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101. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36064/psn-pdf
     June 28, 2006 - Nurse error spotlights drug's danger. June 28, 2006 Greene L. Tampa Bay Times. June 19, 2006. https://psnet.ahrq.gov/issue/nurse-error-spotlights-drugs-danger This article reports on the death of a pregnant 18-year-old after an overdose of magnesium sulfate. https://psnet.ahrq.gov/issue/nurse-error-spotlights-drug…

102. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/850357/psn-pdf
     June 14, 2023 - Government Response to the Investigation into the Death of Elizabeth Dixon. June 14, 2023 Department of Health and Social Care. London, England: Crown Copyright; 2023   https://psnet.ahrq.gov/issue/government-response-investigation-death-elizabeth-dixon Following an investigation into the death of 11-mon…

103. Medication/Drug Errors | PSNet
     psnet.ahrq.gov/curated-library/medicationdrug-errors
     March 12, 2021 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Medication/Drug Errors  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Dr. Yan Xiao, AHRQ TEP Member Date…

104. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/48183/psn-pdf
     August 07, 2019 - Get the Medications Right Institute. August 7, 2019 8230 Old Courthouse Road, Suite 420, Tysons Corner, VA. https://psnet.ahrq.gov/issue/get-medications-right-institute A comprehensive systems-focused approach must be employed in the hospital and at home to ensure reliable medication use. This institute supports m…

105. Spotlight Case July 2008 (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.194_slideshow.ppt
     March 01, 2009 - Spotlight Case July 2008 Spotlight Case All in the History Source and Credits This presentation is based on the February/March 2009 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Christopher Fee, MD, University of California, San Francisco …

106. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867603/psn-pdf
     March 15, 2025 - Request for Information Regarding the Impact of Ageism in Healthcare. January 22, 2025 Request for Information Regarding the Impact of Ageism in Healthcare. Agency for Healthcare Quality and Research. Fed Register. December 27, 2024. 89:105605-105606. https://psnet.ahrq.gov/issue/request-information-regarding-impa…

107. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36802/psn-pdf
     April 11, 2007 - Beth Israel cited for improving obstetrics care. April 11, 2007 Kowalczyk L. https://psnet.ahrq.gov/issue/beth-israel-cited-improving-obstetrics-care This article reports on an award recognizing Beth Israel Deaconess Hospital for its approach to improving patient safety in response to the death of an infant in 200…

108. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/846457/psn-pdf
     March 22, 2023 - Feds move to rein in prior authorization, a system that harms and frustrates patients. March 22, 2023 Sausser L. Kaiser Health News. March 13, 2023. https://psnet.ahrq.gov/issue/feds-move-rein-prior-authorization-system-harms-and-frustrates-patients Lack of access to appropriate testing, procedures, and medication…

109. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50849/psn-pdf
     January 29, 2020 - Prescription drug overload: critics fighting to curb an epidemic of medication side effects. January 29, 2020 Weisman R. Boston Globe. January 13, 2020. https://psnet.ahrq.gov/issue/prescription-drug-overload-critics-fighting-curb-epidemic-medication-side- effects Polypharmacy is a known contributor to adverse dr…

110. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/843323/psn-pdf
     February 01, 2023 - Long-Term Trends of Psychotropic Drug Use in Nursing Homes. February 1, 2023 Grimm CA. Washington DC: Office of the Inspector General; Nov 2022. Report no. OEI-07-20- 00500. https://psnet.ahrq.gov/issue/long-term-trends-psychotropic-drug-use-nursing-homes Misdiagnosis can result in inappropriate medication u…

111. Spotlight Case July 2008 (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.242_slideshow.ppt
     June 01, 2011 - Spotlight Case July 2008 Spotlight Case The ECG is Not Normal * * Source and Credits This presentation is based on the June 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Abigail Zuger, MD, Columbia University Editor, AHRQ WebM&M: Robe…

112. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33657/psn-pdf
     September 01, 2007 - Rediscovering the Power of the Surgical M&M Conference: The M+M Matrix September 1, 2007 Gordon LA. Rediscovering the Power of the Surgical M&M Conference: The M+M Matrix. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/rediscovering-power-surgical-mm-conference-mm-matrix Perspective There is a slumbe…

113. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50701/psn-pdf
     November 26, 2019 - In Conversation With... Heidi Wald, MD November 26, 2019 In Conversation With.. Heidi Wald, MD. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-heidi-wald-md Editor’s note: Dr. Wald, MD, MSPH, is the Chief Quality and Safety Officer at SCL Health in Denver, CO. She has previously served as …

114. PSNet Curated Library (pdf file)
     psnet.ahrq.gov/print/pdf/node/74277
     January 01, 2021 - PSNet Curated Library AHRQ: Agency for Healthcare Research and Quality Medication/Drug Errors Curated Library Primers Medication Administration Errors Paul MacDowell, PharmD, BCPS, Ann Cabri, PharmD, and Michaela Davis, MSN, RN, CNS | March, 12 2021 Medication administration errors are a persistent patient saf…

115. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43739/psn-pdf
     December 03, 2014 - Joshua’s Story. December 3, 2014 Anderson-Wallace M, Denning R. Leeds, UK: Patient Stories; October 18, 2014. https://psnet.ahrq.gov/issue/joshuas-story Patient stories are a growing component of understanding the impact of medical errors on patients and uncovering underlying causes. This video features an in-dept…

116. PowerPoint Presentation (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.344_slideshow.ppt
     April 01, 2015 - PowerPoint Presentation Spotlight Dissecting the Presentation * This presentation is based on the April 2015 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Shirley Beng Suat Ooi, MBBS (S'pore), Emergency Medicine Department, National Univers…

117. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33634/psn-pdf
     May 04, 2006 - The Wild West: Patient Safety in Office-Based Anesthesia May 1, 2006 Kaushal R, Upadhyayula S, Gaba DM, et al. The Wild West: Patient Safety in Office-Based Anesthesia. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/wild-west-patient-safety-office-based-anesthesia Perspective Over the last decade, sur…

118. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/860384/psn-pdf
     January 10, 2024 - Aging stigma and the health of US adults over 65: what do we know? January 10, 2024 Allen J, Sikora N. Aging stigma and the health of US adults over 65: what do we know? Clin Interv Aging. 2023;18:2093-2116. doi:10.2147/cia.s396833. https://psnet.ahrq.gov/issue/aging-stigma-and-health-us-adults-over-65-what-do-we-…

119. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866447/psn-pdf
     August 07, 2024 - Older adults are often misdiagnosed. Specialized ERs and trained clinicians can help. August 7, 2024 Milne-Tyte A. Older adults are often misdiagnosed. Specialized ERs and trained clinicians can help. Health Shots. National Public Radio. July 30, 2024; https://psnet.ahrq.gov/issue/older-adults-are-often-misdiagnos…

120. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49508/psn-pdf
     January 01, 2007 - Language Barrier April 1, 2006 Flores G. Language Barrier. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/language-barrier The Case A previously healthy 10-month-old girl was taken to a pediatrician's office by her monolingual Spanish- speaking parents when they noted that their daughter had generalized we…