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121. Patient Safety Events Involving Opioid Dose Stacking | PSNet
     psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking
     July 08, 2022 - CMAJ . 2009;181(12):891-896. [ Free full text ] Hall KR, Stanley AY. … Pain Manag Nurs . 2020;21(1):7-25. [ Free full text ] Nisbet AT, Mooney-Cotter F. … Mayo Clin Proc . 2009;84(7):602-612. [ Free full text ] Fentanyl Citrate Injection, USP Rx Only. … Pain . 2017;158 Suppl 1(Suppl 1):S11-S 18 . [ Free full text ] Dahan A, van der Schrier R, Smith T, … Anesthesiology . 2018;128(5):1027-1037. [ Free full text ] Ju W, Ren L, Chen J, Du Y.

122. Procedure Complications – Who is Responsible for Follow up? | PSNet
     psnet.ahrq.gov/web-mm/procedure-complications-who-responsible-follow
     July 31, 2023 - Frontline Gastroenterol . 2020;11(1):55-61. [ Free full text ] Sdralis EIK, Petousis S, Rashid F, et … Surg Endosc . 2021;35(7):3492-505. [ Free full text ] Nirula R. Esophageal perforation. … Ann Gastroenterol . 2019;32(3):273-7. [ Free full text ] Rolanda C, Caetano AC, Dinis-Ribeiro M. … Acta Gastroenterol Belg . 2016;79(1):39-46. [ Free full text ] Voiosu T, Boskoski I, Voiosu AM, et … World J Gastroenterol . 2012;18(34):4659-76. [ Free full text ] Hasimoto CN, Cataneo C, Eldib R, et

123. The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department. | PSNet
     psnet.ahrq.gov/web-mm/one-got-away-elopement-suicidal-patient-emergency-department
     September 27, 2023 - Accessed May 25, 2023. [ Free full text ] Barr W, Leitner M, Thomas J. … BMJ Open . 2021;11:e055962. [ Free full text ] Posner K, Brown GK, Stanley B, et al. … Am J Psychiatry . 2011;168(12):1266-1277. [ Free full text ] Allen DE, Fetzer SJ, Cummings KS. … JAMA Psychiatry . 2019;76(6):652-654. [ Free full text ] De Boos J. … PLoS One . 2018;13(3):e0193587. [ Free full text ] Griffin E, Gunnell D, Corcoran P.

124. Bandemia as a Harbinger of Stercoral Colitis and Impending Perforation. | PSNet
     psnet.ahrq.gov/web-mm/bandemia-harbinger-stercoral-colitis-and-impending-perforation
     November 25, 2020 - An abdominal x-ray confirmed a large amount of stool in the colon with no free air. … air, free fluid, and stool outside the bowel wall. … BMC Gastroenterol . 2017;17(1). [ Free full text ] Fernando S, Sarma DR. … AJR Am J Roentgenol. 2005 Apr;184(4):1189-93. [ Free full text ] Wu CH, Wang LJ, Wong YC, et al. … World J Gastroenterol . 2011;17(3):379-384. [ Free full text ] Guyton DP, Evans D, Schreiber H.

125. Radiology Missed an Intracranial Bleed in a Lethargic Infant. | PSNet
     psnet.ahrq.gov/web-mm/radiology-missed-intracranial-bleed-lethargic-infant
     August 21, 2016 - Accessed December 13, 2023. [ Free full text ] Federation of State Medical Boards. … Accessed January 3, 2024. [ Free full text ] Jenny C, Hymel K, Ritzen A, et al. … Pediatr Radiol . 2018;48(8):1048-1065. [ Free full text ] Ryan ME. … Pediatr Radiol. 2023; 53: 739-751. [ Free full text ] World Health Organization. … Accessed December 15, 2023. [ Free full text ] Carty H, Pierce A.

126. Nursing and Patient Safety | PSNet
     psnet.ahrq.gov/primer/nursing-and-patient-safety
     September 07, 2019 - Med Care . 2018;56(12):1001-1008. [ Free full text ] Needleman J, Buerhaus P, Pankratz VS, et al. … Nurs Econ . 2015;33(2):95-108. [ Free full text ] Monteiro C, Avelar AF, Pedreira MD. … Rev Lat Am Enfermagem . 2015;23(1):169-79. [ Free full text ] Di Muzio M, Dionisi S, Di Simone E, … Eur Rev Med Pharmacol Sci. 2019;23(10):4507-19. [ Free full text ] Boamah SA, Spence Laschinger HK … J Adv Nurs . 2009;65(7):1509-17. [ Free full text ] Hogh A, Baernholdt M, Clausen T.

127. A prescription for enhancing electronic prescribing safety. | PSNet
     psnet.ahrq.gov/issue/prescription-enhancing-electronic-prescribing-safety
     March 15, 2017 - Overriding of drug–drug interaction alerts and inclusion of free-text notes that contain inaccurate … The Moore Foundation provides free access to this article. … Free full text Related information PubMed citation Available at Save Save to … February 13, 2019 Communication failure: analysis of prescribers' use of an internal free-text … 11, 2019 Cranky comments: detecting clinical decision support malfunctions through free-text

128. Training Catalog | PSNet
     psnet.ahrq.gov/Psnet
     April 29, 2021 - profit (7) Government organization (4) Government agency (3) Event Fee Fee Associated (51) Free … Event Location: Online Date: April 29, 2021 Event Fee: Free CE or CME Offered? … Event Location: Online Date: On Demand Event Fee: Free CE or CME Offered? … Event Location: Online Date: May  1-3, 2021 Event Fee: Free; Fee Associated CE or CME Offered? … Event Location: Online Date: On demand Event Fee: Free CE or CME Offered?

129. Perioperative Anaphylaxis After Insertion of a Latex Drain in a Patient with Known Latex Allergy | PSNet
     psnet.ahrq.gov/web-mm/perioperative-anaphylaxis-after-insertion-latex-drain-patient-known-latex-allergy
     July 08, 2022 - World Allergy Organ J . 2021;14(8):100569. [ Free full text ] Slater JE. Rubber anaphylaxis.  … MMWR . 40(26): 437, 443 July 5, 1991. [ Free full text ] Gold M, Swartz J, Braude B, et al. … Accessed August 29, 2022. [ Free full text ] Allmers H, Schmengler J, Skudlik C. … Occup Environ Med . 1997;54(5):335-342. [ Free full text ] Kelly KJ, Wang ML, Kancnik M, et al. … Accessed August 29, 2022. [ Free full text ] Kelly KJ, Kurup V, Zacharisen M, et al.

130. Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation | PSNet
     psnet.ahrq.gov/web-mm/agitated-delirium-contributes-missed-testing-and-delayed-diagnosis-gastric-perforation
     June 28, 2023 - However, this procedure – blind insertion of an NGT – is not free of risk. … World J Emerg Surg. 2018;13(1):24-24. [ Free full text ] Hodin R, Bordeianou L. … Heart Lung . 2019;48:226-235. [ Free full text ] Fan E, Tan S, Ang S. … BMJ. 2015;350:h2538. [ Free full text ] Shen Y, Peng K, Zhang J, et al. … BMJ Open . 2020; 10:e030371. [ Free full text ] Ray-Barruel G.

131. Ventricular Wall Injury during a Diagnostic Cardiac Catheterization | PSNet
     psnet.ahrq.gov/web-mm/ventricular-wall-injury-during-diagnostic-cardiac-catheterization
     September 01, 2012 - JACC Cardiovasc Interv . 2012; 5:958. [ Free full text ]   Cao D, Mehran R, Dangas G, et al. … J Am Coll Cardiol . 2020; 75:2711. [ Free full text ]   Kikkert WJ, van Geloven N, van der Laan MH, … J Am Coll Cardiol . 2014; 63:1866. [ Free full text ]   Feit F, Voeltz MD, Attubato MJ, et al. … J Am Coll Cardiol . 2012; 60:2017 [ Free full text ]   Sharif H, Hussain S. … J Thorac Dis . 2017;9(12):5288-5294. [ Free full text ]   Nandal, S, Herman, B.

132. Microsoft PowerPoint - Spotlight Case_Delayed Diagnosis and Treatment of Lupus_SLIDES - FINAL.pptx (pdf file)
     psnet.ahrq.gov/sites/default/files/2024-03/delayed_diagnosis_and_treatment_of_sle.pdf
     January 01, 2024 - [Free full text] 2. Wijnands JM, Zhu F, Kingwell E, et al. … [Free full text] 4. Najjar S, Steiner J, Najjar A, Bechter K. … [Free full text] 5. van der Heijden H, Rameh V, Golden E, et al. … [Free full text] 13. Chapman MR, Vause HE. … [Free full text]

133. Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue. | PSNet
     psnet.ahrq.gov/web-mm/missed-diagnosis-addisons-disease-adolescent-presenting-fatigue
     October 28, 2020 - Ther Clin Risk Manag. 2022;18:47-60. [ Free full text ] Shulman DI, Palmert MR, Kemp SF, et al. … J Investig Med. 2020;68(1):16-25. [ Free full text ] Fisher M. Fatigue in adolescents. … Am Fam Physician. 2008;78(10):1173-1179. [ Free full text ] Bornstein SR, Allolio B, Arlt W, et al … J Clin Endocrinol Metab. 2016;101(2):364-389. [ Free full text ] Kirkgoz T, Guran T. … Best Pract Res Clin Endocrinol Metab. 2018;32(4):397-424. [ Free full text ] Javorsky BR, Raff H,

134. Missing a Large Vessel Occlusion Stroke in a Patient with a History of Seizures. | PSNet
     psnet.ahrq.gov/web-mm/missing-large-vessel-occlusion-stroke-patient-history-seizures
     August 31, 2022 - N Engl J Med . 2018;378(8):708-718. [ Free full text ] Neurocritical Care Society. … Neurocrit Care . 2012;17(1):1-3. [ Free full text ] Virani SS, Alonso A, Benjamin EJ. … [ Free full text ] Campbell BCV, Lansberg MG, Broderick JP, et al. … Stroke . 2006;37(1):263-266. [ Free full text ] American Heart Association. … Acad Med . 2009;84(12):1648-1650. [ Free full text ] Freeman WD, Josephson SA.

135. Analysis of prescribers' notes in electronic prescriptions in ambulatory practice. | PSNet
     psnet.ahrq.gov/issue/analysis-prescribers-notes-electronic-prescriptions-ambulatory-practice
     April 18, 2018 - cross-sectional study, researchers analyzed more than 26,000 electronic prescriptions that included free-text … Two-thirds of free-text notes contained inappropriate content, despite the availability of a standard … authors outline recommended solutions based on the information most commonly included in prescription free-text … PubMed citation Free full text Save Save to your library Print Share

136. Patient Safety in the OR. | PSNet
     psnet.ahrq.gov/issue/patient-safety-or
     March 06, 2005 - Share Facebook Twitter Linkedin Copy URL This free

137. Improving Patient Safety and Team Communication through Daily Huddles | PSNet
     psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles
     September 07, 2019 - Pediatrics. 2013;131(1):e298-308. [ Free full text ] Goldenhar LM, Brady PW, Sutcliffe KM,et al. … BMJ Qual Saf. 2013;22(11):899-906. [ Free full text ] Stapley E, Sharples E, Lachman P, et al. … Int J Qual Health Care. 2018;30(1):44-49. [ Free full text ] Dingley C, Daugherty K, Derieg MK, et … Rockville, MD: Agency for Healthcare Research and Quality; 2008. [ Free full text ] Institute for Healthcare … Agency for Healthcare Research and Quality, Rockville, MD.[ Free full text ] Accessed January 2020

138. High-priority drug-drug interaction clinical decision support overrides in a newly implemented commercial computerized provider order-entry system: override appropriateness and adverse drug events. | PSNet
     psnet.ahrq.gov/issue/high-priority-drug-drug-interaction-clinical-decision-support-overrides-newly-implemented
     February 17, 2021 - PubMed citation Available at Free full text Save Save to your library Print … The burden of opioid-related adverse drug events on hospitalized previously opioid-free … October 17, 2018 Communication failure: analysis of prescribers' use of an internal free-text … 2018 Communication through the electronic health record: frequency and implications of free … September 7, 2022 Free-text computerized provider order entry orders used as workaround

139. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy | PSNet
     psnet.ahrq.gov/web-mm/uterine-artery-injury-during-cesarean-delivery-leads-cardiac-arrests-and-emergency
     September 28, 2005 - J Womens Health (Larchmt) . 2014;23(1):3-9. [ Free full text ] The California Pregnancy-Associated … PLoS One . 2013;8: e57594. [ Free full text ] Bonnar J. Massive obstetric haemorrhage. … Am J Obstet Gynecol . 2016; 214:527.e1-6. [ Free full text ] Umar A, Ameh CA, Muriithi F, et al. … PLoS One . 2019;14(5):e0217864. [ Free full text ] Singh S, McGlennan A, England A, et al. … Anaesthesia . 2012;67(1):12-18. [ Free full text ] Balch, B.

140. Delay in Malignancy Diagnosis Reflects Systemic Failures | PSNet
     psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures
     November 10, 2010 - Arch Pathol Lab Med. 2006;130(5):604-606. [ Free full text ] Ferreiro JA, Myers JL, Bostwick DG. … IJS: Oncology. 2021;6(1):10–17. [ Free full text ] Bhaker P, Mohan H, Handa U, et al. … Accessed September 20, 2023. [ Free full text (PDF) ] Patel S, Smith JB, Kurbatova E, et al. … Arch Pathol Lab Med. 2012;136(2):148-154. [ Free full text ] Lehr, HA, Bosman FT. … Accessed September 4, 2023. [ Free full text ] Liu Y, Kessler M, Zander DS, et al.