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  1. Wrong-Time Error With High-Alert Medication | PSNet

    psnet.ahrq.gov/web-mm/wrong-time-error-high-alert-medication
    February 01, 2014 - Wrong-Time Error With High-Alert Medication Citation Text: Yang A, Nelson LS. Wrong-Time Error With High-Alert Medication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX…

  2. PowerPoint Presentation (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.335_slideshow.ppt
    December 01, 2014 - PowerPoint Presentation Spotlight A Stroke of Error This presentation is based on the December 2014 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Kevin M. Barrett, MD, MSc, Consultant, Associate Professor of Neurology, Director, Neurohospitalist F…

  3. The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department. | PSNet

    psnet.ahrq.gov/web-mm/dose-makes-poison-medication-error-during-procedural-sedation-pediatric-emergency-department
    January 23, 2017 - It includes standardized adverse event definitions which facilitates compiling and sharing data with

  4. Analysis of prescribers' notes in electronic prescriptions in ambulatory practice. | PSNet

    psnet.ahrq.gov/issue/analysis-prescribers-notes-electronic-prescriptions-ambulatory-practice
    July 23, 2018 - Study Analysis of prescribers' notes in electronic prescriptions in ambulatory practice. Citation Text: Dhavle AA, Yang Y, Rupp MT, et al. Analysis of Prescribers' Notes in Electronic Prescriptions in Ambulatory Practice. JAMA Intern Med. 2016;176(4):463-70. doi:10.1001/jamainternmed.201…

  5. Pre-analytical pitfalls: Missing and mislabeled specimens | PSNet

    psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens
    April 18, 2018 - Pre-analytical pitfalls: Missing and mislabeled specimens Citation Text: Tran NK, Liu Y. Pre-analytical pitfalls: Missing and mislabeled specimens . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: …

  6. Diagnostic Errors | PSNet

    psnet.ahrq.gov/perspective/diagnostic-errors
    December 01, 2013 - You need a team structure that includes support staff such as research assistants, coordinators, and

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44513/psn-pdf
    September 23, 2015 - Improving Diagnosis in Health Care. September 23, 2015 Committee on Diagnostic Error in Health Care, National Academies of Science, Engineering, and Medicine. Washington, DC: National Academies Press; 2015. ISBN: 9780309377690. https://psnet.ahrq.gov/issue/improving-diagnosis-health-care The National Academy of Me…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33735/psn-pdf
    August 01, 2012 - Medication Safety in Nursing Homes: What's Wrong and How to Fix It August 1, 2012 Gurwitz JH. Medication Safety in Nursing Homes: What's Wrong and How to Fix It. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/medication-safety-nursing-homes-whats-wrong-and-how-fix-it Perspective At any point in time, …

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49632/psn-pdf
    July 01, 2011 - A Seasonal Care Transition Failure July 1, 2011 Young JQ. A Seasonal Care Transition Failure. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/seasonal-care-transition-failure The Case A 70-year-old healthy man presented to his primary care doctor—a third-year internal medicine resident—for routine follow-up…

  10. Delayed Clozapine Prescription in an Elderly Man With Dementia | PSNet

    psnet.ahrq.gov/web-mm/delayed-clozapine-prescription-elderly-man-dementia
    August 06, 2014 - Delayed Clozapine Prescription in an Elderly Man With Dementia Citation Text: Tsourounis C, Ghomeshi KK. Delayed Clozapine Prescription in an Elderly Man With Dementia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Cita…

  11. Rethinking Root Cause Analysis | PSNet

    psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
    August 21, 2016 - Annual Perspective Rethinking Root Cause Analysis Kiran Gupta, MD, MPH, and Audrey Lyndon, PhD | January 1, 2016  View more articles from the same authors. Citation Text: Gupta K, Lyndon A. Rethinking Root Cause Analysis. PSNet [internet]. Rockville (MD): Age…

  12. Medication Reconciliation Pitfalls | PSNet

    psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls
    May 01, 2006 - Medication Reconciliation Pitfalls Citation Text: Weber RJ. Medication Reconciliation Pitfalls. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 X…

  13. Treatment Challenges After Discharge | PSNet

    psnet.ahrq.gov/web-mm/treatment-challenges-after-discharge
    January 03, 2017 - SPOTLIGHT CASE Treatment Challenges After Discharge Citation Text: Coffey C. Treatment Challenges After Discharge. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar Bib…

  14. Renal Failure Due to Benign Prostatic Hyperplasia | PSNet

    psnet.ahrq.gov/web-mm/renal-failure-due-benign-prostatic-hyperplasia
    February 01, 2004 - Renal Failure Due to Benign Prostatic Hyperplasia Citation Text: Barry MJ, Garnick MB. Renal Failure Due to Benign Prostatic Hyperplasia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google…

  15. Watch the Warfarin! | PSNet

    psnet.ahrq.gov/web-mm/watch-warfarin
    December 01, 2013 - SPOTLIGHT CASE Watch the Warfarin! Citation Text: Khanna R, Fang MC. Watch the Warfarin!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNot…

  16. Discharge Fumbles | PSNet

    psnet.ahrq.gov/web-mm/discharge-fumbles
    September 09, 2009 - SPOTLIGHT CASE Discharge Fumbles Citation Text: Forster AJ. Discharge Fumbles. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…

  17. Barriers and facilitators to healthcare workers' adherence with infection prevention and control (IPC) guidelines for respiratory infectious diseases: a rapid qualitative evidence synthesis. | PSNet

    psnet.ahrq.gov/issue/barriers-and-facilitators-healthcare-workers-adherence-infection-prevention-and-control-ipc
    March 02, 2011 - Review Classic Barriers and facilitators to healthcare workers' adherence with infection prevention and control (IPC) guidelines for respiratory infectious diseases: a rapid qualitative evidence synthesis. Citation Text: Houghton C, Meskell P, Delaney H, et al. …

  18. The Perils of Cross Coverage | PSNet

    psnet.ahrq.gov/web-mm/perils-cross-coverage
    September 22, 2010 - SPOTLIGHT CASE The Perils of Cross Coverage Citation Text: Farnan JM, Arora V. The Perils of Cross Coverage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX En…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46135/psn-pdf
    July 11, 2017 - Two-state collaborative study of a multifaceted intervention to decrease ventilator-associated events. July 11, 2017 Rawat N, Yang T, Ali KJ, et al. Two-State Collaborative Study of a Multifaceted Intervention to Decrease Ventilator-Associated Events. Crit Care Med. 2017;45(7):1208-1215. doi:10.1097/CCM.0000000000…

  20. Interruptions and Distractions in Health Care: Improved Safety With Mindfulness | PSNet

    psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulness
    February 01, 2014 - The Comprehensive Unit-based Safety Program , or CUSP, toolkit includes training tools to make care … It includes a comprehensive set of ready-to-use materials and a customizable training curriculum to successfully
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