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psnet.ahrq.gov/node/72739/psn-pdf
February 10, 2021 - Council for
Continuing Medical Education (ACCME), the University of California, Davis, Health must ensure … Clinicians should independently verify information provided by
consultants to ensure that all available
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psnet.ahrq.gov/node/851568/psn-pdf
July 31, 2023 - Council
for Continuing Medical Education (ACCME), the University of California, Davis, Health must ensure … Effective
physician-nursing communication is paramount to ensure accurate medication administration.
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psnet.ahrq.gov/node/73334/psn-pdf
August 01, 2024 - Council
for Continuing Medical Education (ACCME), the University of California, Davis, Health must ensure … implementing effective communication or an
alerting system is an important additional step to take to ensure
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psnet.ahrq.gov/node/37419/psn-pdf
December 19, 2007 - Ensuring medication reconciliation.
December 19, 2007
Georgia K, Kinney K, Pace A, Helton K. Patient Saf Qual Healthc. November / December 2007.
https://psnet.ahrq.gov/issue/ensuring-medication-reconciliation
The authors describe the team-based process they used to improve medication management at the
admission, t…
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psnet.ahrq.gov/node/60548/psn-pdf
May 28, 2020 - As we are asked to evaluate new science and new technologies, we are always
trying ensure that we are … technology, such as AI, is developing and changing very quickly, how does the FDA
approach its review to ensure
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psnet.ahrq.gov/node/35897/psn-pdf
July 23, 2010 - Ensuring patient safety in wireless medical device
networks.
July 23, 2010
Gehlot V; Sloane EB.
https://psnet.ahrq.gov/issue/ensuring-patient-safety-wireless-medical-device-networks
The authors discuss clinical alarm systems from a technical perspective and propose a toolkit to help make
complex clinical IT syste…
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psnet.ahrq.gov/perspective/conversation-beverley-h-johnson-about-role-patients-family-reducing-harm
June 14, 2023 - There’s exciting work going on right now to ensure diversity in advisory councils. … Families can then work collaboratively with nurses to ensure the plan of care is followed.
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psnet.ahrq.gov/perspective/patient-and-family-roles-safety
June 14, 2023 - Families can then work collaboratively with nurses to ensure the plan of care is followed. … There’s exciting work going on right now to ensure diversity in advisory councils.
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psnet.ahrq.gov/node/49405/psn-pdf
June 01, 2003 - XL or Smaller?
June 1, 2003
Kozer E. XL or Smaller? PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/xl-or-smaller
The Case
With a history of hypertension and chronic renal failure secondary to hemolytic uremia syndrome at age 3,
a 14-year-old boy presented to the emergency department with dehydration second…
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psnet.ahrq.gov/node/49395/psn-pdf
April 01, 2003 - Medication Overdose
April 1, 2003
Kaushal R. Medication Overdose. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/medication-overdose
The Case
A 15-year-old boy with end-stage AIDS was admitted to the pediatric ICU with mental status changes. He
was diagnosed with status epilepticus and started on a loading…
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psnet.ahrq.gov/node/49812/psn-pdf
November 01, 2017 - Specimen Almost Lost
November 1, 2017
Hehe YK. Specimen Almost Lost. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/specimen-almost-lost
The Case
A 29-year-old woman presented to the hospital with a rash that had spread across her legs and abdomen.
She was admitted to the medicine service for further evalu…
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psnet.ahrq.gov/node/49832/psn-pdf
June 01, 2018 - Febrile Neutropenia and an Almost Fatal Medication Error
June 1, 2018
Faig J, Zerillo JA. Febrile Neutropenia and an Almost Fatal Medication Error. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/febrile-neutropenia-and-almost-fatal-medication-error
The Case
A 33-year-old woman with recently diagnosed acute …
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psnet.ahrq.gov/web-mm/shake-well
September 01, 2006 - Shake Well
Citation Text:
Flynn EA. Shake Well. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Downloa…
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psnet.ahrq.gov/node/33825/psn-pdf
January 01, 2017 - Rethinking Root Cause Analysis
January 1, 2016
Gupta K, Lyndon A. Rethinking Root Cause Analysis. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
Annual Perspective 2016
Introduction
Root cause analysis (RCA) is a systematic process to analyze adverse events and near miss…
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psnet.ahrq.gov/node/49649/psn-pdf
March 01, 2012 - Cultural Dimensions of Depression
March 1, 2012
Kinzie DJ. Cultural Dimensions of Depression. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/cultural-dimensions-depression
The Case
A 55-year-old Vietnamese man was admitted to a general medicine ward with vague complaints of inability
to breathe and swallow…
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psnet.ahrq.gov/web-mm/discharged-blindly
October 26, 2022 - Discharged Blindly
Citation Text:
Iezzoni LI. Discharged Blindly. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS…
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psnet.ahrq.gov/node/49595/psn-pdf
December 01, 2009 - "Superficial" Report Leads to "Deep" Problem
December 1, 2009
Dhaliwal G. "Superficial" Report Leads to "Deep" Problem. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/superficial-report-leads-deep-problem
The Case
A 35-year-old woman presented to the emergency department (ED) complaining of left foot and an…
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psnet.ahrq.gov/node/35080/psn-pdf
February 07, 2019 - To Do No Harm: Ensuring Patient Safety in Health Care
Organizations.
February 7, 2019
Morath JM, Turnbull JE. San Francisco, CA: Jossey-Bass; 2005. ISBN: 9780787967703.
https://psnet.ahrq.gov/issue/do-no-harm-ensuring-patient-safety-health-care-organizations
The authors draw from their backgrounds as health care e…
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psnet.ahrq.gov/node/49546/psn-pdf
October 17, 2007 - one member of
the team, in this case the doctor, and corrective action often requires teamwork to ensure … Failing to ensure that a competent physician is available
in a timely manner is professional abandonment … 24 hours a day, 7 days a week, 365 days
a year; therefore, physicians participate in systems that ensure … High-reliability
health care systems must balance workload with time off to ensure the physical and … patient care needs in the specialty, or the system may fail to design call or duty schedules that ensure
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psnet.ahrq.gov/node/43657/psn-pdf
November 26, 2014 - Strategies for Ensuring the Safe Use of Insulin Pens in the
Hospital.
November 26, 2014
American Society of Health-System Pharmacists
https://psnet.ahrq.gov/issue/strategies-ensuring-safe-use-insulin-pens-hospital
Insulin is classified as a high-alert medication due to the potential to cause serious patient harm w…