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1441. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49652/psn-pdf
      May 01, 2012 - Double Dose at Transfer May 1, 2012 Hackman JL. Double Dose at Transfer. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/double-dose-transfer The Case A 74-year-old man with history of diabetes and hypertension was admitted to the emergency department (ED) for left lower extremity pain, swelling, and erythe…

1442. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33586/psn-pdf
      December 15, 2024 - Alert Fatigue December 15, 2024 Alert Fatigue. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/alert-fatigue PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in the patient safety field. Last reviewed in 2024. Bac…

1443. Ambulatory Care Safety | PSNet
      psnet.ahrq.gov/primer/ambulatory-care-safety
      December 15, 2024 - Ambulatory Care Safety Citation Text: Ambulatory Care Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

1444. Health Information Technology. | PSNet
      psnet.ahrq.gov/issue/health-information-technology
      August 21, 2016 - Special or Theme Issue Health Information Technology. Citation Text: Health Information Technology. Am J Manag Care. 2014;20(spec 17):492-554,e1-e31. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter …

1445. Ways to Improve Electronic Health Record Safety. | PSNet
      psnet.ahrq.gov/issue/ways-improve-electronic-health-record-safety
      February 08, 2017 - Book/Report Ways to Improve Electronic Health Record Safety. Citation Text: Ways to Improve Electronic Health Record Safety. Philadelphia, PA: Pew Charitable Trusts, American Medical Association, and Medstar Health; 2018. Copy Citation Save Save to your library …

1446. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47408/psn-pdf
      September 19, 2018 - Ways to Improve Electronic Health Record Safety. September 19, 2018 Philadelphia, PA: Pew Charitable Trusts, American Medical Association, and Medstar Health; 2018. https://psnet.ahrq.gov/issue/ways-improve-electronic-health-record-safety Electronic health records both contribute to and detract from safe care. This…

1447. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46266/psn-pdf
      July 19, 2017 - New unintended adverse consequences of electronic health records. July 19, 2017 Sittig DF, Wright A, Ash J, et al. New Unintended Adverse Consequences of Electronic Health Records. Yearb Med Inform. 2016;(1):7-12. https://psnet.ahrq.gov/issue/new-unintended-adverse-consequences-electronic-health-records Pressures…

1448. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46792/psn-pdf
      February 14, 2018 - Emerging trends in perinatal quality and risk with recommendations for patient safety. February 14, 2018 Simpson KR. Emerging Trends in Perinatal Quality and Risk With Recommendations for Patient Safety. J Perinat Neonatal Nurs. 2018;32(1). doi:10.1097/jpn.0000000000000294. https://psnet.ahrq.gov/issue/emerging-tr…

1449. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49681/psn-pdf
      April 01, 2013 - Total Parenteral Nutrition, Multifarious Errors April 1, 2013 Boullata JI. Total Parenteral Nutrition, Multifarious Errors. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/total-parenteral-nutrition-multifarious-errors Case Objectives Define parenteral nutrition (PN). Describe the PN-use process. Identify …

1450. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50698/psn-pdf
      November 27, 2019 - Missed Opportunities for Suicide Risk Assessment November 27, 2019 Xiong G, Kahn D. Missed Opportunities for Suicide Risk Assessment. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment Disclosure of Relevant Financial Relationships: As a provider accredited by the Acc…

1451. Misplaced Nasogastric Tube Resulting in Aspiration | PSNet
      psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
      August 01, 2009 - Misplaced Nasogastric Tube Resulting in Aspiration Citation Text: Singh A, Huang C. Misplaced Nasogastric Tube Resulting in Aspiration. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: Google S…

1452. The Perils of Cross Coverage | PSNet
      psnet.ahrq.gov/web-mm/perils-cross-coverage
      September 22, 2010 - SPOTLIGHT CASE The Perils of Cross Coverage Citation Text: Farnan JM, Arora V. The Perils of Cross Coverage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX En…

1453. Delayed Diagnosis of Endocrinologic Emergencies | PSNet
      psnet.ahrq.gov/web-mm/delayed-diagnosis-endocrinologic-emergencies
      November 13, 2024 - Delayed Diagnosis of Endocrinologic Emergencies Citation Text: Gomes-Lima C, Burman KD. Delayed Diagnosis of Endocrinologic Emergencies. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google …

1454. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50392/psn-pdf
      September 01, 2019 - It's hard to track a single patient across claims, across EHRs, across registries.

1455. Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions | PSNet
      psnet.ahrq.gov/perspective/using-human-factors-engineering-and-seips-model-advance-patient-safety-care-transitions
      November 16, 2022 - Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions Pascale Carayon, PhD; Nicole Werner, PhD; Anita Makkenchery, MPH; Sarah E. Mossburg, RN, PhD | November 16, 2022  Also Read the Conversation View more articles from the same aut…

1456. In Conversation With... Pascale Carayon, PhD and Nicole Werner, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-pascale-carayon-phd-and-nicole-werner-phd
      November 16, 2022 - In Conversation With... Pascale Carayon, PhD and Nicole Werner, PhD November 16, 2022  Also Read the Essay Citation Text: In Conversation With.. Pascale Carayon, PhD and Nicole Werner, PhD. PSNet [internet]. 2022.In Conversation With... Pascale Carayon, PhD and Ni…

1457. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33866/psn-pdf
      September 01, 2018 - We know that EHRs are not always https://psnet.ahrq.gov/issue/tackling-ambulatory-safety-risks-through-patient-engagement-what

1458. In Conversation With… Sigall K. Bell, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-sigall-k-bell-md
      February 26, 2025 - We know that EHRs are not always accurate.

1459. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.299_slideshow.ppt
      May 01, 2013 - Spotlight Case July 2008 Spotlight Case Right Regimen, Wrong Cancer: Patient Catches Medical Error * * Source and Credits This presentation is based on the May 2013 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Joseph O. Jacobson, MD, MSc…

1460. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.257_slideshow.ppt
      December 01, 2011 - Spotlight Case July 2008 Spotlight Case Order Interrupted by Text: Multitasking Mishap * * Source and Credits This presentation is based on the December 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: John Halamka, MD, MS, Chief Informa…