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psnet.ahrq.gov/node/33735/psn-pdf
August 01, 2012 - Medication Safety in Nursing Homes: What's Wrong and
How to Fix It
August 1, 2012
Gurwitz JH. Medication Safety in Nursing Homes: What's Wrong and How to Fix It. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/medication-safety-nursing-homes-whats-wrong-and-how-fix-it
Perspective
At any point in time, …
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psnet.ahrq.gov/node/49598/psn-pdf
February 01, 2010 - Medication Reconciliation Pitfalls
February 1, 2010
Weber RJ. Medication Reconciliation Pitfalls. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls
The Case
A 90-year-old woman who lived alone suffered a mechanical fall with subsequent hip fracture and was
brought to the eme…
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psnet.ahrq.gov/node/33850/psn-pdf
January 01, 2018 - EHR Copy and Paste and Patient Safety
January 1, 2018
Dean SM. EHR Copy and Paste and Patient Safety. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/ehr-copy-and-paste-and-patient-safety
Perspective
Although the ability to copy and paste text is a central benefit of computing in general, and electronic…
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psnet.ahrq.gov/node/33812/psn-pdf
August 01, 2016 - In Conversation With… Bernardo Perea-Pérez, MD, DDS,
PhD
August 1, 2016
In Conversation With… Bernardo Perea-Pérez, MD, DDS, PhD. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-bernardo-perea-perez-md-dds-phd
Editor's note: Dr. Perea-Pérez is Director de la Escuela de Medicina Legal y For…
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psnet.ahrq.gov/node/49842/psn-pdf
September 01, 2018 - The Wrong Blade: A Lack of Familiarity With Pediatric
Emergency Equipment
September 1, 2018
Katznelson J. The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment. PSNet
[internet]. 2018.
https://psnet.ahrq.gov/web-mm/wrong-blade-lack-familiarity-pediatric-emergency-equipment
The Case
As part of…
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psnet.ahrq.gov/node/49577/psn-pdf
January 01, 2009 - Are Two Insulin Pumps Better Than One?
January 1, 2009
Cook CB. Are Two Insulin Pumps Better Than One? PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/are-two-insulin-pumps-better-one
The Case
A 62-year-old man with type 1 diabetes mellitus was admitted to the hospital for coronary artery bypass
graft surge…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.287_slideshow.ppt
December 01, 2012 - Spotlight Case July 2008
Spotlight Case
The Lung Nodule That Refused To Grow
*
*
Source and Credits
This presentation is based on the December 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Alex A. Balekian, MD, MSHS, Keck School of Med…
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psnet.ahrq.gov/primer/measurement-patient-safety
September 15, 2024 - Measurement of Patient Safety
Citation Text:
Measurement of Patient 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 Pu…
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psnet.ahrq.gov/node/49581/psn-pdf
March 21, 2009 - Double Dosing, by the Rules
March 21, 2009
Cohen H. Double Dosing, by the Rules. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/double-dosing-rules
The Case
A 65-year-old woman with rheumatoid arthritis and chronic obstructive pulmonary disease (COPD) was
admitted to a medical unit during the night with wo…
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psnet.ahrq.gov/node/45236/psn-pdf
June 15, 2016 - Advancing Patient Safety in Cataract Surgery: A Betsy
Lehman Center Expert Panel Report.
June 15, 2016
Boston, MA: Betsy Lehman Center for Patient Safety and Medical Error Reduction; 2016.
https://psnet.ahrq.gov/issue/advancing-patient-safety-cataract-surgery-betsy-lehman-center-expert-panel-
report
Cataract surg…
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psnet.ahrq.gov/perspective/conversation-ann-l-hendrich-rn-phd
February 26, 2025 - psnet
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psnet.ahrq.gov/node/837863/psn-pdf
August 17, 2022 - The Nursing Home Expert Panel’s Falls Investigation
Guide Toolkit: How-To Guide.
August 17, 2022
Portland, OR: Oregon Patient Safety Commission; 2022.
https://psnet.ahrq.gov/issue/nursing-home-expert-panels-falls-investigation-guide-toolkit-how-guide
Patient falls are common sentinel events. The latest revis…
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psnet.ahrq.gov/issue/medication-administration-errors-hospitals-challenges-and-recommendations-their-measurement
December 09, 2015 - Government Resource
Medication administration errors in hospitals—challenges and recommendations for their measurement.
Citation Text:
Medication administration errors in hospitals—challenges and recommendations for their measurement. McLeod M, Barber N, Franklin BD. National Quality Mea…
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psnet.ahrq.gov/node/34735/psn-pdf
June 16, 2014 - An Organisation with a Memory: Report of an Expert
Group on Learning from Adverse Events in the NHS
Chaired by the Chief Medical Officer.
June 16, 2014
Donaldson L. London, UK: The Stationery Office, 2000.
https://psnet.ahrq.gov/issue/organisation-memory-report-expert-group-learning-adverse-events-nhs-
chaired-ch…
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psnet.ahrq.gov/perspective/missed-nursing-care-key-measure-patient-safety
March 01, 2018 - Missed Nursing Care: A Key Measure for Patient Safety
Jane Ball, PhD, and Peter Griffiths, PhD | March 1, 2018
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Ball JE, Griffiths P. Missed Nursing Care: A Key Measure for Patient…
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psnet.ahrq.gov/node/836850/psn-pdf
March 31, 2022 - Annual Perspective: Topics in Medication Safety
March 31, 2022
Harris IB, Dowell P, Mossburg SE. Annual Perspective: Topics in Medication Safety. PSNet [internet].
2022.
https://psnet.ahrq.gov/perspective/annual-perspective-topics-medication-safety
Introduction
Issues with medication management and errors in medi…
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psnet.ahrq.gov/perspective/conversation-linda-aiken-phd-rn
March 01, 2018 - In Conversation With… Linda Aiken, PhD, RN
March 1, 2018
Also Read an Essay
Citation Text:
In Conversation With… Linda Aiken, PhD, RN. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. …
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psnet.ahrq.gov/issue/measurement-diagnostic-errors-key-first-step-their-reduction
June 27, 2016 - Government Resource
Measurement of diagnostic errors is a key first step to their reduction.
Citation Text:
Measurement of diagnostic errors is a key first step to their reduction. Singh H. National Quality Measures Expert Commentaries. November 23, 2015.
Copy Citation
…
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psnet.ahrq.gov/node/34693/psn-pdf
February 10, 2011 - Effect of outcome on physician judgments of
appropriateness of care.
February 10, 2011
Caplan RA, Posner KL, Cheney FW. Effect of outcome on physician judgments of appropriateness of care.
JAMA. 1991;265(15):1957-60.
https://psnet.ahrq.gov/issue/effect-outcome-physician-judgments-appropriateness-care
The authors …
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psnet.ahrq.gov/node/44515/psn-pdf
February 23, 2018 - The Expert Panel Report to Texas Health Resources
Leadership on the 2014 Ebola Events.
February 23, 2018
Cortese D, Abbott P, Chassin M, Lyon GM III, Riley WJ. Dallas, TX: Texas Health Resources Leadership;
2015.
https://psnet.ahrq.gov/issue/expert-panel-report-texas-health-resources-leadership-2014-ebola-events
…