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psnet.ahrq.gov/sites/default/files/2021-06/final_spotlight_miscommunication_possible_artifact_06.21.2021.pdf
January 01, 2021 - Spotlight
Spotlight
The Consequences of Miscommunication
Regarding a Possible Artifact
Source and Credits
• This presentation is based on the June 2021 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Kriti Gwal, MD
o AHRQ WebM&M Edit…
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psnet.ahrq.gov/node/37791/psn-pdf
September 29, 2017 - Controversy and quality improvement: lingering
questions about ethics, oversight, and patient safety
research.
September 29, 2017
Kass N, Pronovost P, Sugarman J, et al. Controversy and quality improvement: lingering questions about
ethics, oversight, and patient safety research. Jt Comm J Qual Patient Saf. 2008;3…
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psnet.ahrq.gov/node/38434/psn-pdf
June 15, 2011 - Trends in healthcare incident reporting and relationship
to safety and quality data in acute hospitals: results from
the National Reporting and Learning System.
June 15, 2011
Hutchinson A, Young TA, Cooper KL, et al. Trends in healthcare incident reporting and relationship to
safety and quality data in acute hospi…
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psnet.ahrq.gov/node/60241/psn-pdf
February 24, 2022 - Coronavirus Disease 2019 (COVID-19) and Safety of Older
Adults Residing in Nursing Homes
February 24, 2022
Bakerjian D. Coronavirus Disease 2019 (COVID-19) and Safety of Older Adults Residing in Nursing
Homes. PSNet [internet]. 2022.
https://psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-safety-older-…
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psnet.ahrq.gov/sites/default/files/2021-05/final_psnet_spotlight_inadvertent_bolus_of_norepinephrine_pp.pdf
January 01, 2021 - Spotlight
Spotlight
An Inadvertent Bolus of Norepinephrine
Source and Credits
• This presentation is based on the May 2021 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Sarina Fazio, PhD, RN, Emma Blackmon, PhD,
RN, Amy Doroy, PhD,…
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psnet.ahrq.gov/node/42231/psn-pdf
June 18, 2013 - Identification of doctors at risk of recurrent complaints: a
national study of healthcare complaints in Australia.
June 18, 2013
Bismark M, Spittal MJ, Gurrin LC, et al. Identification of doctors at risk of recurrent complaints: a national
study of healthcare complaints in Australia. BMJ Qual Saf. 2013;22(7):532-40…
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psnet.ahrq.gov/node/46515/psn-pdf
December 22, 2018 - A contemporary medicolegal analysis of outpatient
medication management in chronic pain.
December 22, 2018
Abrecht CR, Brovman EY, Greenberg P, et al. A Contemporary Medicolegal Analysis of Outpatient
Medication Management in Chronic Pain. Anesth Analg. 2017;125(5):1761-1768.
doi:10.1213/ANE.0000000000002499.
htt…
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psnet.ahrq.gov/node/49589/psn-pdf
August 01, 2009 - This file is licensed under the
Creative Commons Attribution ShareAlike 3.0, Attribution ShareAlike … In short: you are free to share and make derivative works of the file
under the conditions that you
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psnet.ahrq.gov/node/49751/psn-pdf
January 01, 2016 - New Patient Mistakenly Checked in as Another
January 1, 2016
Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another
The Case
A 55-year-old man, presented to a primary care physician's office for an initial vis…
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psnet.ahrq.gov/node/41223/psn-pdf
March 21, 2012 - High-profile investigations into hospital safety problems
in England did not prompt patients to switch providers.
March 21, 2012
Laverty AA, Smith PC, Pape UJ, et al. High-profile investigations into hospital safety problems in England
did not prompt patients to switch providers. Health Aff (Millwood). 2012;31(3):5…
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psnet.ahrq.gov/issue/how-make-emergency-department-visit-safe-one
November 02, 2005 - Government Resource
How to Make an Emergency Department Visit a Safe One.
Citation Text:
How to Make an Emergency Department Visit a Safe One. Clancy CM.
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psnet.ahrq.gov/issue/handwritten-prescription-ban-puts-pharmacists-awkward-position-enforcers
September 21, 2005 - Newspaper/Magazine Article
Handwritten-prescription ban puts pharmacists in awkward position as "enforcers."
Citation Text:
Handwritten-prescription ban puts pharmacists in awkward position as "enforcers." Ostrom CM. Seattle Times. June 22, 2006
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psnet.ahrq.gov/issue/hospitals-tear-bills-medical-mistakes
July 05, 2006 - Newspaper/Magazine Article
Hospitals to tear up bills for medical mistakes.
Citation Text:
Hospitals to tear up bills for medical mistakes. Ostrom CM. Seattle Times. January 29, 2008.
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…
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psnet.ahrq.gov/issue/popular-blood-thinner-causing-deaths-injuries-nursing-homes
May 03, 2017 - Newspaper/Magazine Article
Popular blood thinner causing deaths, injuries in nursing homes.
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July 22, 2015
View more articles from the …
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psnet.ahrq.gov/issue/settlement-be-used-hospital-training-labeling-medicines
May 04, 2015 - Newspaper/Magazine Article
Settlement to be used for hospital training in labeling medicines.
Citation Text:
Settlement to be used for hospital training in labeling medicines. Ostrom CM. The Seattle Times. September 13, 2005.
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psnet.ahrq.gov/issue/training-health-care-professionals-patient-safety
July 09, 2008 - Commentary
Training health care professionals for patient safety.
Citation Text:
Training health care professionals for patient safety. Clancy CM.
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psnet.ahrq.gov/node/60044/psn-pdf
March 16, 2020 - Patient Safety in Medical, Nursing, and Other Clinical
Education
March 16, 2020
Howley LD, Hall KK, Fitall E. Patient Safety in Medical, Nursing, and Other Clinical Education . PSNet
[internet]. 2020.
https://psnet.ahrq.gov/perspective/patient-safety-medical-nursing-and-other-clinical-education
Background
Despit…
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psnet.ahrq.gov/perspective/updates-role-health-it-patient-safety
January 31, 2020 - Annual Perspective
Updates in the Role of Health IT in Patient Safety
February 21, 2020
View more articles from the same authors.
Citation Text:
Hall KK, Fitall E, Hettinger AZ. Updates in the Role of Health IT in Patient Safety. PSNet [internet]. Rockville …
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psnet.ahrq.gov/issue/investigation-role-clinical-pharmacy-services-helping-identify-and-reduce-high-risk
September 29, 2021 - Book/Report
Investigation into the Role of Clinical Pharmacy Services in Helping to Identify and Reduce High-risk Prescribing Errors in Hospital.
Citation Text:
Investigation into the Role of Clinical Pharmacy Services in Helping to Identify and Reduce High-risk Prescribing Errors in Hos…
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psnet.ahrq.gov/issue/california-pharmacies-are-making-millions-mistakes-theyre-fighting-keep-secret
October 14, 2020 - Newspaper/Magazine Article
California pharmacies are making millions of mistakes. They’re fighting to keep that secret.
Citation Text:
California pharmacies are making millions of mistakes. They’re fighting to keep that secret. Peterson M. Los Angeles Times. September 5, 2023.
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