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8121. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866265/psn-pdf
      July 31, 2024 - Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport July 31, 2024 MacDowell P, McGee E. Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/misplaced-vial-medicatio…

8122. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49824/psn-pdf
      March 01, 2018 - Missing ECG and Missed Diagnosis Lead to Dangerous Delay March 1, 2018 O'Connor RE. Missing ECG and Missed Diagnosis Lead to Dangerous Delay. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/missing-ecg-and-missed-diagnosis-lead-dangerous-delay The Case A 35-year-old woman with no prior cardiac history calle…

8123. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49730/psn-pdf
      April 01, 2015 - Transition to Nowhere April 1, 2015 Farrell TW. Transition to Nowhere. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/transition-nowhere The Case A 75-year-old man with a history of prostate cancer, poorly controlled myotonic dystrophy, hypertension, and chronic kidney disease was admitted to the hospital …

8124. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.284_slideshow.ppt
      November 01, 2012 - Spotlight Case July 2008 Spotlight Case Transfusion Overload 1 2 Source and Credits This presentation is based on the November 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Manish S. Patel, MD, and Jeffrey L. Carson, MD, of UMDNJ−Robert Wood …

8125. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49439/psn-pdf
      March 01, 2004 - Lethal Cap March 1, 2004 Schillinger D. Lethal Cap. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/lethal-cap The Case A 9-month-old child was seen by her pediatrician for a fever and decreased appetite. She was found to have otitis media and was prescribed amoxicillin. The doctor gave the first dose to th…

8126. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33615/psn-pdf
      June 01, 2005 - In Conversation with…Peter J. Pronovost, MD, PhD June 1, 2005 In Conversation with…Peter J. Pronovost, MD, PhD. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd Editor's Note: Peter J. Pronovost, MD, PhD, is Medical Director of the Johns Hopkins Center for Innova…

8127. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49520/psn-pdf
      September 01, 2006 - DNR in the OR and Afterwards September 1, 2006 Lo B. DNR in the OR and Afterwards. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/dnr-or-and-afterwards The Case An 85-year-old woman with dementia took a mechanical fall at her skilled nursing facility (SNF) and suffered a fractured femur. After initial eval…

8128. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49781/psn-pdf
      January 01, 2017 - Hazards of Loading Doses January 1, 2017 Mucksavage JJ, Tesoro EP. Hazards of Loading Doses. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/hazards-loading-doses The Case A 40-year-old woman was recently discharged after a prolonged hospitalization for seizures and a cardiac arrest. Two days after discharg…

8129. Quality of care and quality of life: balancing patient safety and physician burnout. | PSNet
      psnet.ahrq.gov/issue/quality-care-and-quality-life-balancing-patient-safety-and-physician-burnout
      September 27, 2023 - Commentary Quality of care and quality of life: balancing patient safety and physician burnout. Citation Text: Minkoff H, O'Brien J, Berkowitz R. Quality of care and quality of life: balancing patient safety and physician burnout. Obstet Gynecol. 2024;144(3):e50-e55. doi:10.1097/aog.0000…

8130. Revealing and resolving patient safety defects: the impact of leadership WalkRounds on frontline caregiver assessments of patient safety. | PSNet
      psnet.ahrq.gov/issue/revealing-and-resolving-patient-safety-defects-impact-leadership-walkrounds-frontline
      June 16, 2011 - Study Revealing and resolving patient safety defects: the impact of leadership WalkRounds on frontline caregiver assessments of patient safety. Citation Text: Frankel A, Grillo SP, Pittman M, et al. Revealing and resolving patient safety defects: the impact of leadership WalkRounds on …

8131. Views of nurses and other health and social care workers on the use of assistive humanoid and animal-like robots in health and social care: a scoping review. | PSNet
      psnet.ahrq.gov/issue/views-nurses-and-other-health-and-social-care-workers-use-assistive-humanoid-and-animal
      July 27, 2022 - Review Emerging Classic Views of nurses and other health and social care workers on the use of assistive humanoid and animal-like robots in health and social care: a scoping review. Citation Text: Papadopoulos I, Koulouglioti C, Ali S. Views of nurses and other …

8132. Transfusion-related errors and associated adverse reactions and blood product wastage as reported to the National Healthcare Safety Network Hemovigilance Module, 2014-2022. | PSNet
      psnet.ahrq.gov/issue/transfusion-related-errors-and-associated-adverse-reactions-and-blood-product-wastage
      September 23, 2020 - Study Transfusion-related errors and associated adverse reactions and blood product wastage as reported to the National Healthcare Safety Network Hemovigilance Module, 2014-2022. Citation Text: Chavez Ortiz JL, Griffin I, Kazakova SV, et al. Transfusion‐related errors and associated adve…

8133. Residents, responsibility, and error: how residents learn to navigate the intersection. | PSNet
      psnet.ahrq.gov/issue/residents-responsibility-and-error-how-residents-learn-navigate-intersection
      August 21, 2019 - Study Residents, responsibility, and error: how residents learn to navigate the intersection. Citation Text: Shepherd L, Chilton S, Cristancho SM. Residents, responsibility, and error: how residents learn to navigate the intersection. Acad Med. 2023;98(8):934-940. doi:10.1097/acm.0000000…

8134. Patient-safety–related hospital deaths in England: thematic analysis of incidents reported to a national database, 2010–2012. | PSNet
      psnet.ahrq.gov/issue/patient-safety-related-hospital-deaths-england-thematic-analysis-incidents-reported-national
      October 31, 2014 - Study Patient-safety–related hospital deaths in England: thematic analysis of incidents reported to a national database, 2010–2012. Citation Text: Donaldson LJ, Panesar S, Darzi A. Patient-safety-related hospital deaths in England: thematic analysis of incidents reported to a national da…

8135. Use of a handheld computer application for voluntary medication event reporting by inpatient nurses and physicians. | PSNet
      psnet.ahrq.gov/issue/use-handheld-computer-application-voluntary-medication-event-reporting-inpatient-nurses-and
      February 16, 2011 - Study Use of a handheld computer application for voluntary medication event reporting by inpatient nurses and physicians. Citation Text: Dollarhide AW, Rutledge T, Weinger MB, et al. Use of a handheld computer application for voluntary medication event reporting by inpatient nurses and…

8136. Trends in the prevalence of intraoperative adverse events at two academic hospitals after implementation of a mandatory reporting system. | PSNet
      psnet.ahrq.gov/issue/trends-prevalence-intraoperative-adverse-events-two-academic-hospitals-after-implementation
      August 09, 2017 - Study Trends in the prevalence of intraoperative adverse events at two academic hospitals after implementation of a mandatory reporting system. Citation Text: Wanderer JP, Gratch DM, St Jacques P, et al. Trends in the Prevalence of Intraoperative Adverse Events at Two Academic Hospitals …

8137. Emergency medicine physicians' perspectives on diagnostic accuracy in neurology: a qualitative study. | PSNet
      psnet.ahrq.gov/issue/emergency-medicine-physicians-perspectives-diagnostic-accuracy-neurology-qualitative-study
      July 21, 2021 - Study Emergency medicine physicians' perspectives on diagnostic accuracy in neurology: a qualitative study. Citation Text: Liberman AL, Cheng NT, Friedman BW, et al. Emergency medicine physicians’ perspectives on diagnostic accuracy in neurology: a qualitative study. Diagnosis (Berl). 20…

8138. The application of the Global Trigger Tool: a systematic review. | PSNet
      psnet.ahrq.gov/issue/application-global-trigger-tool-systematic-review
      December 06, 2023 - Review The application of the Global Trigger Tool: a systematic review. Citation Text: Hibbert PD, Molloy CJ, Hooper TD, et al. The application of the Global Trigger Tool: a systematic review. Int J Qual Health Care. 2016;28(6):640-649. doi:10.1093/intqhc/mzw115. Copy Citation For…

8139. Natural language processing and its implications for the future of medication safety: a narrative review of recent advances and challenges. | PSNet
      psnet.ahrq.gov/issue/natural-language-processing-and-its-implications-future-medication-safety-narrative-review
      December 21, 2014 - Review Emerging Classic Natural language processing and its implications for the future of medication safety: a narrative review of recent advances and challenges. Citation Text: Wong A, Plasek JM, Montecalvo SP, et al. Natural Language Processing and Its Implic…

8140. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. | PSNet
      psnet.ahrq.gov/issue/incidence-adverse-events-and-negligence-hospitalized-patients-results-harvard-medical
      February 18, 2011 - Study Classic Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. Citation Text: Brennan TA, Leape LL, Laird NM, et al. Incidence of Adverse Events and Negligence in Hospitalized Patients. N Eng…