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psnet.ahrq.gov/issue/new-technology-new-errors-how-prime-upgrade-insulin-infusion-pump
July 14, 2010 - Commentary
New technology, new errors: how to prime an upgrade of an insulin infusion pump.
Citation Text:
Rule AM, Drincic A, Galt K. New technology, new errors: how to prime an upgrade of an insulin infusion pump. Jt Comm J Qual Patient Saf. 2007;33(3):155-62.
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psnet.ahrq.gov/node/49514/psn-pdf
July 01, 2006 - One ACE Too Many
July 1, 2006
Juurlink DN. One ACE Too Many. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/one-ace-too-many
The Case
A 72-year-old man with coronary artery disease, diabetes, and recently diagnosed congestive heart failure
presented to the emergency department (ED) with chest pain. An acut…
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psnet.ahrq.gov/web-mm/no-news-may-not-be-good-news
December 07, 2009 - blood sugar was now 450 mg/dL and she had moderate ketones on a urinalysis (showing early signs of diabetic
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psnet.ahrq.gov/node/45458/psn-pdf
November 30, 2016 - Request for comments on the proposed measures and
2020 targets for the National Action Plan for Adverse Drug
Event Prevention: inpatient and outpatient measures for
reduction of adverse drug events from anticoagulants,
diabetes agents, and opioid analgesics.
November 30, 2016
Office of Disease Prevention and Heal…
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psnet.ahrq.gov/web-mm/mid-summer-fog
September 29, 2017 - A Mid-Summer Fog
Citation Text:
Braddock CH. A Mid-Summer Fog. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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…
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psnet.ahrq.gov/issue/accuracy-popular-online-symptom-checker-ophthalmic-diagnoses
March 04, 2011 - Study
Accuracy of a popular online symptom checker for ophthalmic diagnoses.
Citation Text:
Shen C, Nguyen M, Gregor A, et al. Accuracy of a Popular Online Symptom Checker for Ophthalmic Diagnoses. JAMA Ophthalmol. 2019;137(6):690-692. doi:10.1001/jamaophthalmol.2019.0571.
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psnet.ahrq.gov/issue/literature-review-individual-and-systems-factors-contribute-medication-errors-nursing
April 22, 2011 - Review
A literature review of the individual and systems factors that contribute to medication errors in nursing practice.
Citation Text:
Brady A-M, Malone A-M, Fleming S. A literature review of the individual and systems factors that contribute to medication errors in nursing practice…
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psnet.ahrq.gov/primer/personal-health-literacy
October 31, 2023 - events include medication errors , communication errors , patients with serious conditions including diabetic
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psnet.ahrq.gov/node/49733/psn-pdf
May 01, 2015 - Transitions in Adolescent Medicine
May 1, 2015
Okumura MJ, Williams RG. Transitions in Adolescent Medicine. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/transitions-adolescent-medicine
The Case
A 21-year-old woman with a history of Marfan syndrome complicated by aortic root dilation presented to the
emer…
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psnet.ahrq.gov/issue/insulin-pump-associated-adverse-events-qualitative-descriptive-study-clinical-consequences
May 19, 2018 - Study
Insulin pump-associated adverse events: a qualitative descriptive study of clinical consequences and potential root causes.
Citation Text:
Estock JL, Codario RA, Keddem S, et al. Insulin pump-associated adverse events: a qualitative descriptive study of clinical consequences and po…
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psnet.ahrq.gov/perspective/conversation-kathleen-sutcliffe-mn-phd
April 26, 2023 - One resident said that he had a patient once who was a 16-year-old diabetic who had a horrible infection
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psnet.ahrq.gov/node/866579/psn-pdf
August 28, 2024 - Infection After Carpal Tunnel Surgery
August 28, 2024
Szabo RM. Infection After Carpal Tunnel Surgery. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/infection-after-carpal-tunnel-surgery
The Case
A woman presented for surgery on her right wrist as a treatment for carpal tunnel syndrome. There were no
repo…
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psnet.ahrq.gov/issue/unintentional-therapeutic-errors-involving-insulin-ambulatory-setting-reported-poison-centers
June 06, 2018 - Study
Unintentional therapeutic errors involving insulin in the ambulatory setting reported to poison centers.
Citation Text:
Spiller HA, Borys DJ, Ryan ML, et al. Unintentional therapeutic errors involving insulin in the ambulatory setting reported to poison centers. Ann Pharmacother.…
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psnet.ahrq.gov/issue/factors-influence-recognition-reporting-and-resolution-incidents-related-medical-devices-and
July 08, 2015 - Review
Factors that influence the recognition, reporting and resolution of incidents related to medical devices and other healthcare technologies: a systematic review.
Citation Text:
Polisena J, Gagliardi AR, Urbach DR, et al. Factors that influence the recognition, reporting and resolut…
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psnet.ahrq.gov/issue/poetry-and-medicine-mistakes
September 25, 2019 - Commentary
Poetry and Medicine. Mistakes.
Citation Text:
Poetry and Medicine. Mistakes. Kittleson M. JAMA. 2019;322:984.
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psnet.ahrq.gov/node/45714/psn-pdf
December 20, 2017 - US emergency department visits for outpatient adverse
drug events, 2013–2014.
December 20, 2017
Shehab N, Lovegrove MC, Geller AI, et al. US Emergency Department Visits for Outpatient Adverse Drug
Events, 2013-2014. JAMA. 2016;316(20):2115-2125. doi:10.1001/jama.2016.16201.
https://psnet.ahrq.gov/issue/us-emergenc…
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psnet.ahrq.gov/node/44427/psn-pdf
October 13, 2015 - Problem list completeness in electronic health records: a
multi-site study and assessment of success factors.
October 13, 2015
Wright A, McCoy AB, Hickman T-TT, et al. Problem list completeness in electronic health records: A multi-
site study and assessment of success factors. Int J Med Inform. 2015;84(10):784-90.…
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psnet.ahrq.gov/web-mm/double-trouble
August 01, 2012 - Since the patient’s prior diabetic history is not described, we do not know whether he was started on
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psnet.ahrq.gov/web-mm/one-ace-too-many
June 21, 2016 - One ACE Too Many
Citation Text:
Juurlink DN. One ACE Too Many. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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…
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psnet.ahrq.gov/issue/creating-culture-safety-coaching-clinicians-competence
January 10, 2024 - Commentary
Creating a culture of safety by coaching clinicians to competence.
Citation Text:
Duff B. Creating a culture of safety by coaching clinicians to competence. Nurse Educ Today. 2013;33(10):1108-11. doi:10.1016/j.nedt.2012.05.025.
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DOI Googl…