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psnet.ahrq.gov/node/46304/psn-pdf
November 01, 2017 - Comparative performance of pediatric weight estimation
techniques: a human factor errors analysis.
November 1, 2017
Abdel-Rahman SM, Jacobsen R, Watts JL, et al. Comparative performance of pediatric weight estimation
techniques: a human factor errors analysis. Pediatr Emerg Care. 2015;33(8):548-552.
doi:10.1097/pe…
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psnet.ahrq.gov/perspective/diagnostic-errors-new-chapter-patient-safety-science-policy-and-practice
January 01, 2016 - The best estimate from autopsy studies is that there are 40,000 to 80,000 deaths a year from diagnostic
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psnet.ahrq.gov/node/34680/psn-pdf
February 09, 2011 - Estimating hospital deaths due to medical errors:
preventability is in the eye of the reviewer.
February 9, 2011
Hayward RA, Hofer TP. Estimating hospital deaths due to medical errors: preventability is in the eye of the
reviewer. JAMA. 2001;286(4):415-20.
https://psnet.ahrq.gov/issue/estimating-hospital-deaths-du…
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psnet.ahrq.gov/web-mm/or
August 22, 2013 - On O.R. Off?
Citation Text:
Leonard M. On O.R. Off?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Do…
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psnet.ahrq.gov/web-mm/managing-ascites-hazards-fluid-removal
June 01, 2018 - Managing Ascites: Hazards of Fluid Removal
Citation Text:
Moore K. Managing Ascites: Hazards of Fluid Removal. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/node/50930/psn-pdf
February 21, 2020 - Pharmacist Role in Patient Safety
February 21, 2020
Dopp AL, Hall KK. Pharmacist Role in Patient Safety. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/pharmacist-role-patient-safety
Background: The Evolving Role of the Pharmacist
Medication errors are highly pervasive across all settings of care,[1] w…
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psnet.ahrq.gov/web-mm/forgotten-med
July 01, 2006 - The Forgotten Med
Citation Text:
Cucina R. The Forgotten Med. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/web-mm/painful-dilemma
September 01, 2013 - A Painful Dilemma
Citation Text:
Davison SN. A Painful Dilemma. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/web-mm/delayed-diagnosis-kidney-transplant-complications
January 29, 2020 - Delayed Diagnosis of Kidney Transplant Complications
Citation Text:
Kapa N, Morfín JA. Delayed Diagnosis of Kidney Transplant Complications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/web-mm/patient-safety-and-adherence-self-administered-medications
September 29, 2011 - Patient Safety and Adherence to Self-Administered Medications
Citation Text:
Spall H, Van-Spall C, Nieuwlaat R, et al. Patient Safety and Adherence to Self-Administered Medications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011…
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psnet.ahrq.gov/node/49583/psn-pdf
April 01, 2009 - Eptifibatide Epilogue
April 1, 2009
Churchill WW, Fiumara K. Eptifibatide Epilogue. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/eptifibatide-epilogue
The Case
A 62-year-old man was admitted at 11:00 PM on a Saturday night with the provisional diagnosis of acute
coronary syndrome. Serial testing for mark…
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psnet.ahrq.gov/node/41069/psn-pdf
February 21, 2012 - Using the opportunity estimator tool to improve
engagement in a quality and safety intervention.
February 21, 2012
Duval-Arnould J, Mathews SC, Weeks K, et al. Using the Opportunity Estimator tool to improve
engagement in a quality and safety intervention. Jt Comm J Qual Patient Saf. 2012;38(1):41-47, 1.
https://p…
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psnet.ahrq.gov/node/41251/psn-pdf
March 29, 2012 - Patient safety in developing countries: retrospective
estimation of scale and nature of harm to patients in
hospital.
March 29, 2012
Wilson R, Michel P, Olsen S, et al. Patient safety in developing countries: retrospective estimation of scale
and nature of harm to patients in hospital. BMJ. 2012;344:e832. doi:10.1…
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psnet.ahrq.gov/node/46116/psn-pdf
May 24, 2017 - Elimination of emergency department medication errors
due to estimated weights.
May 24, 2017
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.w5476.
https://psnet.ahrq.gov/issue/elimin…
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psnet.ahrq.gov/node/43192/psn-pdf
December 15, 2014 - Using estimated true safety event rates versus flagged
safety event rates: does it change hospital profiling and
payment?
December 15, 2014
Rosen AK, Chen Q, Borzecki A, et al. Using estimated true safety event rates versus flagged safety event
rates: does it change hospital profiling and payment? Health Serv Res.…
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psnet.ahrq.gov/node/40641/psn-pdf
July 27, 2011 - Error in body weight estimation leads to inadequate
parenteral anticoagulation.
July 27, 2011
Macedo LG dos R, de Oliveira L, Pintão MC, et al. Error in body weight estimation leads to inadequate
parenteral anticoagulation. Am J Emerg Med. 2011;29(6):613-7. doi:10.1016/j.ajem.2010.01.006.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/39787/psn-pdf
August 25, 2010 - National estimates of adverse events during
nonpsychiatric hospitalizations for persons with
schizophrenia.
August 25, 2010
Khaykin E, Ford DE, Pronovost P, et al. National estimates of adverse events during nonpsychiatric
hospitalizations for persons with schizophrenia. Gen Hosp Psychiatry. 2010;32(4):419-25.
do…
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psnet.ahrq.gov/node/34918/psn-pdf
December 17, 2009 - Racial, ethnic, and socioeconomic disparities in estimates
of AHRQ patient safety indicators.
December 17, 2009
Coffey RM, Andrews RM, Moy E. Racial, ethnic, and socioeconomic disparities in estimates of AHRQ
patient safety indicators. Med Care. 2005;43(3 Suppl):I48-I57.
https://psnet.ahrq.gov/issue/racial-ethnic-…
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psnet.ahrq.gov/node/38600/psn-pdf
October 03, 2017 - Assessment of transparency of cost estimates in
economic evaluations of patient safety programmes.
October 3, 2017
Fukuda H, Imanaka Y. Assessment of transparency of cost estimates in economic evaluations of patient
safety programmes. J Eval Clin Pract. 2009;15(3):451-9. doi:10.1111/j.1365-2753.2008.01033.x.
https…
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psnet.ahrq.gov/node/43075/psn-pdf
August 02, 2015 - National estimates of insulin-related hypoglycemia and
errors leading to emergency department visits and
hospitalizations.
August 2, 2015
Geller AI, Shehab N, Lovegrove MC, et al. National estimates of insulin-related hypoglycemia and errors
leading to emergency department visits and hospitalizations. JAMA Intern …