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psnet.ahrq.gov/web-mm/delay-appropriate-diagnosis-and-treatment-leading-death-pulmonary-embolism
December 31, 2024 - radiologic findings
Failure of the primary team to review imaging studies
Failure to recognize multiple indicators
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psnet.ahrq.gov/web-mm/breathe-easy-safe-tracheostomy-management
June 07, 2023 - Breathe Easy: Safe Tracheostomy Management
Citation Text:
Russell MS, Russell MD. Breathe Easy: Safe Tracheostomy Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/dont-pick-picc
December 01, 2011 - Don't Pick the PICC
Citation Text:
McGill RL. Don't Pick the PICC. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/node/49411/psn-pdf
July 01, 2003 - Code Status Confusion
July 1, 2003
Lo B, Tulsky JA. Code Status Confusion. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/code-status-confusion
Case Objectives
Appreciate challenges of determining goals of care in hospitalized patients
Understand patients’ common misconceptions about CPR
List typical mist…
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psnet.ahrq.gov/node/49804/psn-pdf
September 01, 2017 - Transfusion Thresholds in Gastrointestinal Bleeding
September 1, 2017
Strate L, Swanson S. Transfusion Thresholds in Gastrointestinal Bleeding. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/transfusion-thresholds-gastrointestinal-bleeding
Case Objectives
Describe risk factors for poor outcome in patients w…
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psnet.ahrq.gov/web-mm/ectopic-or-not
March 27, 2024 - Ectopic or Not?
Citation Text:
Givens VM, Lipscomb GH. Ectopic or Not?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/mistaken-dose-naloxone
March 21, 2009 - A Mistaken Dose of Naloxone
Citation Text:
Cutler E, Gunawardena D. A Mistaken Dose of Naloxone . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/discharge-against-medical-advice
July 01, 2017 - Discharge Against Medical Advice
Citation Text:
Hwang SW. Discharge Against Medical Advice. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/periodic-issue/periodic-issue-471
December 31, 2024 - January 22, 2025 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, report…
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psnet.ahrq.gov/issue/geriatric-medication-reconciliation-home-setting
September 01, 2021 - Newspaper/Magazine Article
Geriatric medication reconciliation in the home setting.
Citation Text:
Geriatric medication reconciliation in the home setting. Taylor K. American Nurse J. 2021;16(7):14-17.
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psnet.ahrq.gov/issue/drug-name-confusion-preventing-medication-errors
January 29, 2018 - Newspaper/Magazine Article
Drug name confusion: preventing medication errors.
Citation Text:
Rados C. Drug name confusion: preventing medication errors. FDA consumer. 2005;39(4):35-7.
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psnet.ahrq.gov/issue/mail-service-and-community-pharmacies-must-work-tandem
December 07, 2022 - Newspaper/Magazine Article
Mail service and community pharmacies must work in tandem.
Citation Text:
Mail service and community pharmacies must work in tandem. ISMP Safe Medication Alert! Acute care edition. November 17, 2005.
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psnet.ahrq.gov/issue/epidural-iv-route-mix-ups-reducing-risk-deadly-errors
May 02, 2018 - Newspaper/Magazine Article
Epidural-IV route mix-ups: reducing the risk of deadly errors.
Citation Text:
Epidural-IV route mix-ups: reducing the risk of deadly errors. ISMP Medication Safety Alert! Acute Care Edition. July 3, 2008;13:1-3.
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psnet.ahrq.gov/issue/pharmacist-staffing-and-use-technology-small-rural-hospitals-implications-medication-safety
August 01, 2012 - Book/Report
Pharmacist Staffing and the Use of Technology in Small Rural Hospitals: Implications for Medication Safety.
Citation Text:
Pharmacist Staffing and the Use of Technology in Small Rural Hospitals: Implications for Medication Safety. Casey MM, Moscovice I, Davidson G. Minn…
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psnet.ahrq.gov/issue/ismp-survey-shows-provider-text-messaging-often-runs-afoul-patient-safety
May 07, 2018 - Newspaper/Magazine Article
ISMP survey shows provider text messaging often runs afoul of patient safety.
Citation Text:
ISMP survey shows provider text messaging often runs afoul of patient safety. ISMP Medication Safety Alert! Acute Care Edition. November 16, 2017;22:1-5.
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psnet.ahrq.gov/issue/first-annual-review-data-submitted-ismp-national-vaccine-errors-reporting-program-verp
June 10, 2018 - Newspaper/Magazine Article
First annual review of data submitted to the ISMP National Vaccine Errors Reporting Program (VERP).
Citation Text:
First annual review of data submitted to the ISMP National Vaccine Errors Reporting Program (VERP). ISMP Medication Safety Alert! Acute Care Editi…
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psnet.ahrq.gov/issue/ockenden-report-emerging-fndings-and-recommendations-independent-review-maternity-services
April 27, 2022 - Book/Report
Ockenden Report. Emerging Fndings and Recommendations from the Independent Review of Maternity Services at the Shrewsbury and Telford Hospital NHS Trust.
Citation Text:
Ockenden Report. Emerging Fndings and Recommendations from the Independent Review of Maternity Services at …
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psnet.ahrq.gov/issue/ismp-survey-provides-insights-preparation-and-admixture-practices-outside-pharmacy
December 02, 2020 - Newspaper/Magazine Article
ISMP Survey provides insights into preparation and admixture practices OUTSIDE the pharmacy.
Citation Text:
ISMP Survey provides insights into preparation and admixture practices OUTSIDE the pharmacy. ISMP Medication Safety Alert! Acute care edition. November 5…
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psnet.ahrq.gov/issue/follow-markedly-elevated-serum-potassium-results-ambulatory-setting-implications-patient
September 29, 2021 - Study
Follow-up of markedly elevated serum potassium results in the ambulatory setting: implications for patient safety.
Citation Text:
Follow-up of markedly elevated serum potassium results in the ambulatory setting: implications for patient safety. Moore CR; Lin JJ; O'Connor N; Hal…
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psnet.ahrq.gov/issue/medication-errors-attributed-health-information-technology
March 27, 2018 - Newspaper/Magazine Article
Medication errors attributed to health information technology.
Citation Text:
Medication errors attributed to health information technology. Lawes S, Grissinger M. PA-PSRS Patient Saf Advis. March 2017;14:1-8.
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