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psnet.ahrq.gov/node/49494/psn-pdf
January 01, 2006 - Moreover, any system-based oversight must be educational; for example, when an intern is directed
not
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psnet.ahrq.gov/node/33665/psn-pdf
March 01, 2008 - In addition, procedures that were previously directed to interventional radiology are
now conducted
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psnet.ahrq.gov/node/74206/psn-pdf
December 22, 2021 - Direct oral anticoagulant-related medication incidents and
pharmacists' interventions in hospital in-patients:
evaluation using Reason's accident causation theory.
December 22, 2021
Haque H, Alrowily A, Jalal Z, et al. Direct oral anticoagulant-related medication incidents and pharmacists’
interventions in hospita…
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psnet.ahrq.gov/node/48181/psn-pdf
August 07, 2019 - Managing the risks of direct oral anticoagulants.
August 7, 2019
Sentinel Event Alert. July 30, 2019;(61):1-5.
https://psnet.ahrq.gov/issue/managing-risks-direct-oral-anticoagulants
Anticoagulant medications are known to be high-risk for adverse drug events. Although direct oral
anticoagulants (DOACs) require less…
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psnet.ahrq.gov/node/851348/psn-pdf
July 12, 2023 - Widespread misinterpretation of advance directives and
Portable Orders for Life-Sustaining Treatments threatens
patient safety and causes undertreatment and
overtreatment.
July 12, 2023
Mirarchi FL, Pope TM. Widespread misinterpretation of advance directives and Portable Orders for Life-
Sustaining Treatments thr…
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psnet.ahrq.gov/node/50401/psn-pdf
October 02, 2019 - Discrepant advanced directives and code status orders: a
preventable medical error.
October 2, 2019
Meisenberg B, Zaidi S, Franks L, et al. Discrepant Advanced Directives and Code Status Orders: A
Preventable Medical Error. J Hosp Med. 2019;14(10):716-718. doi:10.12788/jhm.3244.
https://psnet.ahrq.gov/issue/discre…
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psnet.ahrq.gov/node/866348/psn-pdf
July 24, 2024 - How can interventions more directly address drivers of
unprofessional behaviour between healthcare staff?
July 24, 2024
Aunger JA, Abrams R, Mannion R, et al. How can interventions more directly address drivers of
unprofessional behaviour between healthcare staff? BMJ Open Qual. 2024;13(3):e002830.
doi:10.1136/bmj…
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psnet.ahrq.gov/node/866859/psn-pdf
October 02, 2024 - Severe hypertension in pregnancy: progress made and
future directions for patient safety, quality improvement,
and implementation of a patient safety bundle.
October 2, 2024
Prior A, Taylor I, Gibson KS, et al. Severe hypertension in pregnancy: progress made and future directions
for patient safety, quality improv…
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psnet.ahrq.gov/node/60849/psn-pdf
January 01, 2021 - Associations between double-checking and medication
administration errors: a direct observational study of
paediatric inpatients.
August 26, 2020
Westbrook JI, Li L, Raban MZ, et al. Associations between double-checking and medication administration
errors: a direct observational study of paediatric inpatients. BM…
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psnet.ahrq.gov/node/837631/psn-pdf
July 06, 2022 - The impact of an electronic alert to reduce the risk of co-
prescription of low molecular weight heparins and direct
oral anticoagulants.
July 6, 2022
Brown A, Cavell G, Dogra N, et al. The impact of an electronic alert to reduce the risk of co-prescription of
low molecular weight heparins and direct oral anticoag…
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psnet.ahrq.gov/node/73095/psn-pdf
March 31, 2021 - Work effort, readability and quality of pharmacy
transcription of patient directions from electronic
prescriptions: a retrospective observational cohort
analysis.
March 31, 2021
Zheng Y, Jiang Y, Dorsch MP, et al. Work effort, readability and quality of pharmacy transcription of patient
directions from electronic…
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psnet.ahrq.gov/node/43987/psn-pdf
March 25, 2015 - Emergency physicians' views of direct notification of
laboratory and radiology results to patients using the
internet: a multisite survey.
March 25, 2015
Callen J, Giardina TD, Singh H, et al. Emergency physicians' views of direct notification of laboratory and
radiology results to patients using the Internet: a m…
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psnet.ahrq.gov/node/50567/psn-pdf
October 23, 2019 - Diagnostic errors in the neonatal intensive care unit: state
of the science and new directions.
October 23, 2019
Shafer G, Singh H, Suresh G. Diagnostic errors in the neonatal intensive care unit: State of the science and
new directions. Semin Perinatol. 2019;43(8):151175. doi:10.1053/j.semperi.2019.08.004.
https:…
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psnet.ahrq.gov/node/842769/psn-pdf
January 18, 2023 - Production pressure and its relationship to safety: a
systematic review and future directions.
January 18, 2023
Hashemian SM, Triantis K. Production pressure and its relationship to safety: a systematic review and
future directions. Safety Sci. 2023;159:106045. doi:10.1016/j.ssci.2022.106045.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/837971/psn-pdf
September 01, 2022 - Frailty and potentially inappropriate prescribing in older
people with polypharmacy: a bi-directional relationship?
September 1, 2022
Randles MA. Frailty and potentially inappropriate prescribing in older people with polypharmacy: a bi-
directional relationship? Drugs Aging. 2022;39(8):597-606. doi:10.1007/s40266-0…
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psnet.ahrq.gov/node/49762/psn-pdf
June 01, 2016 - The Case of Mistaken Intubation
June 1, 2016
Silveira MJ. The Case of Mistaken Intubation. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/case-mistaken-intubation
Case Objectives
Appreciate that most older adults and many younger chronically ill patients have discussed or
documented their preferences for l…
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psnet.ahrq.gov/node/60843/psn-pdf
August 26, 2020 - Scoping review of patients' attitudes about their role and
behaviours to ensure safe care at the direct care level.
August 26, 2020
Duhn L, Godfrey C, Medves J. Scoping review of patients’ attitudes about their role and behaviours to
ensure safe care at the direct care level. Health Expect. 2020;23(5):979-991. doi:…
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psnet.ahrq.gov/node/843089/psn-pdf
May 01, 2020 - Direct observation of depression screening: identifying
diagnostic error and improving accuracy through
unannounced standardized patients.
May 1, 2020
Schwartz A, Peskin S, Spiro A, et al. Direct observation of depression screening: identifying diagnostic
error and improving accuracy through unannounced standardiz…
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psnet.ahrq.gov/node/49563/psn-pdf
May 01, 2008 - Is It Safe to Be Direct?
May 1, 2008
Kulkarni NS, Williams M. Is It Safe to Be Direct? PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/it-safe-be-direct
The Case
A 92-year-old man with hypertension and heart failure (HF) was evaluated by his primary care physician
(PCP) for progressive shortness of breat…
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psnet.ahrq.gov/web-mm/case-mistaken-intubation
July 01, 2016 - SPOTLIGHT CASE
The Case of Mistaken Intubation
Citation Text:
Silveira MJ. The Case of Mistaken Intubation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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