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5421. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49870/psn-pdf
      August 10, 2019 - Anemia and Delayed Colon Cancer Diagnosis August 10, 2019 Pathipati MP, Richter JM. Anemia and Delayed Colon Cancer Diagnosis. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/anemia-and-delayed-colon-cancer-diagnosis Case Objectives Describe the initial evaluation for iron deficiency anemia in elderly adults…

5422. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49771/psn-pdf
      July 01, 2016 - Unintended Consequences of CPOE October 1, 2016 Wears RL. Unintended Consequences of CPOE. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/unintended-consequences-cpoe Case Objectives Explain how technology, including computerized provider order entry, can transform, rather than eliminate, hazards. Recogni…

5423. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49744/psn-pdf
      October 01, 2015 - The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy October 1, 2015 Reider J. The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/risks-absent-interoperability-me…

5424. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49855/psn-pdf
      March 01, 2019 - Which Line: Ordering Provider or Proceduralist? March 1, 2019 Blackmore CC. Which Line: Ordering Provider or Proceduralist? PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist Case Objectives Review the role of mistake-proofing to block errors from leading to adverse…

5425. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73642/psn-pdf
      August 25, 2021 - Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected August 25, 2021 Wieck M. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect- unexpected …

5426. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50763/psn-pdf
      December 18, 2019 - Their kids died on the psych ward. They were far from alone, a Times investigation found. December 18, 2019 Karlamangla S. Los Angeles Times. December 1, 2019. https://psnet.ahrq.gov/issue/their-kids-died-psych-ward-they-were-far-alone-times-investigation-found Patient suicide is considered a sentinel event. This …

5427. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45721/psn-pdf
      June 28, 2017 - Rude providers jeopardize patient safety. So stop it. June 28, 2017 Thew J. HealthLeaders Media. June 14, 2017. https://psnet.ahrq.gov/issue/rude-providers-jeopardize-patient-safety-so-stop-it Rudeness can affect teamwork and hinder safe, transparent care. This news article reports on one hospital's approach to ma…

5428. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41254/psn-pdf
      April 11, 2012 - The Daily Plan: including patients for safety's sake. April 11, 2012 King BJ, Mills PD, Fore AM, et al. The Daily Plan®: Including patients for safety's sake. Nurs Manage. 2012;43(3):15-8. doi:10.1097/01.NUMA.0000412229.53136.3e. https://psnet.ahrq.gov/issue/daily-plan-including-patients-safetys-sake This study re…

5429. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39585/psn-pdf
      June 09, 2010 - Bar code technology and medication administration error. June 9, 2010 Young J, Slebodnik M, Sands L. Bar Code Technology and Medication Administration Error. J Patient Saf. 2010;6(2):115-120. doi:10.1097/pts.0b013e3181de35f7. https://psnet.ahrq.gov/issue/bar-code-technology-and-medication-administration-error This…

5430. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44226/psn-pdf
      November 03, 2015 - The Patient Survival Handbook. November 3, 2015 Powell SM, Stone RD. Peachtree City, GA: Synensis; 2015. https://psnet.ahrq.gov/issue/patient-survival-handbook Engaging patients in their care is increasingly advocated as a way to improve safety. This book recommends actions for patients and families to reduce risk…

5431. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37815/psn-pdf
      June 18, 2008 - A 2-year study of patient safety competency assessment in 29 clinical laboratories. June 18, 2008 Reed RC, Kim S, Farquharson K, et al. A 2-Year Study of Patient Safety Competency Assessment in 29 Clinical Laboratories. Am J Clin Pathol. 2008;129(6). doi:10.1309/bm8jje1auca408tq. https://psnet.ahrq.gov/issue/2-yea…

5432. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40066/psn-pdf
      January 01, 2011 - Communication errors in dispatch of air medical transport. December 8, 2010 Vilensky D, MacDonald RD. Communication errors in dispatch of air medical transport. Prehosp Emerg Care. 2011;15(1):39-43. doi:10.3109/10903127.2011.519817. https://psnet.ahrq.gov/issue/communication-errors-dispatch-air-medical-transport …

5433. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42814/psn-pdf
      February 06, 2014 - Twelve tips on engaging learners in checking health care decisions. February 6, 2014 Sibbald M, de Bruin A, van Merrienboer JJG. Twelve tips on engaging learners in checking health care decisions. Med Teach. 2014;36(2):111-5. doi:10.3109/0142159X.2013.847910. https://psnet.ahrq.gov/issue/twelve-tips-engaging-learn…

5434. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35625/psn-pdf
      June 22, 2010 - Improving the safety of medication administration using an interactive CD-ROM program. June 22, 2010 Schneider PJ, Pedersen CA, Montanya KR, et al. Improving the safety of medication administration using an interactive CD-ROM program. Am J Health Syst Pharm. 2006;63(1):59-64. https://psnet.ahrq.gov/issue/improving…

5435. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35888/psn-pdf
      July 23, 2010 - Medication errors and patient complications with continuous renal replacement therapy. July 23, 2010 Barletta JF, Barletta G-M, Brophy PD, et al. Medication errors and patient complications with continuous renal replacement therapy. Pediatr Nephrol. 2006;21(6):842-5. https://psnet.ahrq.gov/issue/medication-errors-…

5436. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42343/psn-pdf
      June 19, 2013 - Top 10 patient safety issues: what more can we do? June 19, 2013 Steelman VM, Graling PR. Top 10 patient safety issues: what more can we do? AORN J. 2013;97(6):679- 98, quiz 699-701. doi:10.1016/j.aorn.2013.04.012. https://psnet.ahrq.gov/issue/top-10-patient-safety-issues-what-more-can-we-do This commentary reveal…

5437. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36828/psn-pdf
      August 29, 2011 - Pediatric medication errors in the postanesthesia care unit: analysis of MEDMARX data. August 29, 2011 Payne CH, Smith CR, Newkirk LE, et al. Pediatric medication errors in the postanesthesia care unit: analysis of MEDMARX data. AORN J. 2007;85(4):731-40; quiz 741-4. https://psnet.ahrq.gov/issue/pediatric-medicati…

5438. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44109/psn-pdf
      November 06, 2015 - Safer Clinical Systems. November 6, 2015 London, UK: Health Foundation. https://psnet.ahrq.gov/issue/safer-clinical-systems This Web site highlights the work of a United Kingdom initiative launched in 2008 to apply safety improvement tactics from high-risk industries to care services. The program engages teams to …

5439. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39609/psn-pdf
      June 27, 2010 - Identification and Prevention of Common Adverse Drug Events in the Intensive Care Unit. June 27, 2010 Papadopoulos J, Kane-Gill SL, Cooper B, eds. Crit Care Med. 2010;38:(suppl 6):S83-S264.   https://psnet.ahrq.gov/issue/identification-and-prevention-common-adverse-drug-events-intensive-care-unit This supplem…

5440. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36284/psn-pdf
      March 10, 2011 - E-prescribing, efficiency, quality: lessons from the computerization of UK family practice. March 10, 2011 Schade CP, Sullivan FM, de Lusignan S, et al. e-Prescribing, efficiency, quality: lessons from the computerization of UK family practice. J Am Med Inform Assoc. 2006;13(5):470-5. https://psnet.ahrq.gov/issue/…