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  1. 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. Copy Citation Forma…
  2. Psn-Pdf (pdf file)

    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…
  3. 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
  4. Psn-Pdf (pdf file)

    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…
  5. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  6. 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. Copy Citatio…
  7. 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…
  8. psnet.ahrq.gov/primer/personal-health-literacy
    October 31, 2023 - events include medication errors , communication errors , patients with serious conditions including diabetic
  9. Psn-Pdf (pdf file)

    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…
  10. 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…
  11. 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
  12. Psn-Pdf (pdf file)

    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…
  13. 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.…
  14. 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…
  15. 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. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL …
  16. Psn-Pdf (pdf file)

    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…
  17. Psn-Pdf (pdf file)

    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.…
  18. 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
  19. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  20. 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. Copy Citation Format: DOI Googl…

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