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461. The association between hospital characteristics and rates of preventable complications and adverse events. | PSNet
     psnet.ahrq.gov/issue/association-between-hospital-characteristics-and-rates-preventable-complications-and-adverse
     April 17, 2009 - Study The association between hospital characteristics and rates of preventable complications and adverse events. Citation Text: The association between hospital characteristics and rates of preventable complications and adverse events. Thornlow DK; Stukenborg GJ. Copy Citation …

462. Seven Leadership Leverage Points for Organization-Level Improvement in Health Care. Second edition. | PSNet
     psnet.ahrq.gov/issue/seven-leadership-leverage-points-organization-level-improvement-health-care
     November 18, 2011 - Book/Report Seven Leadership Leverage Points for Organization-Level Improvement in Health Care. Second edition. Citation Text: Seven Leadership Leverage Points for Organization-Level Improvement in Health Care. Second edition. Reinertsen JL, Bisognano M, Pugh MD. Cambridge, MA: Institute…

463. The other big drug problem: older people taking too many pills. | PSNet
     psnet.ahrq.gov/issue/other-big-drug-problem-older-people-taking-too-many-pills
     December 14, 2016 - Newspaper/Magazine Article The other big drug problem: older people taking too many pills. Citation Text: The other big drug problem: older people taking too many pills. Boodman SG. Washington Post. December 9, 2017. Copy Citation Save Save to your library P…

464. Joshua’s Story. | PSNet
     psnet.ahrq.gov/issue/joshuas-story
     February 26, 2014 - Audiovisual Joshua’s Story. Citation Text: Joshua’s Story. Anderson-Wallace M, Denning R. Leeds, UK: Patient Stories; October 18, 2014. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter Linkedin …

465. Artificial intelligence will improve medical treatments. | PSNet
     psnet.ahrq.gov/issue/artificial-intelligence-will-improve-medical-treatments
     February 06, 2019 - Newspaper/Magazine Article Artificial intelligence will improve medical treatments. Citation Text: Artificial intelligence will improve medical treatments. The Economist. June 7, 2018. Copy Citation Save Save to your library Print Download PDF …

466. Misadministration of IV insulin associated with dose measurement and hyperkalemia treatment. | PSNet
     psnet.ahrq.gov/issue/misadministration-iv-insulin-associated-dose-measurement-and-hyperkalemia-treatment
     August 24, 2016 - Newspaper/Magazine Article Misadministration of IV insulin associated with dose measurement and hyperkalemia treatment. Citation Text: Misadministration of IV insulin associated with dose measurement and hyperkalemia treatment. ISMP Medication Safety Alert! Acute Care Edition. August 11,…

467. An Introduction to the Improved FDA Prescription Drug Labeling. | PSNet
     psnet.ahrq.gov/issue/introduction-improved-fda-prescription-drug-labeling
     September 29, 2010 - Meeting/Conference Proceedings An Introduction to the Improved FDA Prescription Drug Labeling. Citation Text: An Introduction to the Improved FDA Prescription Drug Labeling. Silver Spring MD; US Food and Drug Administration: 2006. Copy Citation Save Save to yo…

468. Opening the Door to Change. NHS Safety Culture and the Need for Transformation. | PSNet
     psnet.ahrq.gov/issue/opening-door-change-nhs-safety-culture-and-need-transformation
     February 08, 2017 - Book/Report Opening the Door to Change. NHS Safety Culture and the Need for Transformation. Citation Text: Opening the Door to Change. NHS Safety Culture and the Need for Transformation. Newcastle upon Tyne, UK: Care Quality Commission; December 2018. Copy Citation Save…

469. Patient Safety: Investigating and Reporting Serious Clinical Incidents. | PSNet
     psnet.ahrq.gov/issue/patient-safety-investigating-and-reporting-serious-clinical-incidents
     November 10, 2017 - Book/Report Patient Safety: Investigating and Reporting Serious Clinical Incidents. Citation Text: Patient Safety: Investigating and Reporting Serious Clinical Incidents. Kelsey R. CRC Press: Boca Raton, FL; 2017. ISBN: 9781498781169. Copy Citation Save Save to yo…

470. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49511/psn-pdf
     May 01, 2006 - Citrate Mix-Up May 1, 2006 Weber RJ. Citrate Mix-Up. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/citrate-mix The Case A 36-year-old woman with multiple sclerosis, diabetes, and chronic renal failure was transferred from a skilled nursing facility (SNF) to the hospital for treatment of an infection. On a…

471. Beeline to Spine | PSNet
     psnet.ahrq.gov/web-mm/beeline-spine
     March 01, 2014 - SPOTLIGHT CASE Beeline to Spine Citation Text: Smetana GW. Beeline to Spine. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endno…

472. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49537/psn-pdf
     June 01, 2007 - Beeline to Spine June 1, 2007 Smetana GW. Beeline to Spine. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/beeline-spine Case Objectives Understand the elements of preoperative medical evaluation. Appreciate the limited role for preoperative laboratory testing. Appreciate the importance of communication a…

473. Diagnostic errors in primary care: lessons learned. | PSNet
     psnet.ahrq.gov/issue/diagnostic-errors-primary-care-lessons-learned
     September 12, 2011 - Study Diagnostic errors in primary care: lessons learned. Citation Text: Ely JW, Kaldjian LC, D'Alessandro DM. Diagnostic errors in primary care: lessons learned. J Am Board Fam Med. 2012;25(1):87-97. doi:10.3122/jabfm.2012.01.110174. Copy Citation Format: DOI Google Scho…

474. Safety paradoxes and safety culture. | PSNet
     psnet.ahrq.gov/issue/safety-paradoxes-and-safety-culture
     February 06, 2008 - Commentary Safety paradoxes and safety culture. Citation Text: Reason J. Safety paradoxes and safety culture. Inj Control Safety Promot. 2003;7(1):3-14. doi:10.1076/1566-0974(200003)7:1;1-v;ft003. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML …

475. Beyond the organisational accident: the need for "error wisdom" on the frontline. | PSNet
     psnet.ahrq.gov/issue/beyond-organisational-accident-need-error-wisdom-frontline
     November 18, 2015 - Commentary Beyond the organisational accident: the need for "error wisdom" on the frontline. Citation Text: Reason J. Beyond the organisational accident: the need for "error wisdom" on the frontline. Qual Saf Health Care. 2004;13 Suppl 2:ii28-33. Copy Citation Format: Goo…

476. Solicitation for written comments on draft National Action Plan for Adverse Drug Event Prevention. | PSNet
     psnet.ahrq.gov/issue/solicitation-written-comments-draft-national-action-plan-adverse-drug-event-prevention
     October 21, 2016 - Government Resource Solicitation for written comments on draft National Action Plan for Adverse Drug Event Prevention. Citation Text: Solicitation for written comments on draft National Action Plan for Adverse Drug Event Prevention. Federal Register. Washington, DC: Office of Disease…

477. Using the ISMP Medication Safety Self-Assessment to improve medication use processes. | PSNet
     psnet.ahrq.gov/issue/using-ismp-medication-safety-self-assessment-improve-medication-use-processes
     January 05, 2017 - Study Using the ISMP Medication Safety Self-Assessment to improve medication use processes. Citation Text: Lesar TS, Mattis A, Anderson E, et al. Using the ISMP Medication Safety Self-Assessment to improve medication use processes. Jt Comm J Qual Saf. 2003;29(5):211-26. Copy Citation …

478. Luer Connector Misconnections: Under-Recognized but Potentially Dangerous Events. | PSNet
     psnet.ahrq.gov/issue/luer-connector-misconnections-under-recognized-potentially-dangerous-events
     May 24, 2015 - Multi-use Website Luer Connector Misconnections: Under-Recognized but Potentially Dangerous Events. Citation Text: Luer Connector Misconnections: Under-Recognized but Potentially Dangerous Events. Medical Product Safety Network. Silver Spring, MD; US Food and Drug Administration. Novembe…

479. Clearing the Error: Using Public Deliberation to Define Patient Roles as Partners in the Diagnostic Process. | PSNet
     psnet.ahrq.gov/issue/clearing-error-using-public-deliberation-define-patient-roles-partners-diagnostic-process
     September 13, 2016 - Book/Report Clearing the Error: Using Public Deliberation to Define Patient Roles as Partners in the Diagnostic Process. Citation Text: Clearing the Error: Using Public Deliberation to Define Patient Roles as Partners in the Diagnostic Process. St. Paul, MN: Society to Improve Diagnosis …

480. Establishing a culture for patient safety - the role of education. | PSNet
     psnet.ahrq.gov/issue/establishing-culture-patient-safety-role-education
     August 23, 2017 - Commentary Establishing a culture for patient safety - the role of education. Citation Text: Milligan FJ. Establishing a culture for patient safety - the role of education. Nurse Educ Today. 2007;27(2):95-102. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 …