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8061. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46551/psn-pdf
      October 25, 2017 - Inpatient notes: diagnostic excellence starts with an incessant watch. October 25, 2017 Dhaliwal G. Annals for Hospitalists Inpatient Notes - Diagnostic Excellence Starts With an Incessant Watch. Ann Intern Med. 2017;167(8):HO2-HO3. doi:10.7326/m17-2447. https://psnet.ahrq.gov/issue/inpatient-notes-diagnostic-exce…

8062. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47544/psn-pdf
      December 12, 2018 - Using good catches to promote a just culture and perioperative patient safety. December 12, 2018 Monahan JJ. Using Good Catches to Promote a Just Culture and Perioperative Patient Safety. AORN J. 2018;108(5):548-552. doi:10.1002/aorn.12394. https://psnet.ahrq.gov/issue/using-good-catches-promote-just-culture-and-p…

8063. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44032/psn-pdf
      April 01, 2015 - ACOG Committee Opinion #621: patient safety and health information technology. April 1, 2015 Improvement C on PS and Q, Management C on P. Committee opinion no. 621: Patient safety and health information technology. Obstet Gynecol. 2015;125(1):282-3. doi:10.1097/01.AOG.0000459867.14114.7a. https://psnet.ahrq.gov/i…

8064. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46753/psn-pdf
      January 30, 2018 - Leadership oversight for patient safety programs: an essential element. January 30, 2018 Moffatt-Bruce SD, Clark S, DiMaio M, et al. Leadership Oversight for Patient Safety Programs: An Essential Element. Ann Thorac Surg. 2017;105(2):351-356. doi:10.1016/j.athoracsur.2017.11.021. https://psnet.ahrq.gov/issue/leade…

8065. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45094/psn-pdf
      May 04, 2016 - Actions Needed to Improve Newly Enrolled Veterans' Access to Primary Care. May 4, 2016 Washington, DC: United States Government Accountability Office; March 18, 2016. Publication GAO-16- 328. https://psnet.ahrq.gov/issue/actions-needed-improve-newly-enrolled-veterans-access-primary-care This analysis found that s…

8066. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46386/psn-pdf
      April 03, 2018 - The impact of electronic health records on diagnosis. April 3, 2018 Graber ML, Byrne C, Johnston D. The impact of electronic health records on diagnosis. Diagnosis (Berl). 2017;4(4):211-223. doi:10.1515/dx-2017-0012. https://psnet.ahrq.gov/issue/impact-electronic-health-records-diagnosis Health information technol…

8067. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/839825/psn-pdf
      November 09, 2022 - Preventing medication errors in pediatric anesthesia: a systematic scoping review. November 9, 2022 Shawahna R, Jaber M, Jumaa E, et al. Preventing medication errors in pediatric anesthesia: a systematic scoping review. J Patient Saf. 2022;18(7):e1047-e1060. doi:10.1097/pts.0000000000001019. https://psnet.ahrq.gov…

8068. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43943/psn-pdf
      December 04, 2015 - Culture Change in the NHS: Applying the Lessons of the Francis Inquiries. December 4, 2015 Department of Health. London, England: Crown Publishing; February 2015. ISBN: 9781474112116. https://psnet.ahrq.gov/issue/culture-change-nhs-applying-lessons-francis-inquiries The Francis inquiry uncovered numerous problems …

8069. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47408/psn-pdf
      September 19, 2018 - Ways to Improve Electronic Health Record Safety. September 19, 2018 Philadelphia, PA: Pew Charitable Trusts, American Medical Association, and Medstar Health; 2018. https://psnet.ahrq.gov/issue/ways-improve-electronic-health-record-safety Electronic health records both contribute to and detract from safe care. This…

8070. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44674/psn-pdf
      December 18, 2017 - Achieving Safe Health Care: Delivery of Safe Patient Care at Baylor Scott & White Health. December 18, 2017 Compton J. Boca Raton, FL: CRC Press; 2016. ISBN: 9781498732390. https://psnet.ahrq.gov/issue/achieving-safe-health-care-delivery-safe-patient-care-baylor-scott-white-health Since the publication of the Inst…

8071. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73077/psn-pdf
      March 24, 2021 - Well-Being Playbook 2.0. A COVID-19 Resource for Hospital and Health System Leaders. March 24, 2021 AHA Physician Alliance. Chicago, IL: American Hospital Association. February 2021.  https://psnet.ahrq.gov/issue/well-being-playbook-20-covid-19-resource-hospital-and-health-system-leaders Human factors enginee…

8072. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33619/psn-pdf
      September 01, 2005 - In Conversation with…Carolyn Clancy, MD September 1, 2005 In Conversation with…Carolyn Clancy, MD. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/conversation-withcarolyn-clancy-md Editor's Note: Dr. Carolyn Clancy has been the Director of the Agency for Healthcare Research and Quality (AHRQ) since 200…

8073. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853772/psn-pdf
      September 27, 2023 - Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable September 27, 2023 Camarillo H. Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/insulin-administration-pen-vs-vial-similar-not-interchangeable The Case A fourteen-ye…

8074. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/849598/psn-pdf
      May 31, 2023 - Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis May 31, 2023 https://psnet.ahrq.gov/innovation/remote-response-team-and-customized-alert-settings-help-improve- management-sepsis Summary Seeking a sustainable process to enhance their hospitals’ response to sepsis, a multidiscip…

8075. Home | PSNet
      psnet.ahrq.gov/
      March 25, 2025 - This website is up to date as of March 24, 2025. You will not be able to register for an account and will no longer be able to obtain Continuing Medical Education (CME), Maintenance of Certification (MOC), or Continuing Pharmacy Education (CPE) credits. We are not taking submissions for WebM&M cases, Innovations, Train…

8076. The Role of Community Pharmacists in Patient Safety | PSNet
      psnet.ahrq.gov/perspective/role-community-pharmacists-patient-safety
      October 24, 2021 - Pharmacy contributions to improved population health: expanding the public health roundtable.

8077. Microsoft PowerPoint - FINAL Spotlight Case_Medication Error During Procedural Sedation in the Pediatric ED_03.27.2023.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-04/april_2023_spotlight_the_dose_makes_the_poison.pdf
      January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_Medication Error During Procedural Sedation in the Pediatric ED_03.27.2023.pptx Spotlight The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department Source and Credits • This presentation is based on the April 2023 AH…

8078. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44597/psn-pdf
      October 28, 2015 - Smarter clinical checklists: how to minimize checklist fatigue and maximize clinician performance. October 28, 2015 Grigg EB. Smarter Clinical Checklists: How to Minimize Checklist Fatigue and Maximize Clinician Performance. Anesth Analg. 2015;121(2):570-3. doi:10.1213/ANE.0000000000000352. https://psnet.ahrq.gov/…

8079. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45034/psn-pdf
      February 25, 2019 - Future directions for diagnostic decision support. February 25, 2019 Carr S. ImproveDx. April 2016;3:1-3. https://psnet.ahrq.gov/issue/future-directions-diagnostic-decision-support Clinical decision support systems are tools being used to augment clinical reasoning and diagnostic accuracy. This newsletter article …

8080. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/48149/psn-pdf
      July 31, 2019 - Zero Harm: How to Achieve Patient and Workforce Safety in Healthcare. July 31, 2019 Clapper C, Merlino J, Stockmeier C, eds. New York, NY: McGraw-Hill Education; 2019. ISBN: 9781260440928. https://psnet.ahrq.gov/issue/zero-harm-how-achieve-patient-and-workforce-safety-healthcare Achieving zero preventable harms h…