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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/42600/psn-pdfSeptember 18, 2013 - Oral medications inadvertently given via the intravenous route. September 18, 2013 Shah-Mohammadi AR, Gaunt MJ. PA-PSRS Patient Saf Advis. September 2013;10:85-91. https://psnet.ahrq.gov/issue/oral-medications-inadvertently-given-intravenous-route Analyzing data submitted to the Pennsylvania Patient Safety Reporti… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/38021/psn-pdfAugust 27, 2008 - A review of the current evidence base for significant event analysis. August 27, 2008 Bowie P, Pope L, Lough M. A review of the current evidence base for significant event analysis. J Eval Clin Pract. 2008;14(4):520-36. doi:10.1111/j.1365-2753.2007.00908.x. https://psnet.ahrq.gov/issue/review-current-evidence-base… -
psnet.ahrq.gov/web-mm/perioperative-anaphylaxis-after-insertion-latex-drain-patient-known-latex-allergyJuly 08, 2022 - Physical paper charts had highly visible stickers identifying the patient with latex allergy.
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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/841306/psn-pdfDecember 14, 2022 - Resilient Healthcare and the Safety-I and Safety-II Frameworks December 14, 2022 Deutsch ES, Van CM, Mossburg SE. Resilient Healthcare and the Safety-I and Safety-II Frameworks. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/resilient-healthcare-and-safety-i-and-safety-ii-frameworks Resilient healthca… -
Spotlight Case July 2008 (ppt file)
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.233_slideshow.pptFebruary 01, 2011 - Spotlight Case July 2008 Spotlight Case One Toxic Drug Is Not Like Another * * Source and Credits This presentation is based on the February 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Eric S. Holmboe, MD, American Board of Internal… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49496/psn-pdfDecember 01, 2005 - Discharged Blindly December 1, 2005 Iezzoni LI. Discharged Blindly. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/discharged-blindly The Case An elderly blind man developed a deep vein thrombosis during his hospital stay. At discharge, he was to receive enoxaparin (Lovenox) for self-administration at home… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/36933/psn-pdfSeptember 09, 2011 - Retained foreign bodies after surgery. September 9, 2011 Lincourt AE, Harrell A, Cristiano J, et al. Retained Foreign Bodies After Surgery. Journal of Surgical Research. 2007;138(2). doi:10.1016/j.jss.2006.08.001. https://psnet.ahrq.gov/issue/retained-foreign-bodies-after-surgery The authors performed a case contr… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/37013/psn-pdfJuly 14, 2010 - Engagement of leadership in quality improvement initiatives: executive quality improvement survey results. July 14, 2010 Vaughn T, Koepke M, Kroch E, et al. J Patient Saf. 2006;2(1):2-9. https://psnet.ahrq.gov/issue/engagement-leadership-quality-improvement-initiatives-executive-quality- improvement-survey The in… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/41575/psn-pdfAugust 08, 2012 - Threats to patient safety in the primary care office: concerns of physicians and nurses. August 8, 2012 Schwappach DLB, Gehring K, Battaglia M, et al. Threats to patient safety in the primary care office: concerns of physicians and nurses. Swiss Med Wkly. 2012;142:w13601. doi:10.4414/smw.2012.13601. https://psnet.… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/39049/psn-pdfJanuary 16, 2010 - Approaching the evidence basis for aviation-derived teamwork training in medicine. January 16, 2010 Zeltser M, Nash DB. Approaching the evidence basis for aviation-derived teamwork training in medicine. Am J Med Qual. 2010;25(1):13-23. doi:10.1177/1062860609345664. https://psnet.ahrq.gov/issue/approaching-evidence… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/38755/psn-pdfJuly 01, 2009 - Review of Patient Safety for Children and Young People. July 1, 2009 London, UK: National Patient Safety Agency; 2009. ISBN: 978906624071. https://psnet.ahrq.gov/issue/review-patient-safety-children-and-young-people Analyzing research and more than 900,000 incident reports submitted to the National Patient Safety … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/40046/psn-pdfJune 15, 2012 - Applying HFMEA to prevent chemotherapy errors. June 15, 2012 Cheng C-H, Chou C-J, Wang P-C, et al. Applying HFMEA to prevent chemotherapy errors. J Med Syst. 2012;36(3):1543-51. doi:10.1007/s10916-010-9616-7. https://psnet.ahrq.gov/issue/applying-hfmea-prevent-chemotherapy-errors This study provides a practical ex… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/34584/psn-pdfJuly 08, 2014 - Advocate Health Care: a systemwide approach to quality and safety. July 8, 2014 Willeumier D. Advocate health care: a systemwide approach to quality and safety. Jt Comm J Qual Patient Saf. 2004;30(10):559-566. https://psnet.ahrq.gov/issue/advocate-health-care-systemwide-approach-quality-and-safety Advocate is a l… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/38024/psn-pdfAugust 27, 2008 - Promoting patient safety using an early warning scoring system. August 27, 2008 Higgins Y, Maries-Tillott C, Quinton S, et al. Promoting patient safety using an early warning scoring system. Nurs Stand. 2008;22(44):35-40. https://psnet.ahrq.gov/issue/promoting-patient-safety-using-early-warning-scoring-system Imp… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/33892/psn-pdfMay 03, 2016 - Critical Incident Technique Bibliography—2001. May 3, 2016 Fivars G; Fitzpatrick R https://psnet.ahrq.gov/issue/critical-incident-technique-bibliography-2001 A research tool to identify critical requirements for performance in applied areas of psychology and behavioral science. This technique, used in anesthesia t… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/39750/psn-pdfAugust 11, 2010 - Medication reconciliation in a community pharmacy setting. August 11, 2010 Johnson CM, Marcy TR, Harrison DL, et al. Medication reconciliation in a community pharmacy setting. J Am Pharm Assoc (2003). 2010;50(4):523-6. doi:10.1331/JAPhA.2010.09121. https://psnet.ahrq.gov/issue/medication-reconciliation-community-p… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/39306/psn-pdfFebruary 17, 2010 - Detection of patient risk by nurses: a theoretical framework. February 17, 2010 Despins LA, Scott-Cawiezell J, Rouder JN. Detection of patient risk by nurses: a theoretical framework. J Adv Nurs. 2010;66(2). doi:10.1111/j.1365-2648.2009.05215.x. https://psnet.ahrq.gov/issue/detection-patient-risk-nurses-theoretica… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/39678/psn-pdfJuly 14, 2010 - Medication errors recovered by emergency department pharmacists. July 14, 2010 Rothschild JM, Churchill WW, Erickson A, et al. Medication errors recovered by emergency department pharmacists. Ann Emerg Med. 2010;55(6):513-21. doi:10.1016/j.annemergmed.2009.10.012. https://psnet.ahrq.gov/issue/medication-errors-rec… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/36454/psn-pdfJanuary 31, 2019 - Front Line of Defense: The Role of Nurses in Preventing Sentinel Events. Third Edition. January 31, 2019 Oakbrook, IL: Joint Commission Resources; 2018. ISBN: 9781635850611. https://psnet.ahrq.gov/issue/front-line-defense-role-nurses-preventing-sentinel-events-third-edition Nurses have an important role in ensurin… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/39770/psn-pdfAugust 18, 2010 - Comparison of potential risk factors for medication errors with and without patient harm. August 18, 2010 Zaal RJ, van Doormaal JE, Lenderink AW, et al. Comparison of potential risk factors for medication errors with and without patient harm. Pharmacoepidemiol Drug Saf. 2010;19(8). doi:10.1002/pds.1977. https://ps…
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