faf78b.
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psnet.ahrq.gov/node/49528/psn-pdf
January 01, 2015 - The "Customer" Is Always Right
February 1, 2007
Sehgal NL. The "Customer" Is Always Right. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/customer-always-right
Case Objectives
Understand the importance of identifying a patient's agenda.
Appreciate the factors that contribute to unmet patient expectations.
…
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psnet.ahrq.gov/node/852808/psn-pdf
August 30, 2023 - Prolonged DKA in Pregnancy: A Case of Communication
Breakdown.
August 30, 2023
Marshall S, Boe NM. Prolonged DKA in Pregnancy: A Case of Communication Breakdown. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown
Disclosure of Relevant Financial Relationship…
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psnet.ahrq.gov/sites/default/files/2023-08/spotlight_case_prolonged_dka_in_pregnancy_-_slides_-_revised.pdf
January 01, 2023 - Spotlight
Spotlight
Prolonged DKA in Pregnancy: A Case of Communication
Breakdown
Source and Credits
• This presentation is based on the August 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Sarah Marshall, MD and Nina M. …
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psnet.ahrq.gov/node/49633/psn-pdf
September 01, 2011 - The Safety and Quality of Long Term Care
September 1, 2011
Vogelsmeier AA. The Safety and Quality of Long Term Care. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/safety-and-quality-long-term-care
Case Objectives
Identify commonly reported adverse events in long-term care.
Identify two to three challenges…
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psnet.ahrq.gov/node/865376/psn-pdf
March 27, 2024 - Navigating Chaos: Fatal Iatrogenic Liver Injury in a
Patient Admitted for Leg Fractures
March 27, 2024
Loseth C. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admi…
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psnet.ahrq.gov/node/33696/psn-pdf
June 01, 2010 - In Conversation with…Pat Croskerry, MD, PhD
June 1, 2010
In Conversation with…Pat Croskerry, MD, PhD. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/conversation-withpat-croskerry-md-phd
Editor's note: Pat Croskerry, MD, PhD, is a professor in emergency medicine at Dalhousie University in
Halifax, Nova…
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psnet.ahrq.gov/node/33738/psn-pdf
December 01, 2012 - In Conversation With... John G. Reiling, PhD
December 1, 2012
In Conversation With.. John G. Reiling, PhD. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-john-g-reiling-phd
Editor's note: John G. Reiling, PhD, is president and CEO of Safe by Design. Dr. Reiling consults with
hospitals and…
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psnet.ahrq.gov/node/33635/psn-pdf
July 01, 2006 - In Conversation with...Allan Frankel, MD
July 1, 2006
In Conversation with..Allan Frankel, MD. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-withallan-frankel-md
Dr. Robert Wachter, Editor, AHRQ WebM&M: Tell us a little bit about how you became interested in this
kind of work.
Dr. Allan …
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psnet.ahrq.gov/node/33818/psn-pdf
November 01, 2016 - In Conversation With… Andrew Bindman, MD
November 1, 2016
In Conversation With… Andrew Bindman, MD. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-andrew-bindman-md
Editor's note: Dr. Bindman was appointed as Director of the Agency for Healthcare Research and Quality
(AHRQ) in May 2016. P…
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psnet.ahrq.gov/web-mm/dangerous-dialysis
June 12, 2024 - SPOTLIGHT CASE
Dangerous Dialysis
Citation Text:
Holley JL. Dangerous Dialysis . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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