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psnet.ahrq.gov/issue/elimination-emergency-department-medication-errors-due-estimated-weights
July 08, 2020 - Commentary
Elimination of emergency department medication errors due to estimated weights.
Citation Text:
Greenwalt M, Griffen D, Wilkerson J. Elimination of Emergency Department Medication Errors Due To Estimated Weights. BMJ Qual Improv Rep. 2017;6(1). doi:10.1136/bmjquality.u214416.w5…
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psnet.ahrq.gov/issue/cognitive-bias-clinical-medicine
February 20, 2019 - Commentary
Classic
Cognitive bias in clinical medicine.
Citation Text:
O'Sullivan ED, Schofield SJ. Cognitive bias in clinical medicine. J R Coll Physicians Edinb. 2018;48(3):225-232. doi:10.4997/JRCPE.2018.306.
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psnet.ahrq.gov/issue/pediatric-medication-safety-emergency-department-0
November 19, 2018 - Organizational Policy/Guidelines
Pediatric medication safety in the emergency department.
Citation Text:
Benjamin L, Frush K, Shaw KN, et al. Pediatric Medication Safety in the Emergency Department. Ann Emerg Med. 2018;71(3):e17-e24. doi:10.1016/j.annemergmed.2017.12.013.
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psnet.ahrq.gov/node/49510/psn-pdf
May 01, 2006 - Cups of Error
May 1, 2006
Blegen MA, Pepper GA. Cups of Error. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/cups-error
The Case
An 87-year-old man was 5 days postoperative from a decompressive laminectomy. Although he suffered
from dementia, he remained alert and oriented with only mild short-term memory…
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psnet.ahrq.gov/node/49390/psn-pdf
February 01, 2003 - Flying Object Hits MRI
February 1, 2003
Gosbee JW, Gosbee LL. Flying Object Hits MRI. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/flying-object-hits-mri
The Case
A child was brought to the Magnetic Resonance Imaging (MRI) room for a brain scan. Accompanied by an
anesthesiologist, the child was receiving…
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psnet.ahrq.gov/node/73202/psn-pdf
April 28, 2021 - A Postpartum Woman with an Erroneous SARS-CoV-2
Test
April 28, 2021
Martin SA, Kanjilal S, Schiff G. A Postpartum Woman with an Erroneous SARS-CoV-2 Test. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/postpartum-woman-erroneous-sars-cov-2-test
The Case
A full-term pregnant patient was admitted in March 2…
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psnet.ahrq.gov/node/60328/psn-pdf
May 27, 2020 - Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced
Respiratory Depression
May 27, 2020
Fazio S, Firestone R. Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression.
PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory-
…
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psnet.ahrq.gov/perspective/making-healthcare-safer-iii-report
March 30, 2020 - Making Healthcare Safer III Report
March 30, 2020
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Gaffey AD, Spurlock B, Fitall E, et al. Making Healthcare Safer III Report. PSNet [internet]. Rockville (MD): Agency for Health…
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psnet.ahrq.gov/issue/tragedy-policy-quantitative-study-nurses-attitudes-toward-patient-advocacy-activities
June 01, 2011 - Study
Tragedy into policy: a quantitative study of nurses' attitudes toward patient advocacy activities.
Citation Text:
Black LM. Tragedy into policy: a quantitative study of nurses' attitudes toward patient advocacy activities. Am J Nurs. 2011;111(6):26-37. doi:10.1097/01.NAJ.0000398537…
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psnet.ahrq.gov/issue/neonatal-near-miss-audits-systematic-review-and-call-action
August 04, 2021 - Review
Neonatal near-miss audits: a systematic review and a call to action.
Citation Text:
Medeiros PB, Bailey C, Pollock D, et al. Neonatal near-miss audits: a systematic review and a call to action. BMC Pediatr. 2023;23(1):573. doi:10.1186/s12887-023-04383-6.
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psnet.ahrq.gov/issue/deficiencies-after-new-electronic-health-record-go-live-mann-grandstaff-va-medical-center
March 16, 2022 - Book/Report
Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, WA.
Citation Text:
Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, WA. Washington, DC: VA Office o…
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psnet.ahrq.gov/issue/overcoming-barriers-adopting-and-implementing-computerized-physician-order-entry-systems-us
July 10, 2008 - Study
Classic
Overcoming barriers to adopting and implementing computerized physician order entry systems in U.S. hospitals.
Citation Text:
Poon EG, Blumenthal D, Jaggi T, et al. Overcoming barriers to adopting and implementing computerized physician order ent…
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psnet.ahrq.gov/issue/image-gently-step-lightly-promoting-radiation-safety-pediatric-interventional-radiology
August 20, 2018 - Commentary
Image Gently, Step Lightly: promoting radiation safety in pediatric interventional radiology.
Citation Text:
Sidhu M, Goske MJ, Connolly B, et al. Image Gently, Step Lightly: promoting radiation safety in pediatric interventional radiology. AJR Am J Roentgenol. 2010;195(4):W29…
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psnet.ahrq.gov/issue/what-influences-sustainment-and-nonsustainment-facilitation-activities-implementation
April 17, 2017 - Study
What influences sustainment and nonsustainment of facilitation activities in implementation? Analysis of organizational factors in hospitals implementing TeamSTEPPS.
Citation Text:
Baloh J, Zhu X, Ward MM. What influences sustainment and nonsustainment of facilitation activities in…
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psnet.ahrq.gov/issue/confidential-reporting-patient-safety-events-primary-care-results-multilevel-classification
April 07, 2021 - Study
Confidential reporting of patient safety events in primary care: results from a multilevel classification of cognitive and system factors.
Citation Text:
Kostopoulou O, Delaney B. Confidential reporting of patient safety events in primary care: results from a multilevel classific…
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psnet.ahrq.gov/issue/emergency-medical-services-system-changes-reduce-pediatric-epinephrine-dosing-errors
October 06, 2021 - Study
Emergency medical services system changes reduce pediatric epinephrine dosing errors in the prehospital setting.
Citation Text:
Kaji AH, Gausche-Hill M, Conrad H, et al. Emergency medical services system changes reduce pediatric epinephrine dosing errors in the prehospital settin…
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psnet.ahrq.gov/issue/clinical-reasoning-assessment-methods-scoping-review-and-practical-guidance
August 15, 2018 - Review
Clinical reasoning assessment methods: a scoping review and practical guidance.
Citation Text:
Daniel M, Rencic J, Durning SJ, et al. Clinical Reasoning Assessment Methods: A Scoping Review and Practical Guidance. Acad Med. 2019;94(6):902-912. doi:10.1097/ACM.0000000000002618.
C…
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psnet.ahrq.gov/issue/pediatric-emergency-department-discharge-prescriptions-requiring-pharmacy-clarification
October 05, 2011 - Study
Pediatric emergency department discharge prescriptions requiring pharmacy clarification.
Citation Text:
Caruso MC, Gittelman MA, Widecan ML, et al. Pediatric emergency department discharge prescriptions requiring pharmacy clarification. Pediatr Emerg Care. 2015;31(6):403-8. doi:10.…
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psnet.ahrq.gov/issue/meta-review-methods-measuring-and-monitoring-safety-primary-care
November 03, 2021 - Review
A meta-review of methods of measuring and monitoring safety in primary care.
Citation Text:
O’Connor P, Madden C, O’Dowd E, et al. A meta-review of methods of measuring and monitoring safety in primary care. Int J Qual Health Care. 2021;33(3):mzab117. doi:10.1093/intqhc/mzab117.
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psnet.ahrq.gov/issue/transforming-concepts-patient-safety-progress-report
January 20, 2015 - Review
Classic
Transforming concepts in patient safety: a progress report.
Citation Text:
Gandhi TK, Kaplan GS, Leape L, et al. Transforming concepts in patient safety: a progress report. BMJ Qual Saf. 2018;27(12):1019-1026. doi:10.1136/bmjqs-2017-007756.
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