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  1. The Lost Start Date: an Unknown Risk of E-prescribing | PSNet

    psnet.ahrq.gov/web-mm/lost-start-date-unknown-risk-e-prescribing
    December 02, 2020 - SPOTLIGHT CASE The Lost Start Date: an Unknown Risk of E-prescribing Citation Text: Wright A, Schiff G. The Lost Start Date: an Unknown Risk of E-prescribing. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Cit…

  2. The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy | PSNet

    psnet.ahrq.gov/web-mm/risks-absent-interoperability-medication-induced-hemolysis-patient-known-allergy
    April 08, 2019 - SPOTLIGHT CASE The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy Citation Text: Reider J. The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy. PSNet [internet]. Rockville (MD): Agency for Healthcar…

  3. But See the Patient First | PSNet

    psnet.ahrq.gov/web-mm/see-patient-first
    September 27, 2023 - But See the Patient First Citation Text: Sinigayan VR. But See the Patient First. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850450/psn-pdf
    June 14, 2023 - The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department. June 14, 2023 Bourgeois JA, Xiong G, Barnes DK, et al. The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/one-got-away-elopement-suicidal-patient-…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/861760/psn-pdf
    January 31, 2024 - Syringe Swap During Regional Block: A Case of Medication Error and Recovery January 31, 2024 Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recover…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60977/psn-pdf
    January 08, 2020 - Multiple Levels Involved in Prescribing the Wrong Medication September 30, 2020 Chin K, Chau V, Spero H, et al. Multiple Levels Involved in Prescribing the Wrong Medication. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication The Case A 65-year-old woman co…

  7. 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 - The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department. Citation Text: Bourgeois JA, Xiong G, Barnes DK, et al. The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depa…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866261/psn-pdf
    July 10, 2024 - Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic Gynecological Surgery July 10, 2024 Bohringer C, Chavez G. Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic Gynecological Surgery. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/missed-compartment-syndrome…

  9. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_latex_allergies-slides.pdf
    January 01, 2022 - Spotlight Spotlight Perioperative Anaphylaxis After Insertion of a Latex Drain in a Patient with Known Latex Allergy Source and Credits • This presentation is based on the August 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by K…

  10. Microsoft PowerPoint - Spotlight Case_Gabapentin Overdose_12.21.2022 FINAL.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-01/spotlight_overdose_of_gabapentin_and_oxycodone_in_a_patient_with_end-stage_renal_disease.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Gabapentin Overdose_12.21.2022 FINAL.pptx Spotlight Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts Source and Credits • This presentation is based on the January 2023 AHRQ WebM&M Spotli…

  11. Syringe Swap During Regional Block: A Case of Medication Error and Recovery | PSNet

    psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recovery
    July 22, 2020 - Syringe Swap During Regional Block: A Case of Medication Error and Recovery Citation Text: Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…

  12. Glossary | PSNet

    psnet.ahrq.gov/glossary
    January 01, 2003 - Glossary A B C D E F H I J L M N O P R S T U V W Active Error (or Active Failure) The terms active and latent as applied to errors were coined by Reason . Active errors occur at the point of contact between a human and some aspect of a larger system (e.g., a human–machine in…

  13. Glossary | PSNet

    psnet.ahrq.gov/glossary-0
    January 01, 2003 - Glossary   Definitions abound in the medical error and patient safety literature, with subtle and not-so-subtle variations in the meanings of important terms. An effort was made to adopt the most straightforward terminology, with definitions that enjoy the widest use. A B C D E F H I J L M N O P R S T U…

  14. Multiple Levels Involved in Prescribing the Wrong Medication | PSNet

    psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication
    December 23, 2020 - Multiple Levels Involved in Prescribing the Wrong Medication Citation Text: Chin K, Chau V, Spero H, et al. Multiple Levels Involved in Prescribing the Wrong Medication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Cit…

  15. Health Plan Patient Safety Initiatives | PSNet

    psnet.ahrq.gov/perspective/health-plan-patient-safety-initiatives
    July 10, 2024 - Health Plan Patient Safety Initiatives Amy Helwig, MD, MS, FAAFP, Zoe Sousane, BS, Sarah Mossburg, RN, PhD | July 10, 2024  Also Read the Conversation View more articles from the same authors. Citation Text: Helwig A, Sousane Z, Mossburg S. Health Plan Patient S…

  16. In Conversation With...Amy Helwig about Health Plan Patient Safety Initiatives | PSNet

    psnet.ahrq.gov/perspective/conversation-withamy-helwig-about-health-plan-patient-safety-initiatives
    July 10, 2024 - In Conversation With...Amy Helwig about Health Plan Patient Safety Initiatives Amy Helwig, MD, MS, FAAFP, Zoe Sousane, BS, Sarah Mossburg, RN, PhD | July 10, 2024  Also Read the Essay View more articles from the same authors. Citation Text: Helwig A, Sousane Z, …

  17. Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic Gynecological Surgery | PSNet

    psnet.ahrq.gov/web-mm/missed-compartment-syndrome-after-steep-lithotomy-position-laparoscopic-gynecological
    January 29, 2021 - Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic Gynecological Surgery Citation Text: Bohringer C, Chavez G. Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic Gynecological Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qual…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60611/psn-pdf
    June 24, 2020 - Direct Oral Anticoagulants are High-Risk Medications with Potentially Complex Dosing June 24, 2020 Giannini J, Wong M, Dager W, et al. Direct Oral Anticoagulants are High-Risk Medications with Potentially Complex Dosing. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/direct-oral-anticoagulants-are-high-risk…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865655/psn-pdf
    April 24, 2024 - Under Pressure: Delayed Diagnosis of Compartment Syndrome after Lower Leg Fracture. April 24, 2024 Barnes DK, Randhawa SDS, Fitzpatrick EP. Under Pressure: Delayed Diagnosis of Compartment Syndrome after Lower Leg Fracture. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/under-pressure-delayed-diagnosis-comp…

  20. Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts. | PSNet

    psnet.ahrq.gov/web-mm/overdose-gabapentin-and-oxycodone-patient-end-stage-renal-disease-case-appropriate
    June 24, 2020 - SPOTLIGHT CASE Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts. Citation Text: Keenan CR, MacDonald S, Takeshita A, et al. Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case…
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