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  1. Psn-Pdf (pdf file)

    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, …
  2. Psn-Pdf (pdf file)

    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…
  3. Psn-Pdf (pdf file)

    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…
  4. Psn-Pdf (pdf file)

    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…
  5. Psn-Pdf (pdf file)

    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…
  6. Psn-Pdf (pdf file)

    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…
  7. 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…
  8. 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…
  9. Psn-Pdf (pdf file)

    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…
  10. Psn-Pdf (pdf file)

    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…
  11. psnet.ahrq.gov/perspective/conversation-ann-l-hendrich-rn-phd
    February 26, 2025 - psnet
  12. Psn-Pdf (pdf file)

    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…
  13. 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…
  14. Psn-Pdf (pdf file)

    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…
  15. 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…
  16. Psn-Pdf (pdf file)

    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…
  17. 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. …
  18. 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 …
  19. Psn-Pdf (pdf file)

    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 …
  20. Psn-Pdf (pdf file)

    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 …

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